Peri-Arrest Bradycardia Management
Resuscitation Council UK Adult Advanced Life Support Guidelines. Published: Oct 2025
Changes made to this article:
- Link to the latest 2025 Resuscitation Guidelines updated
- Minor changes were made to the guideline
Date: 04/12/25
Peri-Arrest Bradycardia (Resus Council UK 2025)
Bradycardia is defined by a heart rate of <60 bpm.
This page covers the causes, ECG findings, immediate assessment, pharmacological management and pacing in bradycardia/bradyarrhythmias.
Updated UKMLA guide to peri-arrest bradycardia based on the latest Resuscitation Council UK 2025 Advanced Life Support (ALS) guidelines.
Background Information
Definition
Bradycardia is defined by a heart rate of <60 bpm
Management Guidelines
The first step is to check for ANY life-threatening features:
- Shock– hypotension (SBP < 90 mmHg) and/or features of sympathetic compensation
- Syncope– due to ↓ cerebral blood flow
- Myocardial ischaemia– chest pain and/or ECG findings
- Heart failure– pulmonary oedema (LV failure) and/or raised JVP (RV failure)
- Immediately post-ROSC
Life-Threatening Feature(s) Present (Unstable)
Treatment algorithm (step-up accordingly if ineffective):
| Step 1 | IV atropine 500 micrograms (mcg)
If a single dose is ineffective → repeat every 3-5 min up to 6 doses (3 mg in total), then move to step 2 |
| Step 2 | Consider 2nd line drugs:
|
| Step 3 | Consider pacing:
If both transcutaneous and transvenous pacing are not immediately available (and drugs are ineffective) → fist pacing can be attempted while waiting for pacing equipment |
DC shock has NO role in bradycardia, even if the patient is unstable. DC shocks are only used in the management of tachyarrhythmias.
Drugs in Special Scenarios
Additional drugs in specific scenarios:
- Consider giving aminophylline to patients with spinal cord injury or cardiac transplant
- Consider glucagon if bradycardia is potentially caused by beta-blockers or calcium channel blockers
Atropine should NOT be given in the following scenarios:
- High degree AV block with wide QRS (atropine is ineffective and may worsen the block)
- Cardiac transplant patients (atropine can cause a high-degree AV block or even sinus arrest – use aminophylline instead as stated above)
No Life-Threatening Features (Stable)
First, assess the risk of asystole:
- Recent asystole
- 2nd degree Mobitz II AV block
- Complete heart block with broad QRS
- Ventricular pause > 3 sec
Subsequent action:
- Yes (any of the above) → monitor + treat underlying cause + consider transvenous pacing
- No (none) → observe