ECG shows a rate <60bpm


Use ABCDE approach
Monitor oxygen saturations, ECG and blood pressure
Record 12 lead ECG
Identify and treat reversible causes (e.g. electrolyte abnormalities, stop drugs such as beta blockers)
Obtain IV access

If the patient is unstable

(shock, myocardial ischaemia, syncope, heart failure)

Atropine 500mcg IV

If there isn’t a satisfactory response consider interim measures:

  • atropine 500mcg repeat with a maximum of 3mg


  • if experienced try transcutaneous pacing


  • isoprenaline infusion 2mg in 500ml 5% glucose at rate of 1mcg/minute in 2/3 minute intervals

Seek expert help to arrange transvenous pacing

If the patient is stable OR there has been a satisfactory response to atropine

  • risk assess for asystole: recent asystole, Mobitx II AV block, complete heart block with broad QRS or ventricular pause of >3s – if any apply then consider above interim measures
  • continue observations
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