This document discusses the treatment of bradycardia. It describes types of bradycardia including sinus and various atrioventricular blocks. Potential causes are listed ranging from ischemia to infections. Treatment depends on stability and includes identifying and treating the underlying cause, medications like atropine or adrenaline, transcutaneous pacing, and referral to cardiology for temporary pacing wires or permanent pacemaker implantation.

1. Treatment of
Bradycardia
Dan Stevens

2. Types of Bradycardia
 Sinus
• Drugs
• Athletes
• Increased Vagal tone
 Sick Sinus syndrome
• SA node disease
 Sinus puase / arrest, Tachy-brady syndrome
 Atrioventricular
• 1st Degree
• 2nd degree
 Mobitz I (wenchebach), Mobitz II
• 3rd Degree
 Complete HB

3. Causes
 Ischaemic / infarction related
 Neurocardiogenic – reflex mediated
 Toxicology
• Ca channel blockers, B-blockers
 Metabolic
• Hyperkalaemia
 Endocrine
• Hypothyroidism
 Environmental
• Hypothermia
 Infections with cardiac involvement
• Lyme Disease
• Chagas disease

4. Treatment Options
 Treat Cause
 Stable Vs Unstable
 Do Nothing
 Medications
 Transcutaneous Pacing
 Pacing Wire / PPM

5. Evidence For Treatment??
 Not much
 Difficult patient group to study
 Guidelines based on expert opinion

6. Drugs
 Atropine
• Competitive antagonist of acetylcholine at
muscarinic receptors
• Increased HR (by reducing vagal tone)
• 400mcg up to 3mg
• Useful in vagally mediated bradycardia or
possibly very high blocks
• Often no use in complete HB

7. Drugs
 Adrenaline (preferred chronotrope)
• Non selective alpha and B agonist
• Increased blood pressure and HR
• 2-10 mcg/min
 Isoprenaline
• Selective, potent B agonist (B1)
• Risk of hypotension (No alpha effect & B2
agonist)
• Positive inotrope, positive chronotrope
• 1-4 mcg/min
 Dopamine
• 2-10 mcg/kg/min

8. Transcutaneous Pacing
 Place pads in AP position
 Connect ECG leads
 Set Defibrillator to Pacing mode
 Set rate (>30bpm than currently, normally 70)
 Sedation!!
 Start pacing and increase current until ‘capture’
• Electrical capture  QRS and T wave after each pacing
spike
• Mechanical capture  central pulse
 Current fixed at 10 mA (or ~20%) above level of capture
 If reach 130mA and no capture try changing paddle
position

9. Cardiology
 Temporary Pacing wires /
Transvenous Pacing
• Central venous access (right IJV)
• Catheter with pacing wire slowly
inserted until capture
 Permanent Pacemaker

10. Summary
 Investigate and treat cause
 Atropine up to 2mg (in selected pt’s)
 Adrenaline infusion
 Transcutaneous pacing
• Sedation
• Rate 70
• Current 10 mA (or ~20%) above level
of capture
 Early cardiology referral for
transvenous pacing wire / PPM