IBCC Episode 5 - Bradycardia

Bradycardia represents a high-stakes clinical scenario where low heart rates directly compromise cardiac output, often signaling an impending pre-arrest state. Effective management requires a dual-track approach that simultaneously initiates electrical and pharmacological interventions rather than relying on sequential steps. Transcutaneous pacing, ideally using an anterior-posterior pad orientation, serves as the primary electrical stabilization, while epinephrine infusions provide a more reliable chronotropic response than atropine in most unstable patients. Clinicians should prioritize rapid, aggressive dosing—such as "cranking the gas" on pacing milliamps—to ensure myocardial capture, while utilizing bedside ultrasound to confirm mechanical response and guide transvenous wire placement. Beyond standard protocols, considering electrolytes, ischemia, and toxicological causes like beta-blocker or calcium channel blocker overdose remains essential for addressing the underlying etiology of refractory bradyarrhythmias.