Card Set Information
ACLS Provider Manuel 2006
What are the main players in symptomatic brady?
Trancutaneous Pacing / Transvenous Pacing
Patient presents with HR < 60.
WHAT IS THE KEY TO MANAGEMENT?
Is the patient having SYMPTOMS caused by bradycardia?
Ssx of bradycardia
Hypotensive or orthostatic hypo
Pulm congestion/edema (on cxr or exam)
Freq PVC, VT
patient has HR < 50, and altered....
: open? head tilt and chin lift
: adequate? need to intubate? put on bag mask
pt has trach..is it plugged?
put pt on monitor, check for working IV access
pt HR < 60, altered
ABC's intact, now what
Check monitor: what kind of brady is pt in?
*if sinus brady or 1st degree block:
give Atropine 0.5 mg IV (rpt 3-5 min, up to 3 mg, 6 doses)
if 2 degree Mobitz Type II AV block or 3 degree block,
pt HR < 50, altered...
1st doses of Atropine not working...
start pacing or if still waiting for pacer
consider INFUSIONS of epi or dopamine
at 2-10 micrograms/min infusion.
Pt HR < 50, altered
Atropine, Epi and Dopamine not working
Get that TCP started!
Call cardiology for consult on TransVenous pacing.
How do you know?
Check for improved clinical status.
Second, improved heart rate.
Patient not HR 65 on TCP.
More alert, no CP.....
You win :)
Why is symptomatic brady dangerous?
These pt are PRE-CARDIAC ARREST!
When the HR falls, the unstable ventricle may have escape rhythms that often fails to drugs.
Ventricle rhythms can become WIDE COMPLEX and turn into VT/VF then ASYSTOLE.
What is the first line Tx in pts with symptomatic bradycardia without evidence of heart blocks?
Symptomatic Brady first line treatment
Atropine 0.5 mg IV q 3-5 min
May repeat x 6 doses for max of 3mg.
What are Unstable pt with symptomatic Brady?
WHat are these first line tx?
Unstable Pts are
2nd Degree Mobitz type II AV block
3rd Degree AV Block
Must start TCP first.
Atropine wont help (pt has heart blocks, increasing HR wont do no good)
Atropine Precaution in
ACS or AMI pts.
These pts have injured myocardium.
Atropine will increase HR and worsen ischemia.
is really the tx of choice.
Atropine just buys you time.
What does TCP do?
TCP paces the heart, like a temporary pacemaker.
TCP delivers pacing impulses to heart thro skin using cutaneous electrodes.
Indications for TCP
*Hemodynamically Unstable Brady Pts
(decrease BP, altered, angina, pulm edema)
*High degree heart blocks
(2nd degree Mobitz II or 3rd degree AV blocks)
*New L, R or alternating BBB
*Sympt Brady with Ventricular Escape Beats
Always give what with TCP
Pain meds or Benzos in stable pts
TCP: How do you do it?
1. Place electrodes
2. Turn on
3. Set demand rate 60/min (can adjust)
4. Set current output
: 2mA above dose where consistent capture observed
Where should you not check for TCP capture?
Do not check carotid pulse for TCP capture.
Electrical stimulus can cause muscle jerks that look like a pulse.
Standby TCP pacing for
Anticipate clinical DETEROATION in pts with AMI and
*Asympt 2nd degree Mobitz II and 3rd degree AV block
*New L, R or alternating BBB
*bifascicular blocks in setting of AMI.
Brady tx in a nutshell
2. Does pt have ssx of adequate perfusion? Brady causing these symptoms?
If no and no worrisome EKGs
If yes with worrisome EKGs
if yes with no worrisome EKGs
Atropine 0.5 mg IV q 3-5 min, up to 3mg
consider adding Epi or Dopamine if above fail or still waiting for TCP
dose (2-10 microgram/kg/min)
Cardiac consult for
Trans Venous Pacing