Introduction

This rhythm does not require treatment, unless they are causing symptoms, i.e. syncope, dizziness, tiredness and poor effort tolerance. Sinus bradycardia < 50/minute or sinus arrest with slow escape rhythm, accompanied by hypotension, strongly suggests a treatable underlying cause:

• Acute inferior myocardial infarction

• Hyperkalaemia, especially with wide QRS and/or peaked T waves

• Medicines, especially verapamil with a beta-blocker, or digoxin

• Hypothermia

• Hypoxia

Management

• Treat the cause.

• Consider atropine in inferior myocardial infarction: A: atropine IV 0.6–1.2 mg every 3–5 minutes (maximum 3 mg).

• After stabilisation refer to a specialised cardiac centre for evaluation and temporary or permanent pacemaker (single or dual chamber) depending on the cause; vancomycin injection is prepared for the permanent pacemaker pouch.