According to the National Institutes of Health (NIH) Epub 2019 Jul 9, bradycardia is a resting heart rate of 50-60 beats per minute (bpm), which can be normal in some individuals, especially those who are young, physically fit, or during sleep, but can also indicate a medical condition. For most adults, a normal resting heart rate ranges from 60 to 100 beats per minute (bpm).
ACLS Bradycardia Algorithm is a component of Advanced Cardiac Life Support (ACLS) used in emergency care to treat patients experiencing bradycardia. This algorithm offers a step-by-step approach that begins with assessing the patient for symptoms and identifying possible causes of the slow heart rate. It includes ensuring the airway is clear, monitoring vital signs such as heart rhythm, blood pressure, and oxygen saturation, establishing IV (Intravenous) access, and administering appropriate treatments like atropine, transcutaneous pacing, or dopamine/epinephrine when necessary.
It’s a structured step-by-step strategy healthcare professionals use to handle slow heart rates effectively.
Bradycardia may not always cause noticeable symptoms, but when it does, they can include:
These symptoms occur because the heart is not pumping enough blood to meet the body’s needs. If these symptoms you are suspecting, immediate assessment and treatment are essential.
It is important because it helps healthcare providers know what to do when a person’s heart rate is too slow and it’s causing serious symptoms.
Bradycardia treatment varies depending on the patient’s clinical conditions, symptoms, and the root cause of the slow heart rate. The focus is on managing symptoms and identifying the underlying issue using the Hs and Ts framework from the ACLS bradycardia algorithm. We’ll explore the Hs and Ts in more detail later, but first, let’s look at the basic technique for treating bradycardia.
01.
Begin by assessing and stabilizing the patient's airway, breathing, and circulation. Provide necessary interventions as needed.
02.
Continuously check and document key vitals, including heart rate, blood pressure, and oxygen saturation.
03.
Investigate and determine the root cause of the bradycardia. Potential causes include hypoxia, low blood volume, acidosis, toxic exposures, or intrinsic cardiac conditions such as heart blocks.
04.
Differentiate between symptomatic and asymptomatic bradycardia. Symptoms such as chest pain, low blood pressure, altered consciousness, or signs of shock indicate hemodynamic instability and require prompt action.
05.
If the patient shows signs of symptomatic bradycardia with poor circulation, administer atropine.
06.
If atropine fails or isn’t suitable, use dopamine or epinephrine to enhance heart rate and cardiac output:
07.
For severe bradycardia that doesn’t respond to medications or if the patient remains unstable, initiate transcutaneous pacing.
08.
When bradycardia is linked to cardiac conduction abnormalities such as heart blocks, consult a cardiologist or electrophysiologist. A permanent pacemaker may be required for long-term management.
| Possible Causes | How To Recognize | Treatment |
| Hypovolemia | Fast heart rate with a narrow QRS on ECG, along with signs of low blood volume. | Infusion of normal saline or Ringer’s lactate |
|
Hypoxia |
Heart rate will be slow |
Airway management and successful oxygenation |
|
Hydrogen Ion Excess (Acidosis) |
Low QRS voltage on an ECG |
Rapid breathing; consider giving a bolus of sodium bicarbonate |
|
Hypoglycaemia |
Bedside glucose monitoring |
Intravenous (IV) bolus of dextrose |
|
Hypokalaemia |
Flat T waves and the appearance of U wave on the ECG |
Intravenous (IV) magnesium infusion |
|
Hyperkalaemia |
Peaked T waves and wide QRS complex on the ECG |
Think about giving calcium chloride and sodium bicarbonate, along with starting an insulin and glucose protocol |
|
Hypothermia |
Exposure to a cold environment |
Gently rewarming |
|
Tension Pneumothorax |
Heart rate will be slow and insufficient QRS complexes on the ECG; uneasy in breathing |
Needle Decompression or Thoracostomy |
| Tamponade (cardiac) |
Heart rate will be fast and insufficient QRS complexes on the ECG; uneasy in breathing |
Pericardiocentesis (Pericardium) |
| Toxins |
Usually present with a prolonged QT interval on ECG and may be accompanied by neurological symptoms |
Based on particular toxins |
|
Thrombosis (pulmonary) |
Heart rate will be fast with insufficient QRS complexes on the ECG |
Perform a surgical embolectomy or administer fibrinolytic therapy |
|
Thrombosis (myocardial infarction) |
The ECG will show abnormalities corresponding to the location of the infarction |
It depends on the severity and timing of the myocardial infarction (MI) |
Effective management of bradycardia under ACLS guidelines is crucial for optimizing outcomes in emergencies. Quickly noticing the problem, finding out what’s causing it, and giving the right treatment, like medicine or pacing, can help stop the patient from getting worse. Regular training and following up-to-date guidelines help medical teams stay ready to act fast and handle situations well. A systematic approach to bradycardia not only saves lives but also strengthens overall cardiovascular care.
The first steps in managing bradycardia include securing the airway and supporting breathing, providing continuous monitoring, administering oxygen as needed, assessing blood pressure and oxygen saturation, and establishing intravenous (IV) access. It’s also essential to obtain an ECG to accurately assess and monitor the heart rhythm.
It is used when a patient has symptomatic bradycardia, meaning their slow heart rate is causing symptoms like hypotension, dizziness, or altered mental status.
These medications act as vasopressors, increasing heart rate and blood pressure when atropine is ineffective.
Continuous ECG, blood pressure, oxygen saturation, and patient response to interventions should be closely monitored.
CPR is not typically given for bradycardia unless the patient has no pulse or is unresponsive . If this situation arises, CPR must be started immediately, and the ACLS cardiac arrest algorithm should be followed.
TCP is recommended if the patient has severe symptoms (e.g., shock, or altered mental status) and does not respond to atropine.
Bradycardia can be stabilized using medications such as atropine, dopamine, or epinephrine, and may also require a temporary pacemaker to help regulate the heart rate.
