Bradycardia

Question 1

A 67 year old male had a urological procedure yesterday and you are asked to see him because his heart rate is persistently below 60 / min. He has known prostate cancer, gout, hypertension and coronary disease. Assess and manage?

Impression/DDx/Goals

Answer 1

Impression:
Most likely this is a post-surgical sinus bradycardia. Would need to rule out life-threatening differentials including ACS particularly given cardiac history, cardiac arrhythmia (BBB, heart block), electrolytes (hyperkalaemia), raised ICP (cushings response). otherwise could be medications (anaesthetic agents),

Goals:

• Comprehensively assess for stability, institute emergent management as required
• identify underlying aetiology and appropriately manage

Question 2

Bradycardia - Assessment

Answer 2

Assessment
Would take an A to E approach in assessment and management of this patient. Call for help if haemodynamically unstable. Would want to read eMR notes to get understanding of patients background history, allergies, etc.

A - ensure patency, maintaining own. Call for help.
B - sats, RR - provide supplemental as required
C - BP, ECG, IV access, take bloods (FBC, UEC, BNP, serial trops)
D - GCS
E - secondary survey
F - Fluid intake/output for previous days (check charts)
G - BSL

Question 3

Bradycardia - History

Answer 3

History:

• sx: pre-/syncope, light-headedness, palpitations, chest pain (socrates)
• HxPC: prev episodes, resting HR
• Meds: anaesthetics, antihypertensives, B Blockers, opioids, etc
• Fam history
• SNAP

Question 4

Bradycardia - Examination

Answer 4

Examination
- A to E
- Vitals, general obs
- Cardiovascular examination, pulse, HR, murmurs
-

Question 5

Bradycardia - Investigations

Answer 5

Investigations:

• Bedside: ECG, VBG, Vitals
• Bloods: FBC, BNP, Trops, CMP, UEC
• Imaging: ECHO, may require coronary angiogram +/- PCI

Question 6

Bradycardia - Management

Answer 6

Management
Disposition:
- stable: remain on wards, consider altered calling criteria, increase nurse review intervals
- unstable: transfer to ICU/CCU for emergent treatment/management (prepare for transcutaneous pacing), consider pacemaker insertion.

Supportive

• telemetry bed for continuous ECG monitoring
• cardiac consult
• regular monitoring
• fluids
• electrolyte replacement
• medications review

Definitive
- if sinus, only needs treatment if haemodynamically unstable
pharmacological:
- atropine
- can add isoprenaline (can drop BP)/adrenaline (doesn't drop BP)
non-pharm:
- transcutaneous pacing
- if ACS manage according to pathway