# Symptomatic bradycardia

Treat poor perfusion, prepare pacing, and obtain required base contact.

Population: Adult / adolescent. Scope: ALS.
Status: published. Source-linked OCEMS summary.
Summary updated: 2026-09-16.
Source checked: 2026-09-16.
Source version: See linked source for document revision and implementation dates..
Canonical page: https://www.ocmedic.com/guides/bradycardia/
Official source: [SO-C-020 — Symptomatic Bradycardia - Adult/Adolescent](https://www.ochealthinfo.com/sites/healthcare/files/2024-07/SO-C-20%20Bradycardia.pdf)

Independent OC Medic summary. Does not replace the complete policy, current system notices, or clinical judgment.

## Key cautions & base contact

- Pacing should not wait when access delays stabilization.
- An implanted pacemaker does not exclude treating symptomatic bradycardia. Reassess mechanical perfusion as well as monitor rate.

## Source documents

- [SO-C-020 — Symptomatic Bradycardia - Adult/Adolescent](https://www.ochealthinfo.com/sites/healthcare/files/2024-07/SO-C-20%20Bradycardia.pdf)
- [PR-230 — Preparation and Dosing of Push Dose Epinephrine - Adult/Adolescent](https://www.ochealthinfo.com/sites/healthcare/files/2026-01/PR-230%20Push%20Dose%20Epi%201-2026.pdf)
- [PR-110 — Transcutaneous Pacing (TCP)](https://www.ochealthinfo.com/sites/healthcare/files/2025-10/PR-110%20TCP%204-2025.pdf)

## Decide whether it is symptomatic

- The source defines symptomatic bradycardia as a rate at or below 60/min plus hypotension, poor skin perfusion, altered consciousness, chest pain, or dyspnea/pulmonary edema.
- Monitor/document rhythm; assess BP and oxygenation. If room-air SpO₂ is below 95%, give high-flow mask oxygen or nasal cannula at 6 L/min as tolerated.
- Obtain IV access; consider IO if IV is unsuccessful or impractical. In a patient without poor-perfusion symptoms, obtain a 12-lead and assess for acute MI.

## Atropine & pacing

- Give atropine 1 mg IV/IO/IM about every 3–5 minutes as needed, to 3 mg total.
- If access cannot be obtained or 1 mg atropine fails to improve rate, initiate transcutaneous pacing and follow PR-110. Do not delay urgently needed pacing for access.
- Once pacing captures, stop atropine and contact base for possible CVRC destination.

## Perfusion & pacing discomfort

- With systolic BP below 90 and clear lungs, use the source’s 250 mL saline boluses up to 1 L; contact base if BP remains below 90 or CHF is evident.
- For extreme pacing distress with systolic BP above 90: titrate midazolam up to 5 mg IV. If IV cannot be established, 5 mg IN divided between nostrils may repeat once after about 3 minutes. Support ventilation if depressed.

## Escalation & transport

- Base contact is required; provide ALS escort with CVRC destination coordination.
- Consider toxicologic/metabolic causes and request additional direction. Current PR-230 addresses adult push-dose epinephrine and removes that procedure’s base-order requirement; the bradycardia contact requirement still applies.