(Credit: Dr Jenny Lee, Resident at Harbor-UCLA. From core competency lectures)
Pertinent positives/negatives:
_ symptoms of unstability:
no chest pain
no SOB
no encephalopathy
no hypotension/syncope
_ hx of prior HR range
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Complaint specific findings on exam:
Tox exam: no constellation of signs suggestive of toxodromic syndrome on exam
Chronotropic response and orthostatics (contingent upon pt being well appearing and no contraindication e.g. suspected ischemia): normal chronotropic response, not orthostatic
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ED COURSE:
_ Diagnostically
on monitor, pacer pads on patient
EKG
BMP/iStat
troponin
CXR
_dig level
_reveiew pt’s home medications/previously administered medications
EKG: bradycardic, narrow complex, no ST elevation or depression. Interpretation by me find junctional escape rhythm
Therapeutically:
ASA (ppx in case of myocardial ischemia)
DDx (I considered that there is a small but finite risk for the following processes. The patient’s presentation does NOT meet our criteria for being reasonable for additional pursuit of these entities at this time (i.e. reasonable level of consistency with characteristic findings as detailed parenthetically below):
-primary cardiac pathology
-sick sinus syndrome
-myocardial ischemia
-bundle branch block
-electrolyte derangement (K, Ca, Mg, Phos)
-hypothermia
-hypoxia
-infectious
-toxicologic:
-Ca, beta blocker, dig overdose, et al, illicit substances
-reflex with hyper vaguel response
-normal variant, non-pathologic
Considered the following differential for bradycardia
sick sinus syndrome:
Therefore we will pursue ACS workup including EKG, troponin and empirically administered aspirin.
Polypharmacy:
Reviewed patient’s home medication and there are no changes suggestive of pharmacologic etiology to patient’s bradycardia-specifically unlikely beta blocker overdose or calcium channel overdose
Considered possible electrolyte abnormality-specifically hyperkalemia however EKG is not consistent with hyperkalemic morphology and patient does not have history of renal disease however will obtain basic metabolic panel to evaluate for electrolyte derangements
Consider digoxin toxicity however patient not on digoxin
MDM (with A/P):
Level of Dysfunction:
_ Narrow QRS suggestive of high level of conduction abnormality
_ Wide QRS suggestive of low level of conduction abnormality
Rhythm:
_ regular
_ irregular
Stability:
presentation is most consistent with
_ stable bradycardia
Stability:
Patient appears to be stable by virtual following criteria:
Hemodynamic stability by virtual of no hypertension
No encephalopathy or altered mental status
No objective shortness of breath
No chest pain suspected to be secondary to ischemia at this time
_ atropine 0.5mg IV (held if suspected to have myocardial ischemia given potential for increased demand)
_unstable bradycardia
_ atropine 0.5 mg IV
_ epi gtt
_ pacing
_transcutaneous (given able to initiate faster given acuity of patient’s situation): settings: demand mode (not fixed), HR @ 80, 40-80 mA, increased until capture
Chronotropic response:
Upon stimulation patient, patient has sufficient chronotropic response.
Assessment:
_ No source for bradycardia elucidated on ED evaluation, patient admitted for further eval, diagnostics, intervention
_ Suspected etiology of bradycardia to most likely be:
_
Disposition:
_Admission:
_ emergent cardiology consults
_ admission to cardiology CCU
_Home:
_ given pt is stable with bradycardia for period of observation in ED, no reversible cause revealed on diagnostics above, no evidence of end organ damage/hypoperfusion, and has appropriate chronotropic response, patient is at sufficiently low risk for a pathologic process causing the bradycardia and as such, suspect that the patient’s heart rate is a normal variant. Advised for prompt re-evaluation with outpatient PMD/cardiologist and implored strict return precautions with patient.