Unstable Bradycardia Part 4


Evaluate:  5Hs & 5Ts
Hypoxia
Hypovolemia
Hyper/hypokalemia
Hydrogen ions (acidosis)
Hypothermia

Evaluate:  5Hs & 5Ts
Tension pneumothorax
Thrombosis: coronary
Thrombosis: pulmonary
Thrombosis: Tables/toxins
Tamponade, cardiac

Hypoxia
Hypoventilation and hypoxia can lead to bradycardia
Assess ABCs
Give supplemental oxygen
Consider advanced airway management
Mechanical Ventilation- DOPE mnemonic


Hydrogen Ions (acidosis)
Assess ABGs
Bicarb 1mEq/kg
o Known pre-existing bicarbonate responsive acidosis
o Intubated patient with continued long arrest interval
o Upon return of spontaneous circulation after long arrest interval
o Tricyclic antidepressant or aspirin overdose
o Known preexisting hyperkalemia
•Treat respiratory acidosis with ventilation

Hyperkalemia
Assess serum potassium levels
Slow rhythm with tall T waves, widened QRS
o 3.5-5.3  Normal
o 5.3-6.0  Mild
o 6.1-7.0  Moderate
o >7.0     Severe
Rule of 10
o 10ml of 10% calcium chloride or gluconate
o 10 units of regular insulin IV
o One amp D50 over 10 minutes
Kayexalate upon return to ROSC
Lasix IV

Hypokalemia
Slow rhythm with ST segment depression, flattened waves, prominent U wave
Potassium replacement either orally or IV
No IV push boluses!

Tablets
Assess for drug overdose
Assess for hx of drug use
Consult poison control

Tablets: Calcium Channel Blockers
Hypotension
Bradycardia with variable heart block
Altered mental status
EKG: slow rate, prolonged PRI, AV blocks
Rx Calcium chloride 10% 1-4G slow IV
Fluid resuscitation, vasopressor agents, atropine, transvenous pacing

Tablets: Beta blockers
Hypotension
Bradycardia with variable heart block
EKG: slow rate, prolonged PRI
Rx Glucagon 3-10mg IV bolus followed by infusion 2-5mg/hr

Tablets: Tricyclic Antidepressants
Amitriptyline, Doxepine, Trazadone, Nortriptyline
Prolonged QT, Widened QRS
3Cs & 1A - Cardiac dysrhythmias, Convulsions, Coma, & Acidosis
Rx NaHCO3 bolus or infusions
Maintain pH > 7.45

Tension Pneumothorax
Hx trauma, recent pacemaker or central line insertion, ventilator patient
Assess for tracheal deviation
Needle decompression 2nd intercostal space midclavicular line
Chest tube

Thrombosis, Coronary
MONA
Follow ACS algorithm

References
Aehlert, Barbara. ACLS Quick Review Study Guide, 2nd edition.  Mosby, inc.  St. Louis, Mo. 1994.
Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S729–S767

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