The ACLS Bradycardia algorithm offers a systematic approach to managing slow heart rates during emergencies. By assessing the clinical significance of bradycardia and identifying atropine candidates, it continuously monitors and ensures assessment for timely interventions.

Healthcare professionals assess symptoms and make a decision about potential administration of atropine as a primary intervention. If atropine will not suffice or the patient is still in a critical condition, it becomes prudent to use the transcutaneous pacing as an option. During persistent bradycardia, a clinician can try sustainable solutions like prescription of dopamine or epinephrine infusions. Supervising and conducting intervention in time are essential for good patient recovery. Following is an algorithm flowchart for ACLS bradycardia

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Explanation of the flowchart

  1. Determine appropriateness for the clinical condition
    This step involves checking the heart rate. If it is less than 50 beats per minute, then it suggests bradyarrhythmia. This is a condition that is characterized by a slow heart rate.
  2. Find and treat the underlying cause
    This emphasizes maintaining an airway and assisting breathing whenever necessary

    • Administer oxygen when the patient is short of breath:Use a cardio monitor to monitor blood pressure and rhythm, and perform oximetry to evaluate oxygen saturation levels. Ensure a route to administer medications and fluids. Perform a 12-lead ECG without delaying therapy. This helps obtain an electrical view of the heart’s activity.


  3. Check for complications if there is persistent bradyarrhythmia
    Check whether persistent bradyarrhythmia is harmful and leads to complications such as hypotension, signs of shock, and altered mental status
  4. If complications exist, then offer atropine IV dosing
    If complications are present, then provide atropine as follows

    • First dose: Atropine 1mg
    • Repeat it every 3–5 minutes, up to a maximum of 3 mg
  5. If no complications exist, then monitor and observe
    If there are no complications, then closely monitor the patient and observe their response
  6. Interventions if atropine is ineffective
    If atropine fails to address the bradyarrhythmia, you must consider the following

    • Transcutaneous pacing: external electrical stimulation to increase the heart rate.
    • Dopamine IV infusion: administering dopamine intravenously at a rate of 5–20 mcg/kg per minute.
    • Epinephrine IV infusion: administering epinephrine intravenously at a rate of 2–10 mcg per minute
  7. Expert consultation and transvenous pacing
    Seek professional consultation for additional considerations and guidance.If required, consider transvenous pacing. This intervention involves placing a wire directly into the heart.

Key components of ACLS Bradycardia algorithm

  1. Assessment
    Assess the clinical significance of bradycardia and inspect the patient’s condition for potential complications.
  2. Identify atropine candidates:
    Target treating symptomatic bradycardia with altered chest pain, mental status, or hypotension. Ensure to intervene in unstable patients exhibiting poor perfusion or acute heart failure.
  3. Administration of atropine:
    Administer intravenous atropine in measures doses. The initial dose should be 0.5mg to 1mg. Repeat this every 3-5 minutes and up to a maximum of 3mg. Consider the interventions such as dual pacing if insufficient atropine response or high-level heart block.
  4. Transcutaneous pacing:
    Use transcutaneous pacing for patients despite atropine administration. View external pacing and address persistent bradycardia.
  5. Expert consultation:
    Seek guidance from cardiology. This is crucial if instability persists and is not achieved with interventions.
  6. Transvenous pacing:
    Consider transvenous pacing if atropine and external proves ineffective. Reserve for situations where bradycardia persists and leads to low cardiac output.
  7. Reassess and monitor:
    Continuously monitor heart rate, blood pressure and clinical status. Reassess the need for further intervention based on the evolving clinical condition. Down the flowchart to access ACLS Suspected Stroke Algorithm for immediate use

Download PALS ACLS Bradycardia algorithm PDF

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