FIELD REFERENCE
Full criteria & treatment guidance
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.
Decide whether it is symptomatic
- Treat as symptomatic bradycardia when the rate is 60/min or lower and the patient also has 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, give 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.
VISUAL FIELD REFERENCE
Symptomatic bradycardia: access must not delay pacing
Adult / adolescent · ALS
Selected treatment checkpoints; the pacing trigger can bypass the medication step.
Confirm symptoms with the slow rate
Treat as symptomatic bradycardia when the rate is 60/min or lower and the patient also has hypotension, poor skin perfusion, altered consciousness, chest pain, or dyspnea/pulmonary edema.
Atropine pathway
Give atropine 1 mg IV/IO/IM about every 3–5 minutes as needed, to 3 mg total.
Pacing when access is unavailable or atropine fails
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.
After capture
Once pacing captures, stop atropine and contact base for possible CVRC destination.
- An implanted pacemaker does not exclude treating symptomatic bradycardia. Reassess mechanical perfusion as well as monitor rate.
- Base contact is required; provide ALS escort with CVRC destination coordination.
Selected checkpoints; read the complete guide for criteria, exclusions, doses, and ongoing care. SO-C-020 · PR-230 · PR-110
UNDERSTAND THE CARE
Why the pulse and the patient matter more than the displayed rate
The symptomatic pathway pairs bradycardia with poor perfusion or related symptoms. Document pressure, skin findings, mental status, chest symptoms and breathing alongside the rhythm. An existing pacemaker does not prove that the patient is adequately perfused, and a slow number without symptoms does not describe the same clinical branch.
Applying the guidance
When pacing is needed, electrical capture on the monitor must be joined to evidence that circulation is improving. Repeat the pulse and blood-pressure assessment and describe the response. Medication, vascular access and comfort measures should be coordinated around stabilization rather than delaying it. Sedation decisions retain their own blood-pressure and ventilation conditions.
Electrical and mechanical capture
Putting it together
Teaching example: the monitor shows a paced rhythm but the pressure and palpable pulse remain poor. Reassess capture and perfusion rather than reporting successful pacing solely from the monitor display.
Diagram text & teaching checkpoints
- Symptoms
- Connect the slow rate to poor perfusion.
- Stabilization
- Atropine/pacing under the local sequence.
- Capture
- Electrical AND mechanical confirmation.
- Handoff
- Report perfusion response and contact base.
Sources for this explanation
Original OCMedic teaching synthesis of the references below. Educational expansion updated ; this is not a new independent clinical-review date. Source-specific dates and limitations remain in the full guidance.