HR <60 WITH symptoms. Atropine first, then TCP. Avoid atropine in high-degree blocks.
Steps by Cert Level
ALL: O2, monitor, IV access, 12-lead EKG. Identify reversible causes (hypoxia, hypothermia, drug OD, increased ICP).
AEMT: Atropine 0.5mg IV/IO — repeat q3–5min, max 3mg total.
PARAMEDIC: Atropine 0.5mg IV/IO q3–5min (max 3mg). If ineffective: TCP at 60–80bpm, increase mA until capture. Sedate before pacing: Midazolam 2.5–5mg IV + Fentanyl 1mcg/kg IV.
PARAMEDIC: If TCP unavailable: Dopamine 2–10mcg/kg/min IV infusion OR Epinephrine 2–10mcg/min IV infusion.