Management of Bradycardia in DKA Patients

Initial Assessment

The American Heart Association recommends determining if the bradycardia is causing hemodynamic compromise, looking for signs of altered mental status, ischemic chest discomfort, acute heart failure, hypotension, or other signs of shock, with evaluation of vital signs, including blood pressure and oxyhemoglobin saturation, and establishment of IV access and a 12-lead ECG to better define the rhythm 1

For hemodynamically stable patients with a heart rate <60 beats per minute but adequate perfusion with no symptoms, the American College of Cardiology recommends no emergency treatment, with close monitoring for any signs of deterioration 3
For hemodynamically unstable patients, the American College of Cardiology recommends atropine as first-line treatment, administering 0.5-1 mg IV atropine, which may be repeated every 3-5 minutes as needed, with a maximum total dose of 3 mg 1
If there is an inadequate response to atropine, the American College of Cardiology recommends second-line treatment with chronotropic agents, such as dopamine, or third-line treatment with transcutaneous pacing, which should be initiated if the patient remains unstable despite medication therapy, with consideration of sedation and analgesia for conscious patients 4
The American College of Cardiology also recommends fourth-line treatment with transvenous temporary pacing if there is no response to drugs or transcutaneous pacing, which is more reliable than transcutaneous pacing but associated with higher complication rates (14-40%) 4

The American College of Cardiology warns against delaying transcutaneous pacing in unstable patients who don't respond to atropine, and against administering atropine in patients with high-degree AV block, which may worsen the condition 2