Tuesday, July 9, 2013

Heart Block

This was a great case I helped with recently. This is a classic presentation of syncope in an older patient with no medical problems. He just kept passing out when he stood up.
First Point: ALWAYS do a 12 lead when the problem is syncope, and always leave them on the monitor. You never know what you are going to see.

So the EMS crew found him in the above rhythm and correctly identified 3rd degree heart block. He had no symptoms of chest pain. i often think of this happening with an inferior MI, but he did not have the clinical picture.
Point #2: The QRS was wide so they correctly did not try to interpret it for a STEMI.

By ACLS standards, the man is unstable, I guess. He is passing out, he is groggy and has a low BP, but he is not having pain or real dyspnea. This is the first challenge, should you pace him? Pacing means pain, and that means sedation and their goes your ability to use mental status and brain perfusion as a sign of cardiac output. These can get real tricky.
He got atropine, then external pacing and then versed because the mini-taser 80 times a minute gets a little uncomfortable.

So he presents groggy, twitching every .75 seconds and yet his pulse was 24. So the pacing was not effective at the time.
Please send me a note if you have ever felt like you successfully managed a patient with an external pacer. My experience is that you have to crank the energy way up just to capture the heart. And I define capture as feeling a pulse with each twitch, not just a change in appearance on the monitor. In order to get the energy that high, you HAVE to sedate them and I really think you have just complicated the whole picture.

My choice of management was to intubate him immediately so we could remove the patches from his hairy back.
Seriously, I chose not to pace him, watched his HR of 24 and asked him 300 times if he was still with us while waiting for the cath lab to be ready to put in a pacemaker.

And he did fine. My point is this. The decision making around pacing for bradycardia can be very challenging. I do not think that pacing is a great, successful therapy for bradycardia. It has it's own problems. Like the need for sedation and trying to determine if the pacing is really helping. So, follow your protocol, but be willing to critically think about your decision to pace and if you are really helping the patient.


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