Adult ECAT protocol

Compromising bradycardia (suspected)

A3.3 Published: December 2023 Printed on 19 May 2024

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Any person, 16 years and over, presenting with a heart rate less than 40 bpm and has one or more of the following associated symptoms.

This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.

This protocol authorises ALS2 accredited nurses only to give atropine and fluids as indicated below.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

History prompts

Presenting symptoms
Onset of symptoms
Pain assessment – PQRST
Pre-hospital treatment
Past admissions
Medical and surgical history
Cardiac device in situ – PPM/AICD
Current medications, including antiarrhythmic or beta blocker agents
Known allergies
Identify cardiac history and/or risk factors – age over 55 years, familial, hypertension, hyperlipidaemia, diabetes, smoking, Aboriginal and Torres Strait Islander

Signs and symptoms

Syncope
Dizziness
Dyspnoea
Chest pain
Hypotension
Pallor
Diaphoresis (sweating)
Fatigue

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Historical

Cardiac device
Heart failure
Pregnancy
Recent head injury

Clinical

Altered level of consciousness
Syncope
Dizziness
Shortness of breath
Arrhythmia
Chest pain
Blood pressure: SBP less than 90 mmHg
Diaphoresis (sweating)
Seizure-like activity

Remember adult at risk: patient or carer concern, frailty, multiple comorbidities or unplanned return.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Supine depending on clinical status

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Assessment

Intervention

Patency of airway

Maintain airway patency

Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and effort Auscultate chest (breath sounds) Oxygen saturation (SpO₂)	Assist ventilation as clinically indicated Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO₂ over 93% Patients at risk of hypercapnia, maintain SpO₂ at 88–92%

Assessment

Intervention

Respiratory rate and effort

Auscultate chest (breath sounds)

Oxygen saturation (SpO₂)

Assist ventilation as clinically indicated

Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO₂ over 93%

Patients at risk of hypercapnia, maintain SpO₂ at 88–92%

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure Cardiac rhythm	Assess circulation Apply continuous cardiac monitoring Consider monitoring via defibrillator leads and applying transducer pads Insert IV cannula, if trained If unable to obtain IV access, consider intraosseous, if trained If bradycardic and SBP is less than 90 mmHg and/or poor perfusion: Complete 12 lead ECG ALS2 accredited nurses only: Give atropine 0.6 mg IV/intraosseous every 3–5 minutes, titrated to maintain heart rate over 60 bpm and SBP over 90 mmHg. Maximum total dose 3 mg If SBP remains less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous. Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved Monitor blood pressure every 5–10 minutes until stabilised
IVC and/or pathology	Following focused assessment, request pathology as per pathology section

Assessment

Intervention

Perfusion (capillary refill, skin warmth and colour)

Pulse

Blood pressure

Cardiac rhythm

Assess circulation

Apply continuous cardiac monitoring

Consider monitoring via defibrillator leads and applying transducer pads

Insert IV cannula, if trained

If unable to obtain IV access, consider intraosseous, if trained

If bradycardic and SBP is less than 90 mmHg and/or poor perfusion:

Complete 12 lead ECG
ALS2 accredited nurses only:
- Give atropine 0.6 mg IV/intraosseous every 3–5 minutes, titrated to maintain heart rate over 60 bpm and SBP over 90 mmHg. Maximum total dose 3 mg
- If SBP remains less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous. Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Monitor blood pressure every 5–10 minutes until stabilised

IVC and/or pathology

Following focused assessment, request pathology as per pathology section

If no response to atropine, escalate as per local CERS protocol to consider external transthoracic pacing (if available).

If STEMI identified, escalate as per local CERS immediately.

Disability

Assessment	Intervention
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment, as clinically indicated
Pain	Assess pain. Continue A to G assessment

Exposure

Assessment	Intervention
Temperature	Maintain normothermia
Skin inspection, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status: last ate, drank, bowels opened, passed urine or vomited	Commence fluid balance chart, as required

Glucose

Assessment	Intervention
BGL	Measure BGL If BGL less than 4 mmol/L with NO decrease in level of consciousness (Yellow Zone criteria): give quick-acting carbohydrate: sugary soft drink, fruit juice or 40% glucose gel, up to 15 g, buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 4 mmol/L If BGL less than 4 mmol/L WITH a decrease in level of consciousness (Red Zone criteria) OR the patient is unable to tolerate oral intake: give 40% glucose gel, up to 15 g, buccally in incremental doses, as tolerated, while establishing IV access give 10% glucose 200 mL by IV infusion over 15 minutes, once only if delay in IV access, give glucagon 1 mg IM, once only reassess BGL in 15 minutes If the patient is unconscious or peri-arrest: give 50% glucose 50 mL by slow IV injection, once only. Use with caution as extravasation can cause necrosis if delay in IV access, give glucagon 1 mg IM, once only reassess BGL in 15 minutes Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated

Assessment

Intervention

BGL

Measure BGL

If BGL less than 4 mmol/L with NO decrease in level of consciousness (Yellow Zone criteria):

give quick-acting carbohydrate: sugary soft drink, fruit juice or 40% glucose gel, up to 15 g, buccal
reassess BGL in 15–30 minutes and repeat treatment until BGL over 4 mmol/L

If BGL less than 4 mmol/L WITH a decrease in level of consciousness (Red Zone criteria) OR the patient is unable to tolerate oral intake:

give 40% glucose gel, up to 15 g, buccally in incremental doses, as tolerated, while establishing IV access
give 10% glucose 200 mL by IV infusion over 15 minutes, once only
if delay in IV access, give glucagon 1 mg IM, once only
reassess BGL in 15 minutes

If the patient is unconscious or peri-arrest:

give 50% glucose 50 mL by slow IV injection, once only. Use with caution as extravasation can cause necrosis
if delay in IV access, give glucagon 1 mg IM, once only
reassess BGL in 15 minutes

Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated

Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.

Focused assessment

Complete cardiovascular focused assessment.

Precautions and notes

Causes of symptomatic bradycardia include:
- electrolyte disturbance, most notably critical hyperkalaemia
- medications, such as digoxin, beta-blockers or calcium channel blockers
- ischemia or myocardial infarction
- intrinsic conducting system disease.
Inferior myocardial infarction/ischemia may lead to bradyarrhythmias.
Inferior infarcts and bradycardia with hypotension may be responsive to fluid boluses.
Treatment should be aimed at resuscitation and rapid identification of reversible causes.
Stable patients with no adverse signs from the arrhythmia benefit from specialist help early, as treatments have the potential to make the rhythm and heart failure worse.
Patients who fail to respond to pharmacotherapy are high risk for asystole and are likely to need electrical pacing.
Symptomatic complete heart block will require pacing and/or urgent transfer to definitive care.

Interventions and diagnostics

Specific treatment

Serial ECGs: ECG rhythm strip to assist in interpretation of arrhythmia.

Radiology

Pathology

FBC, UEC, Ca/Mg/PO4
VBG for urgent electrolytes, specifically potassium
If acute coronary syndrome (ACS) is considered: troponin

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

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Drug	Dose	Route	Frequency
Atropine	0.6 mg Maximum total dose 3 mg	IV/intraosseous	Repeat every 3–5 minutes to maintain heart rate over 60 bpm and SBP over 90 mmHg
Glucagon	1 mg	IM	Once only
Glucose 10%	200 mL	IV infusion over 15 minutes	Once only
Glucose 40% gel (0.4 g/mL)	15 g	Buccal	Repeat after 15 minutes if required
Glucose 50%	50 mL	Slow IV injection	Once only
Oxygen	2–15 L/min, device dependent	Inhalation	Continuous
Sodium chloride 0.9%	250 mL Maximum dose 1000 mL	IV/intraosseous	Bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Medications with contraindications or requiring dose adjustment are marked:

^H for patients with known hepatic impairment
^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

References

Show

Australian Resuscitation Council. Managing Acute Dysrhythmias. Melbourne: ARC; 2009 [cited 7 Feb 2023]. Available from: https://resus.org.au/?wpfb_dl=59
Beasley R, Chien J, Douglas J, et al. Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: 'Swimming between the flags'. Respirology. 2015 Nov;20(8):1182-91. DOI: 10.1111/resp.12620
Deal N. Evaluation and management of bradydysrhythmias in the emergency department. Emerg Med Pract. 2013 Sep;15(9):1-15; quiz -6.
Munther K, Homoud M. Sinus bradycardia. UptoDate: Wolters Kluwer; 2022 [cited 7 Feb 2023]. Available from: https://www.uptodate.com.acs.hcn.com.au/contents/sinus-bradycardia?search=bradycardia&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
National Heart Foundation of Australia. Arrhythmia. Australia NHFA; 2017 [cited 7 Feb 2023]. Available from: https://www.heartfoundation.org.au/bundles/your-heart/heart-arrhythmia
NSW Health. Australian Medicines Handbook. Australia: Australian Government, NSW; 2022 [cited 13 Apr 2022]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/
Sodeck GH, Domanovits H, Meron G, et al. Compromising bradycardia: management in the emergency department. Resuscitation. 2007 Apr;73(1):96-102. DOI: 10.1016/j.resuscitation.2006.08.006
Therapeutic Guidelines. Bradyarrhythmias. Australia Therapeutic Guidlines Limited; [cited 7 Feb 2023]. Available from: https://tgldcdp.tg.org.au.acs.hcn.com.au/viewTopic?etgAccess=true&guidelinePage=Cardiovascular&topicfile=bradyarrhythmias

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Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au

ECAT home page Glossary

Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/adult/compromising-bradycardia

Compromising bradycardia (suspected)

On this page

History prompts, signs and symptoms

History prompts

Signs and symptoms

Red flags

Historical

Clinical

Clinical assessment and specified intervention (A to G)

Position

Airway

Breathing

Circulation

Disability

Exposure

Fluids

Glucose

Focused assessment

Precautions and notes

Interventions and diagnostics

Specific treatment

Radiology

Pathology

Medications

References