Monday Back to Basics

Bradycardia, Part 2 with Dr. Allison Cash

  1. Treat possible underlying cause if known 
  1. Atropine
    •  Class 2a treatment
    • Dose 0.5 mg IV every 3-5 minutes, up to total dose 3 mg 
    • Can produce paradoxical worsening bradycardia 
    • Less effective in patients with cardiac transplant 
    • Skip if unstable, move directly to pacing 
  1. Transcutaneous pacing  
    • Class 1a recommendation
    • Place pads in anterior lateral or anterior posterior position 
    • Consider sedation or pain control  
    • Set monitor to “Pacer” 
    • Set rate, usually around 60 bpm 
    • Start current at 0 mA and slowly increase until capture is obtained. Consider different placement of pads if capture not achieved by 130 mA 
    • Confirm capture by feeling pulse or cardiac ultrasound 
    • Transcutaneous pacing is ultimately a bridge to transvenous pacing or permanent pacemaker – discuss with cardiology or transfer to center with these capabilities  
    • Capture (pictured below) shows pacer spike followed by a wide QRS and then ST and/or T wave  


  1. Judith E. Tintinall, et al. (2020). Tintinalli’s Emergency Medicine : A Comprehensive Study Guide (Ninth Edition). New York: McGraw-Hill. 
  1. Doukky R, Bargout R, Kelly RF, Calvin JE. Using transcutaneous cardiac pacing to best advantage: How to ensure successful capture and avoid complications. J Crit Illn. 2003 May;18(5):219-225. PMID: 30774278; PMCID: PMC6376978. 
  1. Holger J S, Lamon R P, and Minnigan H J et al.: Use of ultrasound to determine ventricular capture in transcutaneous pacing. Am J Emerg Med.  2003; 21: 227 

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