Doing SLOW Better: How to Effectively Treat Symptomatic Bradycardia

Bradycardias in the prehospital setting are common, high-risk, and often more complex than they initially appear. While transcutaneous pacing (TCP) has long been considered a primary EMS intervention for unstable bradycardia, emerging evidence and field experience suggest that its effectiveness may be far more limited than traditionally believed. Ineffective muscle capture, patient discomfort, poor electrical contact, and delayed decision-making can all undermine pacing success — sometimes giving a false sense of security while the patient continues to deteriorate. This session examines the realities of TCP performance in the field, identifies common pitfalls, and clarifies what pacing can and cannot reliably accomplish. Participants will review best practices for optimizing electrode placement, confirming mechanical capture, minimizing delays, and managing discomfort. Equally important, the talk emphasizes the full spectrum of bradycardia management, including early recognition of high-risk conduction system disease, appropriate pharmacologic interventions, push-dose pressors, airway considerations, and timely consultation or transport to definitive care. Using case examples and physiologic reasoning, we will explore when pacing is appropriate, when alternative strategies may be more effective, and how to build a systematic, paramedic-level approach that prioritizes patient stability, rapid decision-making, and evidence-informed care. Attendees will leave with sharpened clinical judgment and improved confidence in treating bradycardic emergencies.