What is the management of pulseless bradycardia?

Management of Pulseless Bradycardia

Pulseless bradycardia is cardiac arrest and must be treated immediately with high-quality CPR and the pulseless arrest algorithm—this is NOT treated as bradycardia with a pulse. 1

Critical Distinction: Pulseless vs. Bradycardia with Pulse

• If the patient has NO pulse, this is cardiac arrest (pulseless electrical activity/asystole) and requires immediate CPR with chest compressions at a rate of at least 100 per minute without interruption 1
• The term "pulseless bradycardia" refers to organized electrical activity on the monitor with a slow rate but no detectable pulse—this is a form of pulseless electrical activity (PEA) 1
• Do NOT use synchronized cardioversion or pacing for pulseless rhythms—these interventions are only for patients WITH pulses 1

Immediate Management Algorithm for Pulseless Bradycardia

Step 1: Initiate CPR Immediately

• Begin high-quality chest compressions immediately upon recognition of pulselessness 1
• Compression rate: at least 100 per minute 1
• Minimize interruptions in chest compressions—every second without compressions decreases survival 1

Step 2: Follow Pulseless Arrest Algorithm

• Epinephrine 1 mg IV/IO every 3-5 minutes is the primary medication for pulseless arrest 1
• Establish IV/IO access without interrupting CPR 1
• Secure advanced airway (endotracheal intubation or supraglottic airway) 1
• Once advanced airway is placed, provide continuous chest compressions without pauses and deliver 1 breath every 6-8 seconds (8-10 breaths/minute) 1

Step 3: Search for and Treat Reversible Causes (H's and T's)

• Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/hyperkalemia, Hypothermia 1
• Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (coronary or pulmonary) 1
• Treating the underlying cause is essential—pulseless bradycardia often has a reversible etiology 1

Step 4: Rhythm Reassessment Every 2 Minutes

• Check rhythm every 2 minutes during CPR 1
• If rhythm converts to VF/pulseless VT, immediately defibrillate 1
• If organized rhythm returns, check for pulse 1
• Rotate compressors every 2 minutes to prevent fatigue and maintain compression quality 1

What NOT to Do in Pulseless Bradycardia

• Do NOT attempt transcutaneous or transvenous pacing in pulseless arrest—pacing is Class III (harmful) for asystolic cardiac arrest and provides no survival benefit 1
• Randomized controlled trials show no improvement in hospital admission rates or survival when pacing was attempted in asystolic/pulseless patients 1
• Do NOT use atropine—while atropine is indicated for bradycardia WITH a pulse, it has been removed from cardiac arrest algorithms as it provides no benefit in pulseless arrest 2, 3
• Do NOT use synchronized cardioversion—synchronization requires a pulse and organized perfusing rhythm 1
• Pacing may delay or interrupt chest compressions, which are the cornerstone of survival in cardiac arrest 1

Pediatric Considerations

• In children with bradycardia and poor perfusion who receive CPR, 31% progress to pulselessness despite resuscitation efforts 4
• Children who become pulseless despite CPR for bradycardia have 19% lower survival (risk ratio 0.81) compared to those initially pulseless 4
• Longer intervals between CPR initiation and pulselessness predict worse outcomes—for delays >5 minutes, survival drops by 59% (risk ratio 0.41) 4
• This emphasizes the critical importance of early recognition and aggressive management before pulse loss occurs 4

Post-Resuscitation Care

• If return of spontaneous circulation (ROSC) is achieved, immediately assess for perfusing rhythm and begin post-cardiac arrest care 1
• Monitor for recurrent bradycardia and treat with atropine, chronotropic agents, or pacing as needed if pulse is present 2, 5
• Identify and definitively treat the underlying cause to prevent re-arrest 1

Common Pitfalls to Avoid

• Confusing pulseless bradycardia (cardiac arrest) with symptomatic bradycardia (pulse present)—always confirm pulse status immediately 1, 2
• Delaying CPR to attempt pacing or other interventions—CPR is the priority and must not be interrupted 1
• Failing to search for reversible causes—many cases of pulseless bradycardia have treatable underlying etiologies 1
• Using medications or interventions appropriate for bradycardia with pulse (atropine, pacing) in pulseless patients—these provide no benefit and waste critical time 1, 2