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Bradyarrythmias

Bradyarrythmias
Bradycardia is defined as any
rhythm disorder with a heart rate
less than 60 beats per minute. This
could also be called asymptomatic
bradycardia.
Bradycardia can be a normal nonemergent rhythm. For instance, well
trained athletes may have a normal
heart rate that is less than 60 bpm.

The major ECG rhythms classified as


bradycardia include:
Sinus Bradycardia
First-degree AV block
Second-degree AV block
Type I Wenckenbach/Mobitz I
Type II Mobitz II
Third-degree AV block complete block

1st Degree AV Block

PR interval >200ms
If accompanied by wide QRS, refer to cardiology,
high risk of progression to 2nd and 3rd deg block
Otherwise, benign if asymptomatic

2nd Degree AV Block Mobitz


type I (Wenckebach)

Progressive PR longation, with eventual


non-conduction of a p wave
May be in 2:1 or 3:1

Wenckebach, Mobitz type I

Usually asymptomatic, but with accompanying


bradycardia can cause angina, syncope esp in
elderlywill need pacing if sxs
Also can be caused by drugs that slow conduction
(BB, CCB, dig)
2-10% long distance runners
Correct if reversible cause, avoid meds that block
conduction

2nd degree block Type II (Mobitz


2)

Normal PR intervals with sudden failure of a p wave to


conduct
Usually below AV node and accompanied by BBB or
fascicular block
Often causes pre/syncope; exercise worsens sxs
Generally need pacing, possibly urgently if symptomatic

3rd Degree AV Block

Complete AV disassociation, HR is a ventricular rate


Will often cause dizziness, syncope, angina, heart failure
Can degenerate to Vtach and Vfib
Will need pacing, urgent referral

Symptomatic bradycardia however is


defined as a heart rate less than 60 bpm
that elicits signs and symptoms.
Symptomatic bradycardia exists when
the following 3 criteria are present:

1) The heart rate is slow


2) The patient has symptoms
3) The symptoms are due to the slow
heart rate.

Symptoms of bradycardia
A heart rhythm that's too slow can
cause insufficient blood flow to the
brain with symptoms such as:

Fatigue Dizziness
Lightheadedness
Fainting or near-fainting spells
In extreme cases, cardiac arrest may
occur.

Causes of bradycardia
Problems with the sinoatrial (SA) node,
sometimes called the heart's natural
pacemaker Problems in the conduction
pathways of the heart (electrical
impulses are not conducted from the
atria to the ventricles)
Metabolic problems such as hypothermia
Damage to the heart from heart attack
or heart disease

Functional or relative bradycardia


occurs when a patient may have a
heart rate within normal sinus range,
but the heart rate is insufficient for
the patients condition. An example
would be a patient with an heart rate
of
80
bpm
when
they
are
experiencing septic shock.

Bradycardia Pharmacology
There are 3 medications that are used in the
Bradycardia ACLS Algorithm. They are
atropine,
dopamine
(infusion),
and
epinephrine (infusion)
Atropine: The first drug of choice for
symptomatic bradycardia. Dose in the
Bradycardia ACLS algorithm is 0.5mg IV push
and may repeat up to a total dose of 3mg.
Dopamine:
Second-line
drug
for
symptomatic bradycardia when atropine is
not
effective.
Dosage
is
2-10
micrograms/kg/min infusion.
Epinephrine: Can be used as an equal
alternative to dopamine when atropine is not
effective. Dosage is 2-10 micrograms/min.

2010
AHA
Update:
For
symptomatic bradycardia or unstable
bradycardia IV infusion chronotropic
agents (dopamine & epinephrine) is
now recommended as an equally
effective alternative to external
pacing when atropine is ineffective.

Bradycardia Algorithm
The
decision
point
for
ACLS
intervention
in
the
bradycardia
algorithm is determination of adequate
perfusion.
For
the
patient
with
adequate
perfusion,
you
should
observe and monitor.
If the patient has poor perfusion,
preparation for transcutaneous pacing
should be initiated, and an assessment
of contributing causes (Hs and Ts)
should be carried out.

Transcutaneous pacing (TCP)


Preparation for TCP should be taking
place as atropine is being given. If
atropine fails to alleviate symptomatic
bradycardia, TCP should be initiated.
Ideally the patient should receive
sedation prior to pacing, but if the
patient is deteriorating rapidly, it may
be necessary to start TCP prior to
sedation.

REMEMBER
For the patient with symptomatic
bradycardia with signs of poor
perfusion, transcutaneous pacing is
the treatment of choice.

NO QRS
=
NO
CIRCULATION

Thank You