Bradycardia - ACLS Review

all right you guys welcome back to another video lesson from icu advantage my name is eddie watson and my whole goal with this channel is to try to give you guys the confidence to succeed in the icu by taking these complex critical care subjects and breaking them down and making them easy to understand for you guys i hope that i'm able to do just that and if so and you'd be interested in more videos like this then make sure and subscribe to the channel below hit that bell icon that way you never miss out on a new lesson so in this lesson here we are going to continue our review of the american heart association acls algorithms and this time we are specifically going to be talking about the bradycardia algorithm very important distinction here is that this is going to be bradycardia with a pulse if it's a brady rhythm and you have no pulse then you're going to follow the cardiac arrest algorithm which we just discussed in the last lesson now while bradycardia basically is going to be any heart rhythm with a rate that's less than 60 beats per minute what we're most concerned with with this algorithm are going to be our symptomatic bradycardic patients and these patients are typically going to have a heart rate that's less than 50 beats per minute and they're going to elicit specific symptoms in our patient so we're looking specifically for a slow rhythm with specific symptoms that we would associate with that slow rhythm so once again if we have this present in our patient we have a systematic approach to handling this situation which is what we're going to talk about in this lesson here all right so when we're talking about symptomatic bradycardia what we're really talking about is a brady rhythm in our patient that is not providing adequate perfusion thus this is producing the symptoms that's associated with it now if our patient has adequate perfusion then we want to just monitor them for any signs of change and then the development of any of these symptoms which would then lead us into this algorithm now the very first thing we need to do is to really assess the necessity and the appropriateness of using this algorithm and so essentially what this means here is we're assessing whether or not our patient is bradycardic so typically less than 50 beats per minute and do they have associated symptoms with it now some of the typical rhythms that we're going to see associated with symptomatic bradycardia are going to be things like sinus bradycardia first degree av block second degree av block this includes both our mobitz type one or winky block and our mobitz type ii our third degree av block also known as our complete heart block and our junctional and ventricular rhythms so again it's imperative that you guys are able to assess these and pick these up on a monitor for your patient so again i'm going to link above to the series that i already did covering our ecg rhythms and the interpretation of those so if you need more help please follow that link and watch those videos now once we've established that it's appropriate to be using this algorithm then we want to progress in but keep in mind that it's always going to be our priority that we are looking to identify and treat the underlying causes of the bradycardia now keeping that priority in mind there are a few things at this point we need to make sure that we're doing for our patient so you got to make sure that their airway is patent and you want to be assessing their breathing you're going to want to provide oxygen if they're hypoxic make sure you're monitoring ecg blood pressure and your oxygen saturation really important here make sure you have good iv access and then if you have the time and you're able to you want to get a 12 lead ecg but again don't delay therapy in order to obtain this now from here moving along in the algorithm we want to actually assess our patient's persistent bradycardia and then what if any impact that this is having on our patient's perfusion now this is often going to be what is referred to as whether or not they are quote unquote unstable and so signs of this are really going to be bradycardia that's causing the following hypotension so is your map less than 60 or your systolic blood pressure less than 90 an altered level of consciousness and this is really that decreasing mentation that's really resulting from decreased perfusion to the head signs of shock so these are cool clammy skin pale skin cyanosis rapid breathing weakness and fatigue nausea vomiting is a patient having any ischemic chest discomfort and or acute heart failure now if none of these are present in your patient then at this point we're just going to want to continue to monitor and observe our patient but if any of these are present then we're going to need to act and move through this algorithm now our very first intervention is going to be to administer a medication called atropine and our dose here is going to be 1 milligram iv push now the dose used to be 0.5 milligrams but this was actually updated in 2020 by the aha so the new recommendation is one milligram this dose can be repeated every three to five minutes for a maximum dose of three milligrams which in this case is going to be three doses now now it is important to know though that the way atropine works is by increasing activation of both the sa and the av nodes now if your patient is in a third degree heart block that this medication is going to be useless it's also going to be less effective with some of our second degree blocks as well now atropine can also have negative effects if the bradycardia is the result of an acute mi and the reason for this is that atropine is going to increase the heart rate which is going to increase the workload on the heart and thus increasing myocardial oxygen consumption not a good thing with your patients having an mi now all that said if atropine is either ineffective or it's not indicated in your patient then we need to move on and either electrically or chemically paste them at this point now here when i'm talking about electrically pacing what i'm talking about is our transcutaneous pacing and here we're going to deliver electrical energy via pads on the patient's chest with the goal of stimulating the heart to contract now the transcutaneous patient is actually going to be the preferred treatment for patients with the acute mi as well as potentially for patients who are very unstable that said in the time it takes to get the defibrillator ready and to pace a patient a dose of atropine can often be given in that same time now please do remember though that this is often painful for the patient and so you're going to want to have analgesic and sedation available if the patient is going to be able to tolerate it but oftentimes they may not be able to initially so you may need to actually start the pacing then administer those now our other option to electrically pacing a patient is to chemically pace them and this is going to be use of either of the following medications really to help increase our patients heart rate while also supporting their blood pressure and from the aha this is considered an equally effective alternative to transcutaneously pacing now we have two medication options to choose from the first one is going to be dopamine and then the other one is going to be epinephrine now the dopamine is going to be our first line of choice if the atropine is ineffective now also updated in 2020 is going to be the dosa dopamine is now recommended to be 5 to 20 micrograms per kilogram per minute and then we want to titrate it to our patient's response and then taper the medication slowly now important to remember these new changes because the old recommendation used to be 2 to 20 micrograms per kilogram per minute but this is the new recommendation updated in 2020 again by the american heart association now the other medication here that can be used as an alternative to dopamine is going to be our epinephrine and i actually just did a whole lesson talking about all the different specific critical care uses of epinephrine so i'm going to link to that here if you guys haven't watched that but here our dose is going to be 2 to 10 micrograms per minute and again titrating to the patient's response and tapering slowly and then finally from here we want to consider the expert consultation from a cardiologist and if our patient is really persistent in this bradycardia and requiring additional doses of atropine or continuous pacing or continuous medication for their heart rate then at this point we might want to consider something like a transvenous pacer instead and possibly preparing for a trip to cath lab so as you can see the algorithm here for bradycardia is actually pretty simple and the biggest thing is whether or not the bradycardia is causing decreased perfusion for our patients and if so then we need to act with either medication starting with atropine as well as progressing to dopamine and epinephrine if needed or using electricity and transcutaneously pacing them now important aside here many people are really not comfortable with pacing via the defibrillator so i highly suggest that you take the time and learn how to quickly get into the mode of pacing and to make adjustments to the settings so that you're not fumbling around with this when the time comes and you actually have to do this on your unstable patient otherwise though that was our review here for the bradycardia algorithm i really hope that you guys like it i really hope that this lesson helped to solidify the information and cement the knowledge of this algorithm again it's really important that you guys are able to quickly act on this and quickly move through the algorithm especially when your patient is unstable if you guys did like the lesson please leave me a like down below as well as leave me a comment as always i love reading your comments and responding to you guys i try to respond to just about everybody out there make sure and also share this lesson with other people you think might find it useful and if you haven't subscribed already make sure and do so as well a special shout out to our awesome youtube and patreon members out there the support that you guys are willing to show for this channel really means the world to me and it's going to continue to allow me to do bigger and better things for this channel in the future now for the rest of you guys if you'd be interested in showing additional support for this channel then you can join the youtube membership down below or head on over to the patreon page and check out some of the additional perks that you guys get for doing just that you can also support this channel through the links down in the description as well as checking out some of the awesome shirt designs that i have down there as well make sure you stay tuned for the next lesson in this series otherwise in the meantime check out a couple really awesome lessons i'm a link to right here as always thank you guys so much for watching have a great day

Channel: ICU Advantage

Views: 300,687

Keywords: bradycardia, symptomatic bradycardia, atropine, ACLS, advanced cardiac life support, bradycardia algorithm, ACLS Algorithms, ACLS review

Id: jYjdUhfNTPw

Length: 10min 49sec (649 seconds)

Published: Mon Feb 08 2021