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Heart block, atrioventricular nodal bradycardia.
1. Maintaining an adequate level of perfusion.
2. Treatment aimed at addressing one of the root causes of bradycardia:
a) hypoxia
b) shock
c) atrioventricular block of the second or third degree;
d) exposure to toxins (beta-blockers, calcium channel blockers, organophosphorus compounds, digoxin);
e) electrolyte imbalance;
f) hypoglycemia;
g) increased intracranial pressure;
h) other.
1. Heart rate below 60 beats per minute and the presence of one of the following symptoms (impaired consciousness, chest or sternum pain, signs of heart failure, syncope, shock, pallor, excessive sweating, or signs of hemodynamic instability.
2. The main ECG rhythms that are classified as bradycardia include the following:
a) sinus bradycardia;
b) atrioventricular block of the 2nd degree:
c) atrioventricular block of the 3rd degree;
d) rhythmic ventricular extrasystole.
3. Additional inclusion criteria for pediatric patients are given below.
No recommendations.
1. Control of airway patency (if necessary).
2. Conducting (if necessary) oxygen therapy to achieve a saturation rate of 94-98%.
3. Start monitoring the condition and ECG in 12-leaders.
4. Provide intravenous access.
5. Check blood glucose levels and treat hypoglycemia according to the Hypoglycemia and Hyperglycemia guidelines.
6. Consider the following therapies if hemodynamic instability persists:
a) atropine 0.5 mg IV at 3-5 minute intervals (maximum dose – 3 mg);
b) vasopressors (in order of preference from best to worst):
OR
Prepare a 10 μg/mL solution by adding 1 mL of 0.1 mg/mL epinephrine to 9 mL of saline, then administer 10-20 μg bolus (1-2 mL) every 2 minutes until mean arterial pressure rises above 65 mmHg.
OR
c) percutaneous pacing – when performing this procedure, remember to use sedatives or analgesics.
Only patients with appropriate symptoms (pale/blue skin, excessive sweating, impaired consciousness, hypoxia) require treatment.
1. Begin chest compressions if the pulse is less than 60 and there are signs of poor perfusion (impaired consciousness, hypoxia, hypotension, weak pulse, prolonged capillary refill time, cyanosis).
2. Monitor airway patency and perform artificial ventilation with minimal interruptions between chest compressions at a rate of 15:2 (30:2 if there is only one rescuer).
3. Provide supplemental oxygen to achieve a saturation rate of 94-98%.
4. Start monitoring and perform a 12-lead ECG.
5. Provide intravenous access.
6. Check glucose levels and treat hypoglycemia according to the Hypoglycemia guideline.
7. Consider the following therapies if bradycardia and symptoms or hemodynamic instability persist:
a) epinephrine in a shock dose (dissolved in saline). Prepare a 10 μg/ml solution by adding 1 ml of 0.1 mg/ml epinephrine to 9 ml of saline, then administer 0.01 mg/kg bolus (0.1 ml/kg) at a maximum dose of 10 μg (1 ml) every 3-5 minutes until the mean arterial pressure rises above 65 mmHg;
b) atropine 0.01-0.02 mg/kg IV with a minimum dose of 0.01 mg in case of increased vagal tone or cholinergic crisis and a maximum single dose of 0.5 mg (maximum dose -3 mg) is also possible;
c) percutaneous pacing – when performing this procedure, remember to use sedatives or analgesics;
d) epinephrine can also be used in case of bradycardia and poor perfusion, which does not improve after additional oxygen therapy.
Bradycardia caused by increased vagal tone or cholinergic crisis is the basis for atropine administration.
Percutaneous pacing – when performing this procedure, remember to use painkillers and sedatives.
1. Look for signs of decreased perfusion of internal organs: chest pain, dyspnea, confusion, loss of consciousness, and/or other signs of shock/hypotension.
2. In patients who have undergone heart transplantation, there is no response to atropine.
3. Be aware of the harmful effects of an overdose of drugs such as beta-blockers, calcium channel blockers, antidepressants/sodium channel blockers, digoxin, clonidine. If an overdose is suspected, follow the instructions in the Toxicants and the Environment section.
4. Differential diagnosis includes: myocardial infarction, hypoxia, malfunction of an artificial pacemaker, hypothermia, sinus bradycardia, bradycardia typical of athletes, TBI with increased intracranial pressure, stroke, spinal cord injury, sinus node weakness syndrome, overdose, cholinergic substances with nerve-paralytic action.
5. Hyperkalemia is possible in patients with persistent and severe bradycardia.
6. Bradycardia should be treated by the least invasive means, with treatment intensification only if necessary:
a) in case of 3rd degree heart block or denervation of the heart (as in the case of an artificial pacemaker), there may be no response to atropine, and in such cases, use chronotropic drugs (e.g., dopamine or epinephrine) or percutaneous pacing;
b) dopamine should not be used in pediatric patients;
c) in case of increasing hemodynamic instability, immediately initiate percutaneous pacing.
7. Remember that acute coronary syndrome can cause bradycardia in adult patients.
8. When calculating the dose for pediatric patients, the dose should be based on weight for non-overweight patients and on ideal weight for overweight patients.
9. Despite the fact that dopamine is often recommended as a treatment for symptomatic bradycardia, according to recent studies, patients with septic or cardiogenic shock treated with norepinephrine have a lower mortality rate than patients treated with dopamine.
10. WARNING: Norepinephrine can theoretically cause reflex bradycardia.
There are no recommendations..