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Differential Diagnosis

  • Mnemonic: HE DIES
    • Hypothyroidism
    • Elevated intracranial pressure (ICP)
      • Cushings reflex
        • Bradycardia
        • Increased blood pressure
        • Irregular breathing
    • Drugs
      • Beta blockers
      • Calcium channel blockers
      • Digoxin
    • Ischemia
    • Electrolytes
      • Especially potassium!!!
    • Sick Sinus Syndrome

Approach to Bradycardia

  • Step 1: Get an EKG
    • Ischemia?
    • Heart block?
      • 1st degree = PR interval >200ms (5 small boxes)
      • 2nd degree type 1 = PR gradually prolongs until dropped beat
      • 2nd degree type 2 = Intermittent dropped beats
      • 3rd degree = None of the atrial beats result in a ventricular beat
    • Evidence of hyperkalemia?
  • Step 2: Determine if patient is SYMPTOMATIC
    • Hypotension
    • Chest Pain
    • Syncope
    • Lightheadedness
    • Note: Many patients have benign and asymptomatic resting bradycardia (I’ve seen as low as 30s!) and this does not necessarily require aggressive treatments/IV medications
  • Step 3: If patient is having symptoms… Give atropine!
    • Typical dose is 0.5mg IV atropine
  • Step 4: If patient still having symptoms… Give epinephrine!
  • Step 5: If patient still having symptoms… Cardiac pacing!
    • If symptoms are minimal or resolved, patient can sometimes wait for permanent pacemaker with cardiology
    • Transcutaneous pacing
      • Sometimes difficult to get mechanical capture
    • Transvenous pacing
      • Place through the right internal jugular vein

Additional Reading