Indications: Bradycardia and hemodynamic instability
Atropine: If the patient is ≥ 18 years of age, has a HR < 50 BPM and is hypotensive and does not have a history of heart transplant, is not allergic or sensitive to atropine and is not hypothermic administer 0.5mg Atropine IV.
If condition persists after 5 minutes repeat dose. A maximum of 2 doses of atropine may be administered.
Mandatory Patch Point: Contact your BHP for authorization to initiate transcutaneous pacing and/or dopamine infusion.
Transcutaneous Pacing: If the patient is ≥ 18 years of age, has a HR < 50 BPM and is hypotensive and is not hypothermic you may patch to BHP for authorization to utilize transcutaneous pacing.
Dopamine: If the patient is ≥ 18 years of age and has a HR < 50 BPM and is hypotensive and does not have an allergy or sensitivity to dopamine, and does not suffer from pheochromocytoma you may contact your BHP for authorization to infuse Dopamine at an initial rate of 5mcg/kg/min IV.
Titrate every 5 minutes by 5mcg/kg/min to a maximum infusion rate of 20mcg/kg/min.
Clinical Consideration: Atropine may be beneficial with sinus bradycardia, atrial fibrillation, 1st degree AV block, or 2nd degree Type 1 AV block.
A single dose of atropine should be considered for 2nd degree Type II or 3rd degree AV blocks with a fluid bolus while preparing for transcutaneous pacing (TCP) or if TCP is unsuccessful.
The dopamine infusion should be initiated at 5mc/kg/min and titrated upward to effect in increments of 5mcg/kg/min every 5 minutes to a maximum of 20mcg/kg/min. Your desired effect is a systolic BP of 90-110 mmHg.
- Administer 100% O2, manage airway and assist ventilations as required. Initiate cardiac monitoring and pulse oximetry (if available).
- Obtain 10 second cardiac strip to confirm rhythm.
- Establish IV access and administer IV fluids (if indicated as per protocol).
- If the patient is in a sinus bradycardia, atrial fibrillation, 1st degree or 2nd degree type I heart block:
o Administer atropine 0.5 mg IV.
o If the patient remains bradycardic and symptomatic after 3-5 minutes, repeat atropine 0.5 mg IV.
o If patient remains bradycardic and symptomatic patch to the BHP for consideration of further atropine or to initiate TCP. If every attempt to contact the BHP has failed and the patient is worsening the paramedic may initiate TCP. The paramedic should continue to attempt to contact the BHP.
- If the patient is in a 2nd degree type II or 3rd degree heart block:
- Do not administer atropine but initiate TCP then patch to BHP.
- TCP procedure:
- Place pacing pads as per the manufacturer’s guidelines.
- Set pacing rate at 80 and increase output (milliamps) slowly until electrical and mechanical capture is achieved. Increase further by another 5-10 milliamps to ensure consistent capture.
o If capture is unsuccessful after one minute at maximum milliamps, discontinue pacing attempts and consult BHP.
- If TCP is not available patch the BHP for consideration of dopamine.
- The paramedic may initiate dopamine infusion if systolic BP < 100 mmHg:
o Begin at 5mcg/kg/min and increase by 5mcg/kg/min every 3- 5 minutes, if required, to achieve a systolic BP of 100 mmHg, or a maximum of 20mcg/kg/min.
o If discontinuing dopamine electively, do so gradually. If the dopamine infusion goes interstitial, stop infusion immediately and report findings to the receiving hospital.