Management of Severe Bradycardia and Hypotension in Older Patients

First-Line Treatment

The American Heart Association recommends atropine as the first-line medication for older patients presenting with severe bradycardia and hypotension in an EMS setting, administered at 0.5 mg IV every 3-5 minutes to a maximum total dose of 3 mg 1, 2
Atropine remains the first-line drug for acute symptomatic bradycardia with hypotension, particularly in older patients 1
Initial dose should be 0.5 mg IV every 3-5 minutes, with a maximum total dose of 3 mg 1, 2
Atropine administration should not delay implementation of external pacing for patients with poor perfusion 1

The American College of Cardiology recommends epinephrine infusion at 2-10 mcg/min IV for patients with symptomatic bradycardia, particularly if associated with hypotension 3, 2
Dopamine infusion at 5-20 mcg/kg/min IV is particularly useful for hypotension associated with symptomatic bradycardia 4, 2
Lower initial doses (5-10 mcg/kg/min) of dopamine are recommended for older patients 4

Older patients may be more sensitive to the effects of medications and at higher risk for adverse effects, according to the European Society of Cardiology 5
Use lower initial doses and titrate carefully while monitoring vital signs 5
Atropine should be used cautiously in the presence of acute coronary ischemia or myocardial infarction, as increased heart rate may worsen ischemia or increase infarction size 1

The American Heart Association recommends avoiding beta-blockers and calcium channel blockers (like diltiazem and verapamil) as they can worsen bradycardia and hypotension 6, 7
Verapamil is specifically listed as a potentially inappropriate medication in people ≥75 years with chronic constipation, according to the European Heart Journal 5

Assess airway, breathing, circulation, and provide supplemental oxygen if hypoxemic, as recommended by the American Heart Association 1
Establish IV access and cardiac monitoring 1
Determine if bradycardia is causing signs/symptoms of hemodynamic compromise 8
If symptomatic, administer atropine 0.5 mg IV every 3-5 minutes (max 3 mg) 1, 2
If no response to atropine, initiate epinephrine infusion (2-10 mcg/min) or dopamine infusion (5-20 mcg/kg/min) 3, 2, 4, 2

Using doses of atropine less than 0.5 mg, which may worsen bradycardia 2
Delaying transcutaneous pacing in unstable patients who fail to respond to atropine 8
Using beta-blockers or calcium channel blockers which can worsen bradycardia 6, 7
Failing to consider underlying causes of bradycardia and hypotension (e.g., medication effects, inferior myocardial infarction) 8

Doses of dopamine greater than 20 mcg/kg/min may cause vasoconstriction or arrhythmias, according to the American College of Cardiology 9

Glucagon may be used at a dose of 3-10 mg IV with infusion of 3-5 mg/h for bradycardia and hypotension due to beta-blocker or calcium channel blocker overdose, as recommended by the American College of Cardiology 9, 10
High-dose insulin therapy may be used at an IV bolus of 1 unit/kg followed by an infusion of 0.5 units/kg/h for beta-blocker or calcium channel blocker overdose, according to the American College of Cardiology 9, 10
Aminophylline/Theophylline may be used for specific cases of bradycardia, such as post-heart transplant or spinal cord injury, at a dose of 6 mg/kg in 100-200 mL of IV fluid over 20-30 min, as recommended by the American College of Cardiology 9, 10

Temporary pacing may be considered if medications fail and the patient remains unstable, according to the American College of Cardiology 9
For beta-blocker or calcium channel blocker overdose, glucagon or high-dose insulin therapy may be considered, as recommended by the American College of Cardiology 9, 10
For post-heart transplant or spinal cord injury, aminophylline/theophylline may be considered, according to the American College of Cardiology 9, 10

Epinephrine and dopamine may cause tachyarrhythmias and chest pain, according to the American College of Cardiology 9