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ASSESSMENT ACTION Using the ACLS Bradycardia Algorithm for Managing Bradycardia
Is the patient's airway To open the airway for unconscious patients, use The ACLS Bradycardia Algorithm outlines the steps for
obstructed? the head-tilt, chin lift. Insert an oropharyngeal assessing and managing a patient who presents with symptomatic
airway (OPA) or a nasopharyngeal airway (NPA) if bradycardia. It begins with the decision that the patient's heart rate is
needed to keep the airway open. The oral airway is < 60 bpm and that is the reason for the patients symptoms.
ONLY indicated in patients who are deeply
unconscious as they stimulate the gag reflex and Steps
thus cause risk of aspiration.
Does the patient need If yes, use the airway that is appropriate to your 1. Decision: Heart rate is < 60 bpm and is symptomatic.
an advanced airway? skill level. King Airway, LMA, Combitube, and or
2. Assess and manage the patient using the primary and
endotracheal intubation.
secondary surveys:
Is the patient Give bag valve mask ventilations every 6 seconds
breathing? or 10 breaths per minute.
Maintain patent airway.
If bag-mask ventilation is adequate, defer the Assist breathing as needed.
insertion of an advanced airway until it becomes
Administer oxygen if oxygen saturation is less than
essential (patient fails to respond to initial CPR or
94% or the patient is short of breath
until spontaneous circulation returns).
Monitor blood pressure and heart rate.
Is the advanced Confirm correct placement of advanced airway Obtain a 12-lead ECG.
airway device placed device by observing the patient, confirming the Review patient's rhythm.
properly? presence of lung sounds in at least 4 lung fields Establish IV access.
and using waveform capnography.
Complete a problem-focused history and physical
Is the advanced Secure the advanced airway device so it does not
exam.
airway device secured dislodge, especially in patients who are at risk for
correctly? movement. Secure the ET tube with tape or a Search and treat possible contributing factors.
commercial device. Do not use devices to secure
the airway device that are circumferential. 3. Answer two questions to help you decide if the patient's signs
What was the Attach ECG leads. Identify patient's rhythm. and symptoms of poor perfusion are caused by the
patient's initial bradycardia (see Figure 2).
cardiac rhythm?
Are the signs or symptoms serious, such as
What is the patient's Monitor patient for arrhythmias or cardiac arrest
hypotension, pulmonary congestion, dizziness,
current cardiac rhythms (ventricular fibrillation, pulseless
shock, ongoing chest pain, shortness of breath,
rhythm? ventricular tachycardia, asystole, and PEA).
congestive heart failure, weakness or fatigue, or
Does the patient need Establish IV or IO access.
acute altered mental status?
an IV?
Does the patient need Start IV/IO fluids, if needed, using a crystalloid. Are the signs and symptoms related to the slow
fluid? heart rate?
Does the patient need Give appropriate medications to manage rhythm 4. There may be another reason for the patients symptoms other
medications for (eg, amiodarone, lidocaine, atropine) and blood than the slow heart rate.
rhythm or blood pressure (eg, Dopamine or Epinephrine (used with
pressure control? caution as it increases myocardial oxygen
demand).
Is a reversible cause Search for reversible causes of the arrest. Find and
responsible for the treat reversible causes of the arrest.
arrest?
The higher the rate, the more likely the symptoms are a
result of the tachycardia. Underlying heart disease or other problems 1. Start an IV.
can cause symptoms at lower heart rates. Keep in mind the following 2. Give sedation if the patient is conscious.
considerations: 3. Do not delay cardioversion.
4. Consider expert consultation.
If you determine that the patient has a stable tachycardia, start an Patient has Treatment
IV and obtain a 12-lead ECG
Wide (> 0.12) QRS complex
For a patient with a stable tachycardia, decide if the QRS
complex is wide or narrow and if the rhythm is regular. Irregular rhythm Seek expert consultation
Patient has Treatment If pre-excited atrial fibrillation Avoid AV nodal blocking agents such
(AF + WPW) as adenosine, digoxin, diltiazem,
Narrow Try vagal maneuvers verapamil
(< 0.12 sec) QRS
If recurrent polymorphic VT Seek expert consultation
complex
If torsades de pointes Seek expert consultation
Regular rhythm Give adenosine 6 mg rapid IV push
Situation Assessment and Actions The patients QRS is narrow Consider an expert consultation.
(<0.12 sec)
Patient has significant signs or The tachycardia is unstable.
symptoms of tachycardia and they Immediate cardioversion is The patients rhythm is irregular. Control patients rate with
are being caused by the arrhythmia, indicated. diltiazem or beta-blockers. Use
beta-blockers with caution for
Patient has a pulseless ventricular Follow the Pulseless Arrest patients with pulmonary disease
tachycardia. Algorithm Deliver unsynchronized or congestive heart failure.
high-energy shocks.
Patient Treatment
Steps for Managing Stable Tachycardia
Patients rhythm has wide (>0.12 Expert consultation is advised.
Does the patient have a pulse? sec) QRS complex and patients
rhythm is regular.
Yes, the patient has a pulse. Complete the following:
1. Assess the patient using the primary and secondary patient is in ventricular tachycardia Amiodarone 150mg IV over 10 min
surveys. or uncertain rhythm. repeat as needed to maximum dose
of 2.2g in 24 hours. Prepare for
2. Check the airway, breathing, and circulation elective synchronized cardioversion.
3. Give oxygen and monitor oxygen saturation. Patient is in supraventricular Adenosine 6mg rapid IV push if no
tachycardia with aberrancy. conversion. Give adenosine 12mg
4. Get an ECG.
rapid IV push, may repeat 12mg
5. Identify rhythm. dose once.
6. Check blood pressure. Patients rhythm has wide (>0.12) Seek expert consultation.
QRS complex and patients rhythm is
7. Identify and treat reversible causes. irregular.
Is the patient stable? if pre-excited atrial fibrillation (Atrial Avoid AV nodal blocking agents such
Fibrillation in Wolff-Parkinson- as adenosine, digoxin, diltiazem and
Look for altered mental status, ongoing chest pain, hypotension,
White-Syndrome) verapamil.
or other signs of shock.
Consider Amiodarone 150mg IV over
Remember: Rate-related symptoms are uncommon if heart rate is <
10 min
150 bpm.
Patient has recurrent polymorphic Seek expert consultation.
Yes, the patient is stable. Take the following actions:
VT.
1. Start an IV.
If patient has torsades de pointes Give magnesium (load with 1-2g
2. Obtain a 12-lead ECG or rhythm strip. rhythm on ECG over 5-60 min, then infuse
Patient Treatment Caution: If the tachycardia has a wide-complex QRS and is stable,
consult with an expert. Management and treatment for a stable
The patients QRS is narrow and Try vagal maneuvers. Give adenosine
tachycardia with a wide QRS complex and either a regular or
rhythm is regular, 6mg rapid IV push. May repeat
irregular rhythm should be done in the hospital setting with expert
12mg dose of adenosine once.
consultation available. Management requires advanced knowledge of
ECG and rhythm interpretation and anti-arrhythmic therapy.
Considerations: