Ah, bradycardia. That one ECG finding where your heart literally says, “I need a break.” 🫠 But unlike your resident buddy post-48-hour call, this isn’t the kind of break we allow to continue.
During one night shift in the CCU, I had a 62-year-old gentleman from Mashkai wheeled in—pulse slower than a government file in a civil secretariat. BP was hovering just enough to qualify as “technically alive.” I glanced at the monitor, sighed, and called out, “Time for the Brady Algorithm, folks.”
So, let’s talk ACLS Bradycardia Management — the calm, collected protocol that stands between you and a full-on code blue.
🧠 The Mnemonic: “PADS-P”
| Step | Mnemonic Letter | Action | Clinical Tip |
|---|---|---|---|
| 1️⃣ | P | Pulse check + Identify bradyarrhythmia | Make sure it’s not just a bad lead. Spoiler: It’s always lead II. |
| 2️⃣ | A | Assess for signs of instability | Look for hypotension, altered mental status, chest pain, or signs of shock. |
| 3️⃣ | D | Drugs: Atropine first (1 mg IV bolus, repeat every 3–5 mins) | Max dose is 3 mg. Beyond that, you’re just seasoning the arrest. 🧂 |
| 4️⃣ | S | Second-line options: Dopamine or Epinephrine infusion | Start Dopamine at 2–10 mcg/kg/min. Epi at 2–10 mcg/min. Keep a calculator or Dr. Basit Khan nearby. |
| 5️⃣ | P | Pace: Transcutaneous pacing if drugs fail or patient is crashing | It’s like jump-starting a Toyota Corolla in minus-5° Mastung weather. Not comfy, but it works. |
Clinical Scenario from Awaran, Balochistan
Mr. Gul Umrani from Awaran walked into our ER with a HR of 34 bpm, confused, and speaking in 3rd century Balochi. Dr. Imran Baloch raised an eyebrow and muttered, “That’s textbook unstable bradycardia.”
I gave Atropine, waited. HR: still a flatliner’s cousin. Started Dopamine. No dice. Ended up pacing him. Meanwhile, the monitor beeps were the only thing faster than his pulse. By morning, he was wide awake and swearing off his “homemade hypertension medicine” that included rose water and goat bile.
When to Panic (But Look Calm) 😎
According to the 2020 ACLS Guidelines, bradycardia is defined as a HR <60 bpm, but it’s the symptoms that matter. A marathon runner at 48 bpm isn’t your emergency — unless they also say, “I feel like I’m dying.”
Instability signs:
- Hypotension 🩸
- Acute altered mental status 🧠
- Signs of shock 💥
- Ischemic chest discomfort 💔
- Acute heart failure
If these are present → intervene.
If not → monitor, prepare for escalation, and look like you’ve got it all under control (bonus: impress junior docs and visiting auditors).
Bradycardia management isn’t glamorous. No one applauds you for saving a 42 bpm slowpoke. But it’s crucial, it’s life-saving, and if you know your “PADS-P”, you’ll handle it like a pro.
Plus, you’ll get to say, “Let’s pace him,” with all the dramatic flair of a TV cardiologist, and who doesn’t want that?
Thank you for reading! 🙂
— Dr. Aurangzaib Qambrani, Sheikh Khalifa Bin Zayed Hospital, Quetta
📍 Departments: General Medicine, Gastroenterology, Cardiac Care Unit
📚 MBBS | PLAB | MRCP (UK)
