Bradyarrhythmias and Sinus bradycardia conduction disturbances

Junctional bradycardia

Atrioventricular block or intraventricular conduction block

Urgent reversion to sinus rhythm

Restoration of hemodynamic stability

Observation unless hemodynamic compromise None

Reduce heart rate to diminish myocardial work/oxygen demand Reduce ventricular rate; restore sinus rhythm

Reduce ventricular rate; restore sinus rhythm

Search for precipitating cause (e.g., digitalis toxicity); observation unless hemodynamic compromise Increase heart rate only if hemodynamic compromise Increase heart rate only if hemodynamic compromise Increase heart rate; prophylax against progression to high-grade A-V block

Defibrillation; lidocaine; amiodarone;

bretylium* Cardioversion/defibrillation; lidocaine;

amiodarone; procainamide Atropine; atrial pacing


Identify and treat underlying cause:

beta-blockers Cardioversion if unstable; beta-blockers, calcium-blockers; digoxin; rapid atrial pacing (for flutter); anticoagulation; consider anti-arrhythmic therapy Vagal maneuvers; adenosine; beta-blockers, calcium-blockers; cardioversion if unstable Consider overdrive atrial pacing; consider suppressive anti-arrhythmic therapy; Digibind® if digitalis toxic Atropine; temporary pacing

Atropine; temporary pacing

Atropine; aminophylline; ventricular pacing

*Currently unavailable.

Junctional Ventricular Rhythm
Fig. 1. This patient presented early in the course of an acute inferior MI. Note the marked inferior ST elevation. The initial rhythm is junctional. Following a pause, there is a junctional beat, followed by VF. She was promptly defibrillated, and then treated with primary angioplasty.

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