ACLS Algorithm: Adult Bradycardia

For all medical professionals, this blog will help you to know that how you can treat a patient who presents with symptomatic bradycardia as per American Heart Association ACLS guidelines.

The Bradycardia Algorithm comprise of a proper sequence for treating a patient who presents with symptomatic bradycardia with a pulse.

Basically, bradycardia means slow heartbeat i.e. heart rate of lesser than 60 beats in one minute. Some people, especially well-trained athletes, may have a resting heart rate between 40-50 beats per minute without any symptoms, thus it is important to understand and even the identification of the difference between asymptomatic and symptomatic bradycardia is also vital.

Asymptomatic Bradycardia: This is defined as a condition in which a person has slow heartbeat or bradycardia which appears without any of the classic symptoms of bradycardia.

Symptomatic Bradycardia: This is defined as a heart rate of lesser than 50 beats per minute and leads to the generation of symptoms due to low heart rate. You should be capable of differentiating between the symptoms that result directly from the low heart rate and the ones that are not that related.

Following list consists of the symptoms associated with bradycardia:

• Fatigue
• Chest pressure, pain or heaviness
• Weakness
• Dizziness or light headedness
• Dyspnea
• Syncope or near syncope

Following are the various ECG rhythms for treating bradycardia:

• Sinus Bradycardia
• First-Degree AV Block
• Second-Degree AV Block

- Type I (Wenckebach Phenomenon / Mobitz I)

- Type II (Non-Wenckebach / Mobitz II)

• Third-Degree AV Block

Once the identification of symptomatic bradycardia is done, then follow the steps mentioned below:

First step: Identify and treat the underlying cause. In order to help with this step, you can use the H’s and T’s of ACLS. Your help may be required in maintaining the airway and assist breathing, in the administration of oxygen in case of hypoxemia, connect a cardiac and blood pressure monitor, and establish IV access. The normal blood oxygen saturation level (SpO2) should be around 94% to 95%In case a 12-lead ECG is available readily, it should be used. However, there should not be any delay in the treatment in order to obtain one.

The H’s of ACLS:

1. Hypovolemia-A sudden and significant decrease in the volume of blood and fluids in your body
2. Hypoxia-When the body is deprived of sufficient oxygen supply
3. Hydrogen Ions (Acidosis)-Improper pH level caused by too much acid (lactic acidosis) in the body
4. Hyperkalemia/ Hypokalemia (Potassium)-Too much (hyperkalemia) or too little (hypokalemia) potassium in the body
5. Hypothermia-When the body loses the ability to keep itself warm and body temperature drops below 95˙ F (35˙ C)

The T’s of ACLS:  

1. Tension Pneumothorax-When air enters the pleural space but is unable to exit, causing a buildup in the pleural space
2. Tamponade (Pericardial Tamponade)-Buildup of blood or fluid in the pericardial space
3. Toxins-Intentional or accidental overdose
4. Thrombosis (Pulmonary Embolus)-Blockage of the lung’s main artery (pulmonary artery)
5. Thrombosis (Acute Coronary Syndrome)-Blockage of the heart’s coronary artery/arteries

Second step: Next step involves the determination of whether the patient is showing enough perfusion, or if there are signs or symptoms of poor perfusion that are led by the bradycardia.

Following is the list of signs of persistent bradycardia that results in poor perfusion:

• Signs of shock
• Hypotension
• Chest discomfort
• Acute heart failure
• Acutely altered mental status

In case the perfusion is adequate, simply observe and monitor. However, if the patient present with any of the above-stated signs that are suggestive towards poor perfusion move forward to the third step of the algorithm.

Third step: This step involves the administration of atropine. If atropine is not effective, you may also consider an infusion of dopamine or epinephrine or transcutaneous pacing.

To have an even more detailed, step-by-step description of the Adult Bradycardia Algorithm please refer to the flowchart given below.

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