ICU Advantage - Bradycardia Algorithm

Introduction

• Presenter: Eddie Watson
• Goal: Build confidence in understanding ICU subjects by simplifying complex concepts.
• Subject: Review of the American Heart Association's ACLS Bradycardia Algorithm.
• Focus: Bradycardia with a pulse (not cardiac arrest).

Understanding Bradycardia

• Definition: Heart rhythm with a rate < 60 bpm.
• Concern: Symptomatic bradycardia (heart rate < 50 bpm with specific symptoms).
• Symptoms of concern: Slow rhythm with inadequate perfusion causing symptoms.

Algorithm Overview

• Assess necessity and appropriateness of the bradycardia algorithm.
• Key Rhythms:
  • Sinus bradycardia
  • First-degree AV block
  • Second-degree AV block (Mobitz type I & II)
  • Third-degree AV block (Complete heart block)
  • Junctional and ventricular rhythms

Assessment and Initial Steps

• Ensure patient's airway is patent.
• Assess breathing, provide oxygen if hypoxic.
• Monitor ECG, blood pressure, and oxygen saturation.
• Ensure good IV access.
• Optionally obtain a 12-lead ECG (do not delay therapy).

Determining Patient Stability

• Assess persistent bradycardia impact on perfusion ("unstable" condition):
  • Hypotension (MAP < 60 or SBP < 90)
  • Altered level of consciousness
  • Signs of shock (cool, clammy skin, cyanosis, rapid breathing, etc.)
  • Ischemic chest discomfort
  • Acute heart failure

Intervention Steps

1. Administer Atropine: 1 mg IV push, repeat every 3-5 min, max 3 mg.

   • Note: Updated dose since AHA 2020 guidelines.
   • Less effective for third-degree heart block and some second-degree blocks.
   • Caution with acute MI (increases heart rate and myocardial oxygen consumption).

2. If Atropine Ineffective/Not Indicated:

   • Electrical Pacing (Transcutaneous):
     • Preferred for acute MI or very unstable patients.
     • Painful, consider analgesic/sedation.
   • Chemical Pacing:
     • Dopamine: 5-20 mcg/kg/min, titrate and taper slowly.
     • Epinephrine: 2-10 mcg/min, titrate and taper slowly.

3. Consider Expert Consultation

   • Use transvenous pacer or prepare for cath lab if persistent bradycardia.

Key Points

• Quick action required for unstable patients.
• Familiarity with pacing settings on defibrillator is crucial.

Conclusion

• Review of bradycardia algorithm helps in quickly managing unstable patients.
• Encourage sharing and subscribing for more lessons.

Support

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• Options for additional support available through membership or merchandise.

This summary aims to provide a concise yet comprehensive overview of the instructional content on the ACLS Bradycardia Algorithm.