Treatment of Bradycardia

Treatment of Bradycardia

1. Treatment of Bradycardia Dan Stevens

2. Types of Bradycardia Sinus Drugs Athletes Increased Vagal tone Sick Sinus syndrome SA node disease Sinus puase / arrest, Tachy-brady syndrome Atrioventricular 1 st Degree 2 nd degree Mobitz I (wenchebach), Mobitz II 3 rd Degree Complete HB

3. Causes Ischaemic / infarction related Neurocardiogenic – reflex mediated Toxicology Ca channel blockers, B-blockers Metabolic Hyperkalaemia Endocrine Hypothyroidism Environmental Hypothermia Infections with cardiac involvement Lyme Disease Chagas disease

4. Treatment Options Treat Cause Stable Vs Unstable Do Nothing Medications Transcutaneous Pacing Pacing Wire / PPM

5. Evidence For Treatment?? Not much Difficult patient group to study Guidelines based on expert opinion

6. Drugs Atropine Competitive antagonist of acetylcholine at muscarinic receptors Increased HR (by reducing vagal tone) 400mcg up to 3mg Useful in vagally mediated bradycardia or possibly very high blocks Often no use in complete HB

7. Drugs Adrenaline (preferred chronotrope ) Non selective alpha and B agonist Increased blood pressure and HR 2-10 mcg/ min Isoprenaline Selective, potent B agonist (B1 ) Risk of hypotension (No alpha effect & B2 agonist) Positive inotrope, positive chronotrope 1-4 mcg/ min Dopamine 2-10 mcg/kg/min

8. Transcutaneous Pacing Place pads in AP position Connect ECG leads Set Defibrillator to Pacing mode Set rate (>30bpm than currently, normally 70) Sedation!! Start pacing and increase current until ‘capture’ Electrical capture  QRS and T wave after each pacing spike Mechanical capture  central pulse Current fixed at 10 mA (or ~20%) above level of capture If reach 130mA and no capture try changing paddle position

9. Cardiology Temporary Pacing wires / Transvenous Pacing Central venous access (right IJV) Catheter with pacing wire slowly inserted until capture Permanent Pacemaker

10. Summary Investigate and treat cause Atropine up to 2mg (in selected pt’s ) Adrenaline infusion Transcutaneous pacing Sedation Rate 70 Current 10 mA (or ~20%) above level of capture Early c ardiology referral for transvenous pacing wire / PPM