ACLS Bradycardia Algorithm

ACLS Bradycardia Algorithm

Treatment for bradycardia should be based on controlling the symptoms and identifying the cause using the H’s and T’s.

  1. Do not delay treatment but look for underlying causes of the bradycardia using the H’s and T’s
  2. Maintain the airway and monitor cardiac rhythm, blood pressure and oxygen saturation.
  3. Insert an IV or IO for medications.
  4. If the patient is stable, call for consults.
  5. If the patient is symptomatic, administer an atropine 0.5 mg IV or IO bolus; Repeat the atropine every 3-5 minutes to a total dose of 3 mg.
    1. If atropine does not relieve the bradycardia, continue evaluating the patient to determine the underlying cause and consider transcutaneous pacing.
    2. Consider an IV/IO dopamine infusion at 2-10 mcg/kg/minute
    3. Consider an IV/IO epinephrine infusion at 2-10 mcg/kg/minute

The H’s and T’s of Bradycardia

Potential Cause

How to Identify


Hypovolemia Rapid heart rate and narrow QRS on ECG; other symptoms of low volume Infusion of normal saline or Ringer’s lactate
Hypoxia Slow heart rate Airway management and effective oxygenation
Hydrogen Ion Excess (Acidosis) Low amplitude QRS on the ECG Hyperventilation; consider sodium bicarbonate bolus
Hypoglycemia Bedside glucose testing IV bolus of dextrose
Hypokalemia Flat T waves and appearance of a U wave on the ECG IV Magnesium infusion
Hyperkalemia Peaked T waves and wide QRS complex on the ECG Consider calcium chloride, sodium bicarbonate, and an insulin and glucose protocol
Hypothermia Typically preceded by exposure to a cold environment Gradual rewarming
Tension Pneumothorax Slow heart rate and narrow QRS complexes on the ECG; difficulty breathing Thoracostomy or needle decompression
Tamponade – Cardiac Rapid heart rate and narrow QRS complexes on the ECG Pericardiocentesis
Toxins Typically will be seen as a prolonged QT interval on the ECG; may see neurological symptoms Based on the specific toxin
Thrombosis (pulmonary embolus) Rapid heart rate with narrow QRS complexes on the ECG Surgical embolectomy or administration of fibrinolytics
Thrombosis (myocardial infarction) ECG will be abnormal based on the location of the infarction Dependent on extent and age of MI
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