Bradycardia emergencies are uncommon, but these cases can go sideways fast. An appropriately aggressive approach is needed to avoid cardiac arrest. Sometimes the answer is as simple as the appropriate epinephrine dose.

The IBCC chapter is located here .

The podcast & comments are below.

Follow us on iTunes

Electrophysiologist Michael Katz left a series of comments on twitter that were really useful. I've reproduced them here:

I think you’re “underselling” how necessary the panic button on the TVP box is. When floating the wire, I use this button. Unless you are VOO/DOO, your hand motions and wire movements will make TVP inhibit and you won’t know when you actually have capture. — Michael Katz (@MGKatz036) October 14, 2018



This is a nice pearl. On a related note, if you're floating a transvenous pacemaker and the person holding the pacemaker generator doesn't know how to use it you can just ask them to hit the panic button.

thank you, agree. was afraid to go full-out against atropine because in some settings (e.g. ward) atropine may be the only immediately available drug and it may be more likely to help than harm. personally I don't think atropine has a role in an ED/ICU where epi is available — josh farkas (@PulmCrit) October 14, 2018

I'm still struggling with the atropine issue a bit. Dumping atropine from the algorithm completely would go against AHA/ACC guidelines. I'm open to this, but would like some more evidence first.

My other comment is philosophical… and maybe to be added to section on “why bradycardia is bad”…. — Michael Katz (@MGKatz036) October 14, 2018

When a patient is bradycardia, the mechanism of death is rarely hypotension until they are on the spectrum of PEA/peri-arrest bradycardia… the mode of death is pause dependent Torsade and polymorphic VT/VF…. — Michael Katz (@MGKatz036) October 14, 2018

… this being said, bradycardic pts tend to look, well fine. But if you look at their uncorrected QT, it’s probably like 680 if HR is in 20-30s…. One PVC away from dead. — Michael Katz (@MGKatz036) October 14, 2018

Therefore, taking a holistic view, TCP —> TVP should be aggressively offered with extreme bradycardia, even in hypertensive pts. — Michael Katz (@MGKatz036) October 14, 2018

Yes. This is the primary mode of death. When pts are having ectopy with underlying wide complex escape rhythm, they are about to VF. — Michael Katz (@MGKatz036) October 14, 2018

92 yo p/w CP and K 3.3. pic.twitter.com/cq3q0sF7DK — Michael Katz (@MGKatz036) October 14, 2018

Closer look at escape: pic.twitter.com/Vdjf5t1TtZ — Michael Katz (@MGKatz036) October 14, 2018



This is an interesting issue that I wasn't aware of. I've added this concept to the main chapter including the rhythm strip above.