This document provides guidelines for treating bradycardia with pulses. It outlines steps to take a history including potential causes, medications, signs and symptoms. It recommends following general medical care and resuscitation guidelines. For paramedics it recommends advanced airway, 12-lead EKG, IV fluids if hypotensive, atropine or pacing, and epinephrine. It provides specific treatments if hyperkalemia is suspected due to certain patient histories. Signs of shock from bradycardia are also defined. Finally, it lists medications that can cause bradycardia.

1. SAFD COG Version 2.0 August 1, 2020
Bradycardia (with pulses)
History
• Does the patient have bradycardia? (HR < 50)
• Is the patient symptomatic?
• If so, when did the symptoms start?
• What is the patient’s medical history? – Cardiac or
kidney disease? Diabetes? Hypothyroidism?
Pacemaker?
• Has the patient had head, neck or back trauma?
• Has the patient had a toxic exposure or overdose?
• Does the patient have altered mental status or stroke
symptoms?
• What medications does the patient take? (see list)
EMT
• Follow General Medical Care Guideline
• Follow Adult Resuscitation Guideline, as indicated
Paramedic
Signs / Symptoms of Shock
• Advanced airway as indicated
• 12-Lead EKG
• NS 500-1000 mL IV bolus if SBP ≤ 90
• Atropine 0.5 – 1 mg IO/IV – repeat to max dose of 3 mg
o If 2o Type II, 3o heart block or heart transplant, consider immediate pacing
o ***If Hyperkalemia suspected see below***
• Transcutaneous pacing at 100 BPM
o Increase millivolts until electrical and mechanical capture
o Use Ketamine 2mg/kg IV for sedation, amnesia and analgesia
• Epinephrine Push Dose (1:100,000) 10-20 mcg (1-2 mL) IO/IV every 2-3 minutes PRN
(max total 100 mcg / 10 mL) – Consult Medical Director for further doses
• Treat STEMI per appropriate guideline
***If Patient has history of renal failure, active cancer radiation or chemotherapy, or concern for
hyperkalemia – consider aggressive early treatment as follows: ***
• Sodium Bicarbonate 1 mEq/kg IO/IV (100 mEq or 2 amps)
• Calcium Chloride 1g IO/IV (Do not give if taking digoxin)
• Albuterol 7.5 mg/9 ml nebulized or instilled down ET tube
Signs and Symptoms of Hemodynamically
Significant Bradycardia (Shock)
• Hypotension (SBP <90)
• Syncope
• Dizziness / lightheadedness (near-syncope)
• Altered mental status / agitation
• Chest pain
• Shortness of breath / difficulty breathing
• Signs of pulmonary edema – crackles / rales, hypoxia
• Diaphoresis
• Cyanosis
• Decreased capillary refill
Medications That Can Cause Bradycardia
• Beta-blockers (metoprolol, atenolol, labetalol, sotalol, propranolol, carvedilol, pindolol, nadolol)
• Calcium channel blockers (amlodipine, diltiazem, felodipine, isradipine, nicardipine, nifedepine,
verapamil)
• Digitalis (Digoxin, Lanoxin, Digitek, Lanoxicaps) GO TO Hyperkalemia-Digoxin Toxicity Protocol