Peri-arrest rhythms: bradycardia

Peri-arrest rhythms: bradycardia

The 2025 Resuscitation Council UK guidelines recommend that bradyarrhythmia is managed according to:

• the presence of life-threatening features
• the response to initial atropine
• the subsequent risk of asystole

Initial assessment

Perform an ABCDE assessment:

• give oxygen if appropriate
• obtain IV access
• monitor ECG, blood pressure and oxygen saturation
• record a 12-lead ECG
• identify and treat reversible causes, including electrolyte abnormalities

Assess for the following life-threatening features:

• shock
• syncope
• myocardial ischaemia
• severe heart failure
• immediately following return of spontaneous circulation (ROSC)

Bradyarrhythmia with life-threatening features

Give atropine 500 micrograms IV

Symptomatic bradycardia is treated with atropine

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Importance: 57

and assess the response.

If the response is unsatisfactory, use the following interim measures:

• repeat atropine 500 micrograms IV every 3–5 minutes, up to a maximum total dose of 3 mg
  repeat atropine 500 micrograms IV every 3–5 minutes, up to a maximum total dose of 3 mg
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• isoprenaline 5 micrograms/minute IV
  isoprenaline 5 micrograms/minute IV
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• adrenaline 2–10 micrograms/minute IV
  adrenaline 2–10 micrograms/minute IV
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• consider alternative drugs:
  • aminophylline
  • dopamine
  • glucagon if beta-blocker or calcium-channel blocker overdose is suspected
  • glycopyrrolate may be used instead of atropine
• and/or use transcutaneous pacing
  transcutaneous pacing
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Seek expert help. Continue monitoring, treat the underlying cause and consider transvenous pacing

Transvenous pacing should be considered if a bradycardia doesn't respond to drugs or transcutaneous pacing

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Importance: 100

.

Important cautions:

• do not give atropine to patients with a cardiac transplant, as it may cause high-grade AV block or sinus arrest; consider aminophylline
• atropine is ineffective and may worsen high-grade AV block associated with a broad QRS complex

Risk of asystole

Assess the risk of asystole if:

• there are no life-threatening features, or
• there is a satisfactory response to atropine

The following are risk factors for asystole

risk factors for asystole

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:

• recent asystole
• Mobitz type II AV block
• complete heart block with a broad QRS complex
• ventricular pause greater than 3 seconds

If there is a risk of asystole:

• monitor the patient
• identify and treat the underlying cause
• consider transvenous pacing
  Transvenous pacing should be considered if a bradycardia doesn't respond to drugs or transcutaneous pacing
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  Importance: 100

If there are no life-threatening features and no risk of asystole, continue observation.

+PassMedicine Notes

The 2025 Resuscitation Council UK guidelines recommend that bradyarrhythmia is managed according to:

• the presence of life-threatening features
• the response to initial atropine
• the subsequent risk of asystole

Initial assessment

Perform an ABCDE assessment:

• give oxygen if appropriate
• obtain IV access
• monitor ECG, blood pressure and oxygen saturation
• record a 12-lead ECG
• identify and treat reversible causes, including electrolyte abnormalities

Assess for the following life-threatening features:

• shock
• syncope
• myocardial ischaemia
• severe heart failure
• immediately following return of spontaneous circulation (ROSC)

Bradyarrhythmia with life-threatening features

Give atropine 500 micrograms IV and assess the response.

If the response is unsatisfactory, use the following interim measures:

• repeat atropine 500 micrograms IV every 3–5 minutes, up to a maximum total dose of 3 mg
• isoprenaline 5 micrograms/minute IV
• adrenaline 2–10 micrograms/minute IV
• consider alternative drugs:
• aminophylline
• dopamine
• glucagon if beta-blocker or calcium-channel blocker overdose is suspected
• glycopyrrolate may be used instead of atropine
• and/or use transcutaneous pacing

Seek expert help. Continue monitoring, treat the underlying cause and consider transvenous pacing.

Important cautions:

• do not give atropine to patients with a cardiac transplant, as it may cause high-grade AV block or sinus arrest; consider aminophylline
• atropine is ineffective and may worsen high-grade AV block associated with a broad QRS complex

Risk of asystole

Assess the risk of asystole if:

• there are no life-threatening features, or
• there is a satisfactory response to atropine

The following are risk factors for asystole:

• recent asystole
• Mobitz type II AV block
• complete heart block with a broad QRS complex
• ventricular pause greater than 3 seconds

If there is a risk of asystole:

• monitor the patient
• identify and treat the underlying cause
• consider transvenous pacing

If there are no life-threatening features and no risk of asystole, continue observation.