Acute severe bradycardia

When acute severe bradycardia occurs in the critical care setting, the first step should be to administer 0.5 mg atropine intravenously as the initial bolus, followed by 0.5-mg increments up to a cumulative dose of 2 mg. Initial doses below 0.5 mg of atropine should not be used because they can precipitate a paradoxical slowing of heart rate owing to their vagomimetic effect. While atropine is being administered, the patient can be asked to cough several times. Particularly during episodes of vasovagally mediated bradycardia, cough may have a vagolytic effect resulting in a transient increase of heart rate. An intravenous saline bolus can also be given. If bradycardia has resulted in hypotension and vasodilation, the response to atropine can be delayed. Intravenous aminophylline may be tried in a patient who is not unstable. If not contraindicated by acute infarction or ongoing ischemia, isoproterenol (isoprenaline) 1.0 mg in 250 to 500 ml of 5 per cent gluose can also be administered at a rate which increases the pulse to 60 beats/min.

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