EMS 12-Lead: The 12 Rhythms of Christmas – Sinus Bradycardia

This article is the second in our latest series, The 12 Rhythms of Christmas, where each day we examine a new rhythm disorder. It’s a continuation of the theme behind last year’s 12 Leads of Christmas.

Last year I posted a nearly identical article titled Don’t let your bradycardic patient D.I.E., but this is an update focused on sinus bradycardia and with a slightly new mnemonic. Our new post should be called, Don’t let the cause of bradycardia H.I.D.E..

I’ve told you before that I’m terrible with mnemonics, but there is one I used to find both memorable and useful: the DIE mnemonic for insidious but reversible causes of bradycardia in the emergency medicine and acute care setting. DIE stands for drugs, ischemia, electrolytes. While I love its simplicity, I no longer rely on that exact mnemonic because it leaves out an important cause of bradycardia you do not want to miss—hypothyroidism.

Unlike ischemia, hypothyroidism is not a major concern from a prehospital perspective, and unlike hyperkalemia, it’s not quickly reversible, but given its importance in the trajectory of a patient’s care and how easily it can be overlooked, I think it still deserves a spot in my favorite memory aid.


Yes, there are other causes of bradycardia that should be on your differential, but what makes this list special is that all four have specific emergency treatments, the standard ACLS trio of pacing, atropine, and dopamine/norepi does little or nothing to address them, and, if missed, patients are unlikely to get better with only supportive care.

For the rest of this article please follow this link or click on the ECG below.

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