The H’s and T’s of Bradycardia

Potential Cause How to Identify Treatments

Rapid heart rate and narrow QRS on ECG;
Hypovolemia Infusion of normal saline or Ringer’s lactate
other symptoms of low volume
Airway management and effective
Hypoxia Slow heart rate
oxygenation
Hydrogen Ion Excess Hyperventilation; consider sodium
Low amplitude QRS on the ECG
(Acidosis) bicarbonate bolus
Hypoglycemia Bedside glucose testing IV bolus of dextrose
Flat T waves and appearance of a U wave
Hypokalemia IV Magnesium infusion
on the ECG
Consider calcium chloride, sodium
Peaked T waves and wide QRS complex on
Hyperkalemia bicarbonate, and an insulin and glucose
the ECG
protocol
Typically preceded by exposure to a cold
Hypothermia Gradual rewarming
environment
Slow heart rate and narrow QRS
Tension Pneumothorax Thoracostomy or needle decompression
complexes on the ECG; difficulty breathing
Rapid heart rate and narrow QRS
Tamponade – Cardiac Pericardiocentesis
complexes on the ECG
Typically will be seen as a prolonged QT
Toxins interval on the ECG; may see neurological Based on the specific toxin
symptoms
Thrombosis (pulmonary Rapid heart rate with narrow QRS Surgical embolectomy or administration of
embolus) complexes on the ECG fibrinolytics
Thrombosis (myocardial ECG will be abnormal based on the
Dependent on extent and age of MI
infarction) location of the infarction
 Cardioversion Rules

QRS narrow and regular 50-100 Joules

QRS narrow and irregular 120-200 Joules

QRS wide and regular 100 Joules

QRS wide and irregular Turn off the synchronized mode and defibrillate immediately

Stable patients with tachycardia with a palpable pulse can be treated with more conservative measures first.

 Attempt vagal maneuvers

 If unsuccessful, administer adenosine 6 mg IV bolus followed by a rapid normal saline flush
 If unsuccessful, administer adenosine 12 mg IV bolus followed by a rapid normal saline flush
 Beta-blockers and calcium channel blockers may be considered for narrow QRS tachycardia (QRS <0.12 sec)

 For stable, wide QRS complex tachycardia (QRS ≥0.12 sec)

 Strongly consider expert consultation
 Consider procainamide 20-50 mg/min IV, OR
 Amiodarone 150 mg IV over 10 minutes, OR
 Sotalol 100 mg (1.5 mg/kg) over 5 minutes