NHS FORTH VALLEY Management of Symptomatic Bradycardia in ...

NHS FORTH VALLEY

Management of Symptomatic Bradycardia
in Forth Valley Royal Hospital

Date of First Issue 25/ 01 /2016

Approved 06/ 08 /2015

Current Issue Date 25/ 01 /2016

Review Date 25/ 01 /2017

Version 1

EQIA Yes 25 / 01 / 2016

Author / Contact Dr Catherine Labinjoh

Group Committee – Cardiology Management Group

Final Approval

This document can, on request, be made available in alternative formats

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Definition
Symptomatic bradycardia: a bradyarrhythmia responsible for the development of syncope
or near-syncope, transient dizziness or light-headedness, or confusional states. There
should be good correlation of symptoms with the bradycardia before embarking on
treatment.

General Principles
All patients in whom symptomatic bradycardia is noted or suspected should have
continuous ECG monitoring. The treatment of bradycardia depends on the severity of the
symptoms and the underlying rhythm. Unstable patients require immediate intervention.
Symptomatic patients should be supervised when moving from bed to chair or bathroom.
Asymptomatic patients do not usually require urgent intervention.

 Patients presenting with sinus node disease rarely need urgent temporary pacing
as the risk of prolonged asystole is very low although pauses > 3secs may be
noted.

 Patients presenting with symptomatic bradycardia and significant AV node disease
are at risk of asystole. Where there is haemodynamic compromise patients should
have prompt therapy.

 STEMI patients are usually managed in tertiary centres. Where a patient has
bradycardia and AV block complicating MI (especially anterior MI) should they
should be discussed with a cardiologist locally or within a tertiary centre, even in the
absence of symptoms.

Guideline
1. ABC, iv access, 02. Resuscitation Protocols if appropriate.
2. 12 lead ECG and cardiac monitoring.
3. Consider underlying cause (drugs, myocardial ischaemia, hypothyroidism).
4. Place of safety
a. If symptoms resolve and haemodynamically stable admit to Cardiology
Ward/Monitored bed
b. If still symptomatic and/or haemodynamically compromised admit to
Cardiology Bed within Critical Care whilst considering the following
5. Atropine (500 mcg increments up to 3mg total).
6. Isoprenaline infusion: See FVRH Critical Care Unit for protocol.

2mg isoprenaline diluted in in 500ml 5% glucose(=4mcg/ml).
Start at a rate of 1 microgram/minute (15ml/hr) titrating up in steps of 1
microgram/minute at intervals of 2-3minutes, until a satisfactory heart rate is
achieved or adverse effects such as hypotension or ventricular arrhythmias
occur (Usual max: 10 micrograms/min = 150 ml/hr).
If symptoms/compromise persist prepare for Transcutaneous Pacing (see below
- patient may require sedation) and discuss with cardiologist locally or at tertiary
centre.

Temporary Pacing

Temporary pacing (cutaneous/transvenous) should be considered where conservative
therapy has failed in asystole, second or third degree AV block with
symptoms/haemodynamic compromise and in ventricular tachyarrhythmias consequent
upon bradycardia.

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Within Forth Valley temporary transcutaneous pacing (TCP) is available in the emergency
department, cardiology unit, critical care unit and in theatres. Patients may require
sedation to facilitate tolerance of TCP.

Temporary transvenous pacing (TVP) can be provided within critical care. TVP should
only be attempted by an operator experienced in the technique. Advice concerning
TVP should be sought from the on call cardiologist or on call physician. Where a local
operator is unavailable but TVP is thought necessary by the responsible physician the
patient should be discussed with Edinburgh Royal Infirmary (0131 536 1000 – ask for on
call cardiology registrar).

References

SIGN Guideline 94 (Ischaemic heart disease)
Heart 2000;83:715–720
Circulation. 2005;112:IV-67 – IV-77.

Publications in Alternative Formats
NHS Forth Valley is happy to consider requests for publications in other language or
formats such as large print.
To request another language for a patient, please contact 01786 434784.
For other formats contact 01324 590886,
text 07990 690605,
fax 01324 590867 or
e-mail - [email protected]

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