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Priorities in Symptomatic Bradycardia

Question#: 570


The new symptomatic bradycardia medical directives highlight the importance of prioritizing TCP over IV placement. Does this imply that we should not be attempting an IV for atropine administration and proceed directly to TCP for patients that meet this directive ?



Thank you again for your MedicAsk question regarding symptomatic bradycardia. We have received quite a few inquiries due to the recent changes in the ALS PCS, and have recently met with the Medical Director's Team to discuss these concepts.
We certainly defer to your clinical judgement under these complex circumstances. If an intravenous can be obtained rapidly, it may be prudent to have access in anticipation of further interventions (i.e. analgesia, resuscitation). That said, if no veins are visible/palpable and the patient's presentation is acute, delaying transcutaneous pacing for multiple attempts may increase the risk of deterioration. As always, detailed comments in the remarks section help those further along in the circle of care to appreciate barriers and your thought process.

Of additional note, progressive bradycardia is a harbinger of death and often considered a peri-arrest situation. Immediate pad placement is of the upmost importance in these situations. Bradycardia also predisposes the patient to pause dependent arrhythmias and having pads on a patient is always a great idea.
Given the rhythms that are responsive to atropine, in a critically sick patient it is unlikely to be effective and thus stressing pad placement and pacing is important.

We hope that this assist you in your approach, but if you have any further concerns, do not hesitate to reach out for further discussion.


10 February 2022



Please reference the MOST RECENT ALS PCS for updates and changes to these directives.