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Bradycardia (Peri-Arrest)

Resuscitation Council UK Adult Advanced Life Support Guidelines. Published: May 2021.

Guidelines

The first step is to check ANY of the life-threatening features or not:
  • Shock – hypotension (SBP < 90 mmHg) and/or features of sympathetic compensation
  • Syncope – due to ↓ cerebral blood flow
  • Myocardial ischaemia – chest pain and/or 12-ECG findings
  • Heart failure – pulmonary oedema (LV failure) and/or raised JVP (RV failure)

Note this is the same as adult peri-arrest tachycardia algorithm.
 

  • 1st line: atropine 500mcg IV
    • Repeat every 3-5 min, up to 6 doses (3mg)
 
  • If ineffective: consider 2nd line drugs
    • Isoprenaline
    • Adrenaline
 
  • If drugs ineffective:  transcutaneous pacing
  • If ineffective:  transvenous pacing
 

DC shock has NO role in bradyarrhythamis, even if the patient is unstable DC shocks are reserved for tachyarrhythmias.

Consider aminophylline if any of the following:
  • Bradycardia secondary to inferior MI
  • Bradycardia secondary to spinal cord injury
  • Patients with history of  cardiac transplant

Consider  glucagon if bradycardia potentially caused by:
  • Beta blockers, or
  • Calcium channel blockers

First assess risk of asystole:
  • Recent asystole
  • Second degree Mobitz II AV block
  • Complete heart block with broad QRS
  • Ventricular pause > 3 sec

Subsequent action:
  • Yes → proceed as life-threatening features are present
  • No → observe
 

Guidelines for stable (non-life threatening) bradycardia is less clean cut and clear. In exams, stable bradycardia is rarely asked unlike unstable bradycardia and tachycardia (both stable and unstable).

References

 
Author: Adams Lau
Reviewer:
Last edited: 28/07/25