It is about 20 minutes into your shift when EMS arrives with a pleasant 80-year-old woman who has had a syncopal event. She describes standing in her home earlier today and becoming lightheaded and falling to the ground. She is now resting comfortably, and her vital signs are: blood pressure, 140/72 mm Hg; pulse rate, 74 beats/min; respiratory rate, 14 breaths/min; and oxygen saturation, 99% on room air. You have just begun to take her history when you are interrupted and called to your next patient…
You approach the bedside of a 27-year-old woman who is pale, diaphoretic, and writhing in pain. The only history you are able to obtain is that she has had mild lower abdominal pain for a few days that acutely worsened today. Initial vital signs are: blood pressure, 70/40 mm Hg; pulse rate, 58 beats/min; respiratory rate, 20 breaths/min; and oxygen saturation, 99% on room air. Your brief exam is significant for diffuse abdominal tenderness and guarding. You then hear a flurry of activity from the hallway…
Your next patient is being rushed down the hall on a stretcher. Brought in by a family member for intermittent lightheadedness and shortness of breath, this 64-year-old man is pale and diaphoretic, with depressed mental status. A quick check of his radial artery demonstrates a weak pulse with a palpable rate of approximately 40 beats/min. You quickly place him on the cardiac monitor and notice what appears to be a third-degree heart block. Initial vitals are: blood pressure, 82/40 mm Hg; pulse rate, 38 beats/ min; respiratory rate, 18 breaths/min; and oxygen saturation, 98% on room air.
These 3 cases represent some of the variable presentations of patients with bradydysrhythmias. The underlying pathology for these patients ranges from the benign to the life threatening. You approach each case in a systematic manner, knowing that prompt evaluation, recognition, and treatment can make the difference.
How would you manage these 3 patients?
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Last Updated on January 26, 2023
patient A(80 year old female)
order ECG, blood investigations( CBC,RENAL PROFILE,CARDIAC ENZYMES, BLOOD SUGAR) and place her on cardiac monitor while i attend second patient. Dont think she need oxygen, i will set a iv access but iv fluids yet. Will get back to her after settling more serious cases. remind myself to do bedside echo for her later.
patient B (27 year old female) gp through airway breathing and circulation. get 2 large bore iv access
order investigation(CBC STAT, RENAL FUNCTION, Group cross match, UPT STAT,urine dipstick., ECG ) Get quick bed side ultrasound(to look for free fluid and gravid or empty uterus)…a quick physical exam for any sign of trauma…if suggestive heamorroghic shock of any cause(trauma? ruptured ectopic?antepartum or post partum heamorrage) run IV fluids crystolloids 20ml/kg while waiting for blood…consider urgent transfusion….consult surgeon or gynea or other specielity depending on developing scenerio
patient c (64 year old man) go through ABC …
Draw blood investigation(cardiac enzyme)
consider transcutaneous pacing or inotropes (preferably dopamine or adrenaline). Examine volume status(if lungs clear, jvp not raised, bedside ultrasound shows non distended IVC etc ) will give fluid challenge while preparing patient for transcutaneus pacing. And once procedure explained to patient , consent obtained, patient is given adequate analgesia. consult cardiology for further treatment
patient c
BLOOD INVESTIGATION- CBC .cardiac marker, Renal profile, blood sugar, ) and do serial ecg…& place him on cardiac monitor
In these three patients triage is a must.
Taking the third patient first into priority, he has complete heart block with hypotension , management would be first starting fluid resuscitation , isoprenaline infusion, permanent pacing.
Second patient needs fluid resuscitation first , if refractory then pressor support, need to rule out appendicitis and any perforation in this patient accordingly give antibiotics and needs emergency laporaromy.
Ist patient with a history of syncopal attack, now doing well , need to rule out cardiac cause of syncope for which she may require 24 hour holtering monitoring.
Case #1) Place pt on cardiac monitor. Obtain EKG, CBC, CMP and CE’s. Observe for ectopy, dysrhythmias or blocks on monitoring. Because of age of pt and abrupt onset of symptoms, consider arrhythmogenic etiology and admit pt. to monitored setting.
Case #2) The pt is hypotensive and bradycardic with acute onset of pain to abdomen. Insert two large bore IV’s, cardiac monitor and O2. This pt has a ruptured ectopic pregnancy until proven otherwise. Order T&S, CBC, BHCG, and PRBC. A quick FAST exam would confirm the diagnosis if free fluid is seen in the abdomen along with a + urine HCG. The bradycardia stems from the stimulation of the vagus nerve. Call the OB consultant immediately in preparation to transport to OR.
Case #3) This patient is unstable in complete heart block. Place transcutaneous pacer on patient as bridge to insertion of transvenous pacer in ED. Insert 2 large bore IV’s, cardiac monitor and O2. Draw appropriate lab studies and call cardiologist to admit to CCU.
1- needs an EKG (although unlikely that she’s developed a sodium channelopathy at age 80) would also get an accucheck. If all normal, observe briefly and discharge. Vasomotor syncope.
2- ruptured ectopic pregancy. HCG, bedside U/S
manage for shock and stat OB consult
3- transcutaneously pace while working up. ? MI vs digoxin, vs CCB vs Beta blocker
The first patient is fairly haemodynamically stable at present and i would like to secure an iv access,draw samples for electrolytes and cardiac markers , do an electrocardiogram to rule out an MI , start the patient on iv fluids and rule out dyselectrolytemia and send the patient for a neuroimaging inorder to rule out stroke & bleed.
the second patient is haemodynamically unstable,would secure large bore iv access draw samples for complete blood counts, electrolytes ,cultures, take an ecg and an arterial blood gas.would start the patient on iv fluids -normal saline 2 lts rush ,analgesia for abdominal pain, reassess the blood pressure after fluid bolus ,if total counts are elevated would give an antibiotic shot ,and if the bloodpressure has come to be stable would send the patient for an ultrasound imaging of the abdomen and xrays of the abdomen.if the patients bloodpressure doesnt improve with ivfluids would like to start the patient on ionotropic support .
the third patient is extremely unstable ,needs immediate attention and care would start an iv access draw samples for electrolytes and cardiac markers, get an ECG, give the patient inj. atropine 0.5 mg iv stat , arrange for a trans cutaneous pacing,get help from the cardiologist by intimating him as soon as the patient has come.in the meantime if there is no response to atropine would go ahead and do the trans cutaneous pacing while arranging for trans venous pacing .i would also like to look for dyselectrolytemia and give correction for the same mainly the potassium imbalance, look for MI and cardiac markers if elevated patient needs anti platelets with stat ins and urgent consideration for PCI if THERE IS evidence of MI .patient should be stabilized before shes shifted to the cardiac coronary unit.
In the first case we must rule out orthostatic hypotension; in the second we have probabily a vasovagal syncope with predominant cardioinhibitory response; in the third he needs absolutely a permanent PM
1) Little older lady, Look out for transient arrythmia: A-fib, 2nd degree etc, TIA. Tell your nurse to get her on a monitor, a heplock, get blood to R/O MI, put her on O2. Ask if she drinks any any asian tea also
2) Get her an IV stat, give a a bolus, ask when last period, get immediate pregnancy test, gt her monitor too, get all the abd pain blood tests.Ectopic pregnancy is top differencial
3)Get him paced and call cardiology, get cardiac pannel. What are his medications? Any cardiac history?
When done then go back to each of them for more history from the other two..
Call for back up help!! # 1 initiate labs/ ecg & monitor// # 2 Fluids/ ucg/ type & cross match, call in Gyne for presumed rupt’d ectopic/
#3 pace him while getting labs, ECG, D Dimer and getting cardiologist to be ready for a pacemaker insertion!!
sick sinus syndrome can be the important differential in first case.
mesentric infarction secondary to atrial fibrillation
acute myocardial infarction can explain 3rd case
The patient with the 3rd degree heart block is treated with a pacemaker
The patient with abdominal pain is treated with a surgical consult and management for possible sepsis.
The 80 year old woman is treated with and evaluation and hydration as needed. Evaluation included EKG, cbc, ua, full chemistry, thyroid studies, check for seizures and FU care.
First patient seems a non-complicated syncope. Due to her advance age sinus carotid hypersensibility should be seek.
Second patient seems an ectopic gestation with hemorrhagic rupture and acute abodminal picture. Blood test (anemia), Ecography and rush to operating room.
Third patient displays a heart block a should be check for MI (cardiac enzimes) and implant a pacemarker