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

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.

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.

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.

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.