So, as an ICU nurse I made my living treating tachyarrhythmias: V-fib arrest, rapid responses for SVT. Sure I ran into some bradycardia from time to time, but most often it meant 1.) turning on the pacer (gotta love epicardial wires) or 2.) Giving some atropine, if the patient was unconscious with a low heart rate (and obviously low BP) they clearly needed some chest compression with the atropine.

Now, that I've been in the OR for a year as an SRNA, I seem to run into bradycardia quite a bit and CRNAs frequently tell me tales of the healthy young guy who bradied down to 20 on them, or, the lap chole patient whose HR dropped to zero with insuflation.

So here's the question (and the scenario). 39year patient having a having a shoulder scope. BL heart rate in low 50s. After induction he's in the 40s with a systolic in 90s. Suddenly, (either from stimulation or maybe from a slug of narcotic) HR is 28.

The SRNA has all his syringes ready to go (glyco, ephedrine, atropine), he quickly hits the BP.

Assuming the patient has not arrested (pulse is still strong, it's just super low, he has a BP it's just going to be low), at what BP would you initiate chest compressions along with the ?

I frequently hear about CRNA "reaching under the drapes and giving a couple compressions just to be the atropine circulating." Is this a real thing? Do half hearted compressions really help? Will they really speed the travel of the atropine (to the heart) considerably?

Any pearls of wisdom on how to treat this situation? Again what I'm asking about is severe bradycardia (20-30s) with a low BP, but not an arrest. You are going to give atropine, but do you need compressions?