BRADYDYSRHYTHMIAS

Question 1

MANAGEMENT

Answer 1

Check alertness / responsiveness
Check Pulse
Check Breathing

1. MOVIE
   Monitor
   O2
   Vitals
   IV Access
   Place ECG
   Pacer Pads
   Place resuscitation cart and airway equipment at bedside
2. ASSESS STABILITY:
   ALTERED MENTAL STATUS
   Anginal Chest Pain
   Dyspnea due to pulmonary congestion
   Hypotension
   Signs of Shock
   Pre-syncope / syncope

Pulse / Rate Dissociation

12 LEAD ECG:

3. Check P Waves
4. QRS;
   Wide QRS BAD
   Narrow QRS NOT SO BAD

UNSTABLE:

Lay the patient FLAT -> increase cerebral perfusion

UNSTABLE SINUS BRADYCARDIA OR MOBITZ I:

Atropine
First dose: 0.5 - 1 mg IV bolus followed by 20 ml NS push
Repeat every 3-5 min
Max 3 mg

IF ATROPINE INEFFECTIVE
OR
MOBITZ II OR 3RD DEGREE HEART BLOCK:

Transcutaneous pacing:
Start at 80 mA and reduce to lowest energy that initiates pacing
THEN
Set HR (80-100)

Set 2 mA above capture:
Electrical capture
Pacing spike is consistently followed by a widened QRS complex.

Mechanical capture
palpable pulse corresponding to each electrically paced complex.
Patient’s perfusion improves

IF NO IMPROVEMENT WITH ATROPINE OR TRANSCUTANEOUS PACING:

Epinephrine:
20-50 µg IV bolus
OR
2-10 µg/min IV infusion
OR
0.01-0.5 mcg/kg/min
Usual 0-0.3 mcg/kg/min
4 mg epinephrine is mixed with 250 ml of NS
Titrate to patient response

IF NO RESPONSE OR HYPERKALEMIA:

1 g calcium chloride
OR
3 g calcium gluconate IV

THEN

Dobutamine
2-20 µg/kg/min IV infusion

Dopamine
2-20 mcg / kg / min
Usually 5-10 mcg/kg/min
Mix 400 mg in 250 ml NS
Titrate to patient response

Isoproterenol (pure beta agonist) 2-10 µg/min IV, titrate to effect

OVERDOSE (BCCD):
Beta Blocker: Glucagon 5-10 mg IV bolus over 1 min followed by continuous infusion at 1-5 mg/h

CCB: Calcium chloride 1 g (10 mL of 10% solution) IV or calcium gluconate 3 g (30 mL of 10% solution) IV bolus at 1 mL/min. Calcium chloride should be given through a central line.

High-dose insulin 1 unit/kg IV push followed by 0.5-1 unit/kg/h with adequate glucose repletion.

IV lipid emulsion 20% at 1.5 mL/kg IV bolus followed by continuous infusion of 0.25 mL/kg/min over 30-60 min.

INVESTIGATIONS

ECG
core temperature
POC glucose
Electrolytes
Extended Lytes
Troponin
TSH
coagulation panel
complete blood count
cultures

Question 2

DOCUMENTATION

Answer 2

HISTORY
Anginal Chest Pain
Dyspnea due to pulmonary congestion
Hypotension
Signs of Shock
Pre-syncope / syncope

PHYSICAL EXAM:
Mental Status
CVS:
Pulse / Rate Dissociation
L/E Edema
JVD
Pulm: Crackles

Question 3

DDx

Answer 3

DDX:

Top DDx:
Ischemia
Electrolytes (hyperkalemia)
Drugs (BCCD):
BB
CCB
Clonidine
Digoxin

Instrinsic (sinoatrial and AV node dysfunction):
Aging is the most common cause
Ischemic heart disease
Infiltrative disorders
Surgery
Trauma

Extrinsic (non-electrical system cardiac tissues):
Acute coronary syndrome (ACS)
Medications
illicit drugs
toxins
Metabolic(hyperkalemia)
Implanted pacemaker dysfunction
Infectious agents and infections
Endocrinopathies
Increased ICP