Symptomatic Bradycardia

Why This Is Hard

Bradycardia on the monitor is not automatically atropine. A well-perfused 55-year-old at 48 from a beta-blocker is not the same as a mottled, hypotensive complete block at 32. Instability is clinical — hypotension, AMS, shock, ischemic pain, acute failure — caused by the rate.

Street Sequence

1. Pulse? No pulse with organized slow complexes is PEA, not “stable brady.”
2. ABCs, oxygen as indicated, 12-lead when feasible, IV, pads on early.
3. Name the rhythm with your systematic approach (sinus brady vs block vs escape).
4. If unstable from bradycardia: atropine and transcutaneous pacing per protocol. High-grade blocks (Mobitz II, complete) often need pacing readiness even if atropine is tried — atropine may fail at infranodal sites.
5. Cause hunting: ischemia, drugs, electrolytes, post-ROSC, athlete baseline. Treat reversible causes you are authorized to treat.

Key Points

• Do not delay TCP in a crashing complete block to “see if atropine works one more time.”
• Sedation/pain control for conscious pacing per protocol.
• This lesson does not authorize doses. Protocol owns atropine, pressors, and pacing energy.

Field Pitfalls

• Treating a sleeping, well-perfused patient because the rate is under 60.
• Calling PEA “bradycardia” because complexes look organized.
• No pads on a Mobitz II who “looks okay right now.”

Practice

Related: AV Blocks: Three-Question Path, PEA: Without a Pulse.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

• AHA 2025 adult bradycardia / ACLS education
• Unstable bradycardia is a perfusion problem. Do not delay pacing in high-grade block. Protocol owns atropine and TCP.