Atropine

If there are adverse features, give atropine 500 micrograms IV.

If there is not a satisfactory response, this dose of atropine may be repeated up to a maximum total doses of 3 mg IV.

If failed, then transcutaneous pacing

Cardiac pacing

Non-invasive pacing may be used to maintain cardiac output temporarily while expert help to deliver longer-term treatment is obtained.

Cardiac pacemakers

Implanted devices that deliver pacing include:

• pacemakers implanted for the treatment of bradycardia
• (single or dual-chamber)
• biventricular pacemakers (implanted for left ventricular failure)
• ICDs (which have pacing capability).

Percussion pacing

To perform percussion pacing:

• With the side of a closed fist deliver repeated firm thumps to the praecordium just lateral to the lower left sternal edge.
• Raise the hand about 20 cm above the chest for each thump.
• If initial thumps do not produce a QRS complex try using slightly harder thumps and try moving the point of contact around the praecordium until a site is found that produces repeated ventricular stimulation.

If attempted percussion pacing does not achieve a cardiac output within a few seconds, start CPR.

Transcutaneous pacing

Transcutaneous pacing and drugs used in extreme bradycardia should be a bridge to definitive treatment (transvenous pacing and/or correction of the cause of the extreme bradycardia). It causes painful contraction of muscles in the chest wall, so patients are likely to need sedation.