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Treatment for a bradycardic rhythm depends on whether or not there are serious signs and symptoms. In our scenario, you're the ACLS team leader for a 78-year-old female patient. The patient is pale and diaphoretic. She tells you that she feels dizzy and weak. She states that she started feeling this way about three hours ago and it's been getting worse. Now, because the patient is conscious and alert, we can pretty much say that she's stable at the moment. But since we do not have any immediate life-threatening conditions, the first step is going to be getting a set of vitals. So, you direct your assistant to check the vitals, and they tell you that the patient has respirations around 20, heart rate of 48 and irregular, the blood pressure comes in at 78 over 40, with an SpO2 or pulse ox of 94% on room air. Based on these vitals, you would not need oxygen right away, but the patient is obviously bradycardic and hypotensive. In order to know if the hypotension and bradycardia is related to a heart arrhythmia or other cause, we should get an ECG reading. An assistant attaches the ECG monitor so we can take a quick look at the rhythm. As we look at the monitor, we see narrow QRSs. We also see a regular P-wave until the QRS is dropped. We recognize this rhythm as 2nd degree type II heart block. But because this type of heart block is below the bundle of HIS, it can turn into a complete heart block fairly quickly. The hypotension and bradycardia is a concern, so we direct our assistant to start an IV so we can consider giving atropine. If the patient was unstable, such as being unconscious or pulseless, you'd wanna start with transcutaneous pacing. But since our patient is responsive, we choose atropine first. You direct the assistant to give 1mg of atropine rapid IV push. The assistant repeats the order and gives the medication. After about one minute, we recheck the vitals, and find the respirations are still 20, heart rate is around 46 and irregular, weak, and the blood pressure has not improved, it's still 76 over 40, with the pulse ox still reading 94%. Now, based on the vitals, it looks like atropine was ineffective. The assistant tells you that the heart rate and the blood pressure both went down, and the patient just became unconscious. Now we have an unstable bradycardia. We need to start transcutaneous pacing right away. We directed the assistant to apply the pacing pads and turn the pacer on. Protocols will vary from location to location, however, the American Heart Association guidelines recommend that we start at a rate of 60 beats per minute, and adjust the rate up or down based on the patient's clinical changes. As the pacer is running, we turn up the milliamps until the heart muscle is captured. In our scenario we turn the pacemaker up to increments of five milliamps until we have consistent capture at 70 milliamps. We then turn up the milliamps up to 75 to retain capture. Once you have consistent capture, we're going to adjust the rate to between 60 to 80 beats per minute. Remember, you can turn the rate up or down until symptoms improve. In our scenario, we turned the rate up to 68. We see that the patient became responsive again. And upon checking the vitals, we now have a respiratory rate of 16, heart rate of 68 with good electronic capture with transcutaneous pacing. The blood pressure is now 96 over 60, with a pulse ox of 96. Once the patient's perfusion has improved, we need to continue to monitor the patient. We work on improving perfusion by trying to determine the cause of the bradycardia and treating it accordingly. Now, keep in mind, transcutaneous pacing can be very uncomfortable, so pain management may be something to consider while deciding to move them to the next step for cardiac treatment.
In this lesson, we're going to let you play the role of team leader during a cardiac emergency – bradycardia. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations.
In this scenario, you've been presented with a 78-year-old female patient who is pale and diaphoretic. She tells you that she is feeling dizzy and weak and also that she began feeling this way about 3 hours ago. She also tells you that her condition seems to be getting worse.
She is conscious and alert, which means that at the moment she's stable. And since she doesn't seem to have any life-threatening conditions, you determine that the first step should be to get a good set of vitals, which you have instructed an assistant to get.
Your initial assessment recap:
Your assistant tells you that the patient's vital signs are:
Based on these vital signs, you don't need to start oxygen immediately. However, the patient is obviously bradycardic and hypotensive. And in order to know if the patient's hypotension and bradycardia are related to her heart arrythmia or another cause, you decide to get an ECG reading.
The assistant attached the ECG monitor to the patient and takes a quick look at her rhythm. As you look at the monitor, you see narrow QRS complexes along with regular P-waves, until the entire QRS is dropped.
You recognize that this rhythm indicates 2nd degree, Mobitz type II heart block. And because this type of heart block is below the bundle of His, it could turn into complete heart block rather quickly.
Pro Tip #1: Since hypotension and bradycardia are a concern, you direct the assistant to start an IV in order to consider administering atropine to the patient. But if the patient was unstable, as in unconscious and pulseless, you would then begin with transcutaneous pacing instead.
However, since the patient is still responsive, you choose atropine as the first treatment option. You direct the assistant to give 1 mg of atropine via rapid IV push and wait for the assistant to repeat the order back to you, which she does. She follows the order and administers the atropine.
After a minute has passed, you recheck the patient's vital signs and find the following:
Based on these new set of vitals, it appears that the atropine has been ineffective. As you come to this conclusion, the assistant tells you that the patient's heart rate and blood pressure just both went down, and now suddenly the patient just went unconscious.
You now have a situation where the patient has an unstable bradycardia, which means you need to begin transcutaneous pacing as quickly as you can. You direct the assistant to apply the pacing pads and turn the pacer on.
Pro Tip #2: Individual protocols will dictate specifics and vary from place to place. However, the American Heart Association guidelines recommend starting at 60 beats per minute and as the pacer is running, turn up the milliamps until the heart muscle is captured.
In our scenario, you achieve consistent capture at 70 milliamps. Once you have that consistent capture, you should then turn the machine's interval up 2 to 5 milliamps – just enough to keep the capture. In this scenario, you decide to turn it up to 75.
Pro Tip #3: Once you have consistent capture at 60 beats per minute, you turn up the rate until symptoms improve, which is typically between 60 and 70 beats per minute.
In our scenario, you turn the rate up to 68 beats per minute. You then begin to see the patient becoming responsive again. Upon checking her vitals once more, you have:
Once the patient's perfusion improves, you need to continue to monitor the patient closely and work on improving perfusion further by trying to determine her cause of the bradycardia, and then treat it accordingly.
Warning: Keep in mind that transcutaneous pacing can be really uncomfortable for a conscious patient. You may want to consider some sort of pain management while also considering whether or not to move the patient to the next level of care for further cardiac treatment.