ZyraDoc #10 - August 12, 2026

A 68-year-old man presents to the emergency department with severe lightheadedness, diaphoresis, and presyncope.

An ECG reveals symptomatic sinus bradycardia at 32 beats per minute, and he receives the maximum recommended cumulative dose of IV atropine (3 mg total).

His heart rate fails to increase, remaining at 32 bpm, while his blood pressure drops to 76/44 mmHg with signs of worsening hypoperfusion.

Case Summary

Clinical Focus:

A 68-year-old male presents with acute symptomatic bradycardia causing hemodynamic instability that remains refractory to maximal IV atropine therapy.

How to identify Unstable Bradycardia:

Heart rate < 50 bpm with acute hemodynamic compromise
Signs of tissue hypoperfusion: altered mental status, ischemic chest pain, acute heart failure, or severe hypotension
Failure of vagolytic agents (atropine) to restore adequate rate and perfusion

When symptomatic bradycardia causes acute hemodynamic instability and fails to respond to atropine, immediate electrical or continuous chronotropic escalation is required.

Here is the Management Strategy:

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