CathLabHub

CathLabHub complications toolkitcathlabhub.com/toolkit/bradycardia-asystoleIn review, October 24, 2026

Recognize

The signs on the monitor, the image and the patient.

  • MonitorA slowing rate, AV block or a pause after a right coronary injection, balloon inflation, atherectomy or adenosine 12.
  • MonitorAsystole: a flat line with no arterial waveform; check leads and the transducer quickly.
  • PatientYawning, nausea, sweating and pallor with a slow pulse (vasovagal), often at puncture or sheath removal.
  • PatientDizziness, a dimming patient, seizure like movements with a long pause.

Act now

In the order the operator does them. The first three come first, whatever else is happening.

  1. Stop the trigger: pull the catheter out of the coronary, deflate the balloon, stop the burr.
  2. Ask the patient to cough forcefully while you prepare drugs.
  3. Atropine for a symptomatic slow rate 34.
  4. Pace if atropine fails: transcutaneous pads now, then a transvenous wire, or pace through the coronary guidewire 13.
  5. Dopamine or epinephrine infusion as a bridge 3.
  6. Vasovagal: legs up, fluids, atropine 2.
  7. Asystole: CPR, epinephrine 1 mg every 3 to 5 minutes, and look for the cause; do not shock asystole 3.
  8. Adenosine induced block is short; wait, and aminophylline is an antagonist 4.
  9. Sources differ: atropine is 1 mg every 3 to 5 minutes to 3 mg in the 2020 AHA guideline and 0.5 mg repeated to 3 mg in Brilakis 34.

Equipment

From the complications cart. Linked items open in the equipment directory.

Drugs

Adult doses as the cited source gives them. Check your formulary and the label.

  • Atropine1 mg IV every 3 to 5 minutes, maximum 3 mg 3.
  • Dopamine5 to 20 mcg/kg/min IV for bradycardia 3.
  • Epinephrine infusion2 to 10 mcg/min IV for bradycardia 3.
  • Epinephrine, cardiac arrest1 mg IV every 3 to 5 minutes 3.
  • AminophyllineReverses adenosine induced block.Weight based dose in the Cath Med App

Who to call

The escalation ladder, first call first.

  1. Second operator: for venous access and a transvenous wire.
  2. Code team: for asystole or a pause with no output.
  3. Electrophysiology: for persistent high grade block.

The bailout step by step

Pacing through the coronary guidewire 1

  1. Keep the coronary wire in the distal vessel; make sure the balloon or catheter covers the wire except the distal tip.
  2. Connect the negative lead of the temporary pacemaker to the back end of the coronary wire with a sterile clip 1.
  3. Connect the positive lead to the patient: a skin needle or an electrode in the groin or chest 1.
  4. Set a rate and a high output, then reduce to capture.
  5. Confirm capture on the arterial pressure, not only the ECG.
  6. Place a transvenous wire as soon as possible.

Prevent

  • Prophylactic transvenous pacing for right coronary rotational atherectomy and for rheolytic thrombectomy, as in Kern 1.
  • Short, small injections in the right coronary; disengage after each.
  • Adequate sedation, local anesthesia and hydration to reduce vagal reactions 2.
  • Slow adenosine and avoid high doses in the right coronary 4.

After care and documentation

  • ECG; electrolytes; review drugs that slow conduction.
  • Document the rhythm, the trigger, the drugs and any pacing.

Practice

Emergency simulator cases in the Cath Trainer app. The link opens Cases; type the case number in the search box.

  • EMG-0004: The heart rate halves during a right coronary PCI
  • EMG-0033: The heart rate halves during atherectomy
  • EMG-0010: A flat line on the monitor
  • EMG-0013: Faint during the local anesthetic at the groin

References

  1. Berg R, Lim MJ. Complications of percutaneous coronary interventions. In: Kern MJ, ed. The Interventional Cardiac Catheterization Handbook. 3rd ed. Saunders, Elsevier; 2013. Chapter 4.
  2. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 28, Other complications: hypotension, radiation skin injury, contrast induced acute kidney injury.
  3. Panchal AR, Bartos JA, Cabanas JG, et al. Part 3: adult basic and advanced life support. 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2020;142(suppl 2):S366-S468.
  4. Brilakis ES. Manual of Percutaneous Coronary Interventions: A Step-by-Step Approach. Academic Press, Elsevier; 2021. Chapter 3, Medications.
  5. CathLabHub Cath Trainer app, emergency simulator: case library (cathlabhub.com/app, Cases).

Educational reference for cath lab teams, not medical advice and not a standard of care. Your local policy, the device instructions for use and current guidelines govern. Verify every dose before use. Printed from cathlabhub.com/toolkit/bradycardia-asystole. First version, in clinical review: an interventional cardiologist is checking every card before it is final. Every number cites its source on the card.