Step 22: Analyze broad complex regular bradycardia

•Third-degree AV block (distal to AV node)

–Ventricular escape rate is usually 25–45/min.

–Usually symptomatic requiring treatment with transvenous pacemaker.

–AV dissociation, with atrial rate (P wave) greater than QRS, with no relation between these two.

Step 23: Analyze broad complex irregular bradycardia

• Atrial fibrillation, MAT with aberrant conduction, and high-degree AV block

Step 24: General management of bradycardia

•All symptomatic bradycardia should be managed urgently.

•Atropine 0.5 mg IV may be repeated to a total dose of 3 mg.

•Atropine is more successful in sinus bradycardia or block within the AV node.

•If the patient remains symptomatic, temporary transvenous pacing should be started.

•Transcutaneous pacing may be started as a temporary measure.

•Consider epinephrine infusion (2–10 mcg/min) or dopamine infusion (2–10 mcg/ Kg/min) as an interim measure.

•Treat the underlying cause and the precipitating factor.

•Withdraw any offending drug.

•Consider permanent pacing in selected cases (advanced, prolonged AV block) in consultation with the cardiologist.

Suggested Reading

1.Field JM, Hazinski MF, Sayre MR, et al. Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 2;122(18 Suppl 3):S640–56.

The publication marks the 50th anniversary of modern CPR and highlights detailed management of bradyand tachyarrhythmias.

2.Annane D, Sébille V. Incidence and prognosis of sustained arrhythmias in critically ill patients. AJRCCM. 2008;178:20–5.

This study estimates a 12% prevalence of sustained arrhythmias in general ICU patients. Ventricular arrhythmias increase the risk of death and the risk of neurological sequelae.

3.Trappe HJ, Brandts B. Arrhythmias in the intensive care patient. Curr Opin Crit Care. 2003;9(5):345–55.

A comprehensive review of the article

Website

1.circ.ahajournals.org

American Heart Association website with downloadable guidelines