Symptomatic Bradycardia — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

🎓 Want to practice? Do a case challenge with this pathway → (get a case, choose management step by step, scored).

Full pathway

1. [Decision] Cardiorespiratory compromise?
   Bradycardia (HR <50) with cardiorespiratory compromise? (Assess whether symptoms are caused by the slow rate. ABC, oxygen (if hypoxemic), ECG monitoring, IV access, 12-lead ECG; find and treat the cause (H's & T's — hypoxia, drugs [beta-blocker/calcium-channel blocker/digoxin], electrolytes [hyperkalemia], ischemia, vagal). Compromise = hypotension, acute altered mentation, signs of shock, ischemic chest pain, acute heart failure.)
   • Compromised (unstable) → Unstable → atropine / pacing
   • No compromise (stable) → Stable · observe & treat cause
2. [End] Stable · observe & treat cause
   Stable, well-perfused: monitor and observe, identify and treat the cause (stop bradycardic drugs, correct electrolytes/hypoxia/ischemia); cardiology assessment if needed.
3. [End] Unstable → atropine / pacing
   1) Atropine 1 mg IV, repeat every 3–5 min, max total 3 mg (first-line; most effective for vagal or AV-nodal-and-above block). 2) Atropine ineffective → transcutaneous pacing and/or dopamine 5–20 µg/kg/min or epinephrine 2–10 µg/min infusion, titrated. 3) Mobitz II, third-degree AV block, or new wide QRS — atropine is usually ineffective, go straight to transcutaneous pacing or a beta-adrenergic infusion. 4) Expert consultation, transvenous pacing. 5) Treat reversible causes (hyperkalemia, beta-blocker/CCB/digoxin toxicity with specific antidotes).

Source guidelines & references

• AHA 2020/2025 ACLS adult bradycardia (with pulse) algorithm

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

Other pathways