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Lesson

Symptomatic Bradycardia

10 min Cardiac & ECG Skip to quiz

Objective: Treat symptomatic bradycardia as a perfusion problem. Put the pads on early for high-grade block. Do not wait for another dose of atropine if the patient is unstable.

Why this matters

Check for a pulse, then check perfusion. A slow rate on the monitor is not automatically atropine. A well-perfused 55-year-old at 48 from a beta-blocker is not the same patient as a mottled, hypotensive complete heart block at 32. Unstable means hypotension, altered mental status, shock, ischemic pain, or acute heart failure caused by the slow rate. Do not treat a number under 60 when the patient is well perfused.

Clinical sequence

  1. Check for a pulse. No pulse with organized slow complexes is PEA (pulseless electrical activity), not “stable bradycardia.”
  2. Protect the airway, breathing, and circulation. Give oxygen if the oxygen saturation is low. Get a 12-lead when you can. Start an intravenous line. Put the pads on early.
  3. Name the rhythm with your systematic approach: sinus bradycardia, a block, or an escape rhythm.
  4. If they are unstable from bradycardia, use atropine and transcutaneous pacing (TCP) per protocol. High-grade blocks, Mobitz II and complete block, often need pacing ready even if you try atropine. Atropine often fails when the block is below the atrioventricular (AV) node.
  5. Look for the cause: ischemia, drugs, electrolytes, recent return of spontaneous circulation (ROSC, pulses back), or an athlete’s usual slow rate. Treat reversible causes you are authorized to treat.

Key points

  • Do not delay TCP in an unstable complete block to see if atropine works one more time.
  • If the patient is awake, give sedation and pain control for pacing only if protocol allows it.
  • This lesson does not authorize doses. Protocol owns atropine, pressors, and pacing output.
Verbalize
  • Is there a pulse? If not, treat PEA or arrest.
  • Is perfusion failing because of the rate?
  • Name the rhythm: sinus bradycardia, a block, or an escape rhythm.
  • Pads on and TCP ready, especially for Mobitz II or complete block.

Common errors

  • Treating a sleeping, well-perfused patient only because the rate is under 60.
  • Calling PEA “bradycardia” because the complexes look organized.
  • Leaving the pads off a patient with Mobitz II who looks okay right now.

Practice

One-minute check

In CardioStrip Learn mode, open a complete heart block, and a Mobitz II tracing if you have one. Say whether there is a pulse, whether perfusion is poor, whether the pads are on, and that atropine may fail here so pacing should be ready per protocol.

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.

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.

1. Symptomatic / unstable bradycardia is defined by:
2. Organized slow complexes with no pulse should be treated as:
3. For Mobitz II or complete block with instability, you should:
4. A well-perfused adult with rate 52 who is talking normally:
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