Pearls and Pitfalls: Severe Bradycardia

Severe bradycardia is a serious condition that carries with it a high rate of morbidity and mortality.

This review highlights the pearls and pitfalls of severe bradycardia, including presentation, diagnosis, and management in the emergency department based on current evidence.

Severe bradycardias are critical conditions that can cause hemodynamic instability, necessitating emergent evaluation and management. Common causes include intrinsic conduction system disease, acute coronary syndrome, and acute myocardial infarction, pharmacologic agents (e.g., beta-blockers, calcium channel blockers, digitalis), and metabolic disturbances (e.g., hyperkalemia, decompensated hypothyroidism, hypothermia), among others. A focused history and physical examination are necessary to narrow the differential diagnosis. An electrocardiogram is essential and may establish a definitive diagnosis. Laboratory studies directed toward a specific, identifiable diagnosis can be useful, such as elevated serum troponin or potassium values. Initial management aims to increase the heart rate and thus stabilize cardiac output via initiation of transcutaneous pacing and administration of chronotropic agents while addressing the underlying cause. In cases of severe bradycardia with accompanying hypotension despite initial therapy, transvenous pacing may be required. Early recognition and prompt management of severe bradycardia are vital to preventing hemodynamic collapse. By combining a systematic diagnostic approach with tailored interventions, clinicians can effectively address underlying causes and improve patient outcomes, even in the most critical scenarios.

An understanding of severe bradycardia can assist emergency clinicians in diagnosing and managing this potentially deadly condition.