ACLS Bradycardia Algorithm

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Using the ACLS Bradycardia Algorithm for Managing Bradycardia

The ACLS Bradycardia Algorithm outines the steps for assessing and managing a patient who presents with symptomatic bradycardia. It begins with the decision that the patient's heart rate (< 60 bpm) is too slow to be physiologically appropriate for the person.


  1. Decision: Heart rate is < 60 bpm and is inadequate for patient's clinical condition.
  2. Assess and manage the patient using the primary and secondary surveys:
    • Maintain patent airway.
    • Assist breathing as needed.
    • Give oxygen; monitor oxygen saturation.
    • Monitor blood pressure and heart rate.
    • Obtain a 12-lead ECG.
    • Review patient's rhythm.
    • Establish IV access.
    • Take a problem-focused history and physical exam.
    • Search for and treat possible contributing factors.
  3. Answer two questions to help you decide if the patient's signs and symptoms of poor perfusion are caused by the bradycardia (see Figure 2).
    1. Are the signs or symptoms serious, such as hypotension, pulmonary congestion, dizziness, shock, ongoing chest pain, shortness of breath, congestive heart failure, weakness or fatigue, and acute altered mental status?
    2. Are the signs and symptoms related to the slow heart rate?
    There may be another reason for the slow heart rate. For example, the patient's low blood pressure may be caused by a dysfunctional myocardium, rather than by a slow heart rate.
  4. Decide whether the patient has adequate or poor perfusion, since the treatment sequence is determined by the severity of the patient's clinical presentation.
    • If perfusion is adequate, monitor and observe the patient.
    • If perfusion is poor, move quickly through the following actions:
      • Prepare for transcutaneous pacing. Do not delay pacing if rhythm is Mobitz type II second-degree block or third-degree AV block
      • Consider administering atropine 0.5 mg IV during the interval before pacing starts. Repeat PRN every 3 to 5 minutes up to 3 doses.
      • If the atropine is ineffective, begin pacing.
      • Consider epinephrine or dopamine while waiting for the pacer or if pacing is ineffective.
        • Epinephrine 2 to 10 µg/min
        • Dopamine 2 to 10 µg/kg per minute

Progress quickly through these actions as the patient could be in pre-cardiac arrest and need multiple interventions done in rapid succession: pacing, IV atropine, and infusion of dopamine or epinephrine.