Posted by: medicblog999 | February 2, 2010

Part 2 – What would you do – ECG Geek 6

choices

For the first part of this tale click here, and thank you for all of your thought provoking comments. There will be many more people learning from your input than who actually comment on my blog, so thank you!

———————————————————————–

So, I am sitting with Jim wondering if I should intervene or not.

Once I had a better understanding of his dysrhythmia – 3rd Degree complete heart block (Was it really that easy, or are you all just good clued up medics??) I immediately put in the call for a ‘Cat A’ ambulance to get his off to the hospital as soon as possible.

I then had to persuade him that he was going to have to go to hospital, and had a very frank and open discussion about what was happening to him and what could happen to him if I left him at home. It was at this time that his outlook suddenly changed. He seemed to become aware of the risk he was at and he calmly told me

“Okay son, you do what you think is best. Maybe I should go in and let the docs sort me out. I had better get some things together”

He went to get up out of the chair and promptly flopped back into it again.

“Just sit there Jim, don’t worry about getting things together, I’m sure that can be sorted out later. Did you feel dizzy there?”

A little pause, a look of honesty in his eyes and a confession….

“I’ve been feeling dizzy for a few days now. Whenever I move, I feel as though I am on a fairground ride”

I check his blood pressure again whilst he is sitting in his chair and it still reads remarkably stable, although a little low for age – 105/60. His pulse however is fluctuating a bit and at times, I see it move down to under 30 beats per minute.

This is where my own dilemma came in. My guidelines for the use of Atropine state the following:

Symptomatic bradycardia in the presence of ANY of these adverse signs:

  • Absolute Bradycardia (pulse <40 beats per minute)
  • Systolic Blood pressure <90mmHG
  • paroxysmal ventricular arythmias requiring suppression
  • Inadequate perfusion causing, for example, confusion etc

Where there is a high risk of asystole :

  • Recent asystole
  • mobitz II AV Block
  • Complete Heart block with wide QRS complexes
  • Ventricular pauses > 3 seconds

I place the cannula and put him on some low flow O2 via a nasal cannula. His saturations remain at 97% on air and I know that the new guidelines state that he doesn’t need O2; however I remain concerned about the potential for him to deteriorate rapidly and also the potential for rapid hypoxia if his pulse decreases much further.

Now, this being a bit of a teaching post, I should really open myself for your criticism, so here goes.

I did give him one dose of IV Atropine (500mg) and my rationale for that was as follows.

The fact that he is now owning up to feeling very dizzy in movement and change of position, I feel places him in the ‘symptomatic’ range of treatment. He does however, remain a fairly well perfused colour, and doesn’t appear confused in any way and that blood pressure remains fairly stable, although teetering on hypotension. I know that atropine is unlikely to change his rhythm, as he has a narrow complex third degree heart block which is very unlikely to be changed by chemical intervention anyway.

As the vast majority of you have all said in the comments of the last post, he needs pacing, sooner rather than later. Yes, he is compensating, but how long is that going to last?

The UK ambulance service does not currently allow paramedics to transcutaneously pace yet, although our Lifepak 12s are all set up to do it anyway. I am working on that though. After my trip to San Francisco and working with Justin for a week, it is one of the things I would like to change if possible, but I know that is a long way off.

In the back of my head, I can also see the scene as I hand the patient over in A&E with a pulse of 27, and the symptom of postural dizziness. I know that shouldn’t sway my opinion, and it wouldn’t if I could honestly say he had no symptoms at all, however that isn’t the case anymore.

My only concession to my own knowledge as opposed to following the guidelines is that I can give up to 3mg IV in 500mg incremental doses if no response to each subsequent dose, although I have already decided that Jim is getting 500mg and that is it, unless there is some positive impact on his rhythm.

Following his dose, guess what???

Nothing…….

The crew arrived about 7 minutes after I put the call in, and by then I had noticed some change to his ECG. Again, sorry guys, I know I will get lynched for this, but no 12 lead again. However, I can confirm that there was no evidence on new or ongoing ST changes (elevation or depression) and no other concerning findings other than the 3rd degree heart block. Here is the Rhythm strip though:

ECG pt 2

Click to Enlarge

So, we arrive at the next point in the dilemma.

What has happened to his ECG now and would it change your treatment pathway that you have embarked upon following the initial assessment?

Feel free to have a go at me for giving the Atropine. I’m all for a good discussion and I believe that my rationale was sound based on working to my guidelines but also taking into account the extra knowledge that I have gained over the years. But all of that doesn’t mean that you have to think I was right.

The most interesting part is yet to come though, and I will share that with you in another two days time.

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Responses

  1. Ok, getting a bit out of my depth here but going to try. I don’t think you were necessarily wrong in trying atropine as he fits the guidelines for it. The QRS complexes are wider and, as you would expect, the T waves have changed. The narrower QRS complexes he had initially implied a junctional escape rhythm, while the wider QRS complexes imply an escape rhythm somewhere at or below the Bundle of His. This could be because atropine increases the oxygen demand of the nodal tissue causing it to cease to function as a pacemaker, thereby pushing the focus of the escape rhythm further down the conduction pathway. A broader QRS complex means he’s also more likely to go into asystole so it’s starting to get a bit more worrying. My treatment as a member of SJA would not change, get the ambulance there quickly and be prepared with the AED in case he goes into cardiac arrest.

  2. You've dived below my depth, but looking forward to seeing others comments and hearing the rest of the story.

  3. Being conservative, I'd prepare for the worst: pacer pads on, 2nd IV, airway gear ready, and I'd aim for a full-service cardiac capable ER; an extra set of hands in the back of the ambulance, in case he decides to arrest. Lights and siren to the ED, early notification so they'll BE READY when we get in, and a very deep, meaningful talk about the facts of life with Jim as we drive. And his billing info. Sorry Mark, we still ask.

  4. I think I know where this one is going…. Strip is showing LBBB, perhaps a little incomplete so I cannot comment any further on what else I see.

  5. I think I know where this one is going…. Strip is showing LBBB, perhaps a little incomplete so I cannot comment any further on what else I see.

  6. My protocols and everything I learned in paramedic school in the US states not to give Atropine without a 12-lead. If given to a STEMI you could have put the patients downward spiral in overdrive. My opinion is without a 12-lead you put this mans life in danger and because inferior MI's have a high incidence of causing heart blocks and bradycardia. Since the pt had a stable BP and was Alert in my opinion you made the wrong call.

  7. Pmedic my state protocol would also have me giving the same dose of Atropine to a symptomatic bradycardia patient. Not opining on the right or wrong of the protocol just stating it for what it is.

  8. Wow Mark…good case.I probably wouldn't have given the atropine as his postural near-syncope is a stretch to call “symptomatic” (plus it wont do anything to help a complete block) but I can see why a trial of 0.5mg was done.The new EKG (you know we all reeeeally want to see the 12 lead, right?) is still CHB with a different morphology and, though limited by the 3-lead, those T-waves look big. Any consideration of hyperkalemia as a possible cause – K+ supplements, etc?You really need to have TCP as an option – what would you have done if he arrested? – bradyasystolic arrests from high degree block need immediate pacing for any chance of ROSC

  9. If you don't have pacing, you don't have one of the most effective treatments for this. Of course, with his V/S as you listed them it might not be needed. Giving 0.5 mg of Atropine in CHB is like peeing in the ocean to raise the tide. YOU might feel relief, but the ocean won't notice. Several services in my area of the US won't allow the use of Atropine in 3rd degree or 2nd degree type II. Your patient also seems like a “TOUGH” old codger so he may not be honest with all of his signs or symptoms, not wanting to be a bother. After I had him on some O2 and obtained a 12 lead, I may have moved on to Orthostatic V/S. Is his near syncopal episode caused by the CHB, a volume deficit, or something else? These may help you determine. Also knowing his meds could help. Is he taking a Beta Blocker, Dig, or a Calcium Channel blocker which could very well be the cause if the dose is too high. Hope I gave you some food for thought.. goodness knows i don't know everything.

  10. Hi Pmedic,Thanks for the comment and your opinion. As I mentioned in the first post, a 12 lead was taken, in fact a series of 12 leads were taken, but I do not have copies of them as they went with the patient and our vehicle went VOR after the job, so I didn't get a chance to go into the archives and retrieve them. Maybe I should have made it clearer in this post, but when I wrote :”Again, sorry guys, I know I will get lynched for this, but no 12 lead again. However, I can confirm that there was no evidence on new or ongoing ST changes (elevation or depression) and no other concerning findings other than the 3rd degree heart block.”I meant that I did not have the 12 lead to show you, not that I didnt take one.The other thing is that as you quite rightly say, inferior MI is frequently associated with a bradycardia and or blocks, but as you can see in the rhythm strip which shows leads II, III and aVF, this was the not the case in this patient.Regardless of clarifying my points about the 12 lead though, you may still feel that I was wrong to give the Atropine anyway.Thank you for the discussion point.

  11. Is it showing a LBBB or could it be something different?I know I have made it difficult without being able to show you a 12 lead, but what else could it be showing?

  12. Thanks for your input gbmichael.I didnt want to do postural BPs as if he was feeling “a little dizzy” with a BP of 105/60 then I didnt want to stand him to see if he dropped further. I was concerned enough about him already and didnt want to risk him collapsing with me there on my own! His meds consisted of an antihypertensive and simvastatin, with no recent changes to doses etc.Your analogy of peeing into the ocean is a good one. I knew that it was unlikely to work. I also knew that I wasnt going to keep dosing him up with more Atropine, but in the back of my head I was also concerned that by not giving him a dose (according to my protocols), depending on clinical judgement I could be judged one of two ways – either going against guidelines or treating a rhythm that potentially didnt need treating.Which is why I wanted to share this case. Especially when you see what happens tomorrow!!Thanks for your thoughts.

  13. Interesting case, and I am anticipating the update.I am always hesitant to question another medic's treatments, especially if I am not there to see the patient for myself. That being said, what are comments on a case like this for?I personally would not have given Atropine to this gentleman. Like others have said, pacing is the definitive treatment for CHB. Understanding that you do not have pacing protocols set up, yet you have the capabilities with your LP12, I would ask if you considered contacting a physician for orders? At my service, we have standing orders for pacing, and are given the option to judge for ourselves whether or not Atropine is warranted in all bradycardias. That being said, if we were both in the same room looking at this same patient, and it was your turn to “tech” (as we say in Georgia), I would be more than happy to hand the Atropine to you, without argument. I wouldnt say you were wrong for giving it. Much like starting IVs on toothaches. Couldn't hurt, could it?

  14. Interesting case, and I am anticipating the update.I am always hesitant to question another medic's treatments, especially if I am not there to see the patient for myself. That being said, what are comments on a case like this for?I personally would not have given Atropine to this gentleman. Like others have said, pacing is the definitive treatment for CHB. Understanding that you do not have pacing protocols set up, yet you have the capabilities with your LP12, I would ask if you considered contacting a physician for orders? At my service, we have standing orders for pacing, and are given the option to judge for ourselves whether or not Atropine is warranted in all bradycardias. That being said, if we were both in the same room looking at this same patient, and it was your turn to “tech” (as we say in Georgia), I would be more than happy to hand the Atropine to you, without argument. I wouldnt say you were wrong for giving it. Much like starting IVs on toothaches. Couldn't hurt, could it?

  15. Left anterior hemiblock? Now I'm guessing. Steve

  16. Left anterior hemiblock? Now I'm guessing. Steve

  17. well…you picked up his atrial rate!

  18. I can't say that I've ever seen 3AVB with a narrow complex escape rhythm turn into 3AVB with a wide complex escape rhythm. Interesting! Doesn't seem to be much difference in the rate though. As a side note, is there a reason you monitor leads II, III, and aVF? Seems a little redundant to me! Regardless, I don't think it's a big deal that you tried 0.5 Atropine. I probably wouldn't have done it, but I probably wouldn't have stopped you from doing it either. It almost never works with 3AVB, even with narrow complexes, but you never know! 🙂

  19. As of now I see what your protocols say and I suppose you could permit giving atropine for the bradycardic rate but again it is contraindicated in a 3rd degree block which is still what I see. I also see that the atropine did nothing for his rate as it is still in the 30's. As far as changes go obviously the t wave elevation, some st elevation, and a widening qrs in lead 2. A LBBB was mentioned, I could go with that based on the widened qrs in lead 2 but again a 12 lead would be rather nice to look at:) I understand a 12 lead was taken just not posted. In my opnion without being able to see a 12 lead were all in essence shooting at a deer 1000 yards away. What else is going on? Im going to guess now but the t wave eleveation could be hyperkalemia which was previously mentioned by somebody a LBBB could be possible, maybe multiple blocks? The t wave and qrs changes do worry me based on everything that has been said I would be getting ready for a code.

  20. remember you can get an accurate set of orthos from a sitting to prone position. I usually do that as a means of getting orthos and positioning for possible compressions and 12 lds. As for atropine, every protocol in every state i've worked in (4) stated that atropine was not to be used in a 3rd AVB. i otherwise agree with the others tx options given previously, this doesn't appear to be symptomatic except for the lightheadedness. I also agree with the possibility of hyperkalemia or some other imbalance. Does the patients living situation, past hx, or skin signs indicated dehydration or other dietary concerns? Does your service allow hematocrit testing or metabolic panels?

  21. I do not see a LBBB in this rhythm. I think the original strip showed junctional escape. When the 0.5mg atropine was administered and the atrial rate kicked up to about 100, it became a ventricular escape (possibly, as someone said, due to increased oxygen demand, which would have been a strong-enough concern in my mind to hold off on the atropine). The T waves are tall and wide due to the slowly conducted ventricular depolarization. They are not hypokalemic–besides having a good story for why they are big, hypokalemic T waves are usually narrow with tall, prominent peaks. They are also associated with diminishing p wave amplitude. I also do not see any evidence of a fasicular block. When the rate becomes ventricular, we note an indeterminate or high left axis shift, but this is expected due to the ventricular pacemaker, so I do not think we need concern ourself with a sudden (magic-fast MI?) onset LAHB.I'm not sure how orthostatic vital signs will change your treatment or provide new information. I agree with Mark; we already know he's positional.This guy is sick, but not super-sick. Slap the pacer on him if you have it, otherwise, IVx2, oxygen, monitor, mellow transport.Also, his QTc might be a smidge long, which could be a problem if someone does manage to speed up his ventricular rate

  22. I do not see a LBBB in this rhythm. I think the original strip showed junctional escape. When the 0.5mg atropine was administered and the atrial rate kicked up to about 100, it became a ventricular escape (possibly, as someone said, due to increased oxygen demand, which would have been a strong-enough concern in my mind to hold off on the atropine). The T waves are tall and wide due to the slowly conducted ventricular depolarization. They are not hypokalemic–besides having a good story for why they are big, hypokalemic T waves are usually narrow with tall, prominent peaks. They are also associated with diminishing p wave amplitude. I also do not see any evidence of a fasicular block. When the rate becomes ventricular, we note an indeterminate or high left axis shift, but this is expected due to the ventricular pacemaker, so I do not think we need concern ourself with a sudden (magic-fast MI?) onset LAHB.I'm not sure how orthostatic vital signs will change your treatment or provide new information. I agree with Mark; we already know he's positional.This guy is sick, but not super-sick. Slap the pacer on him if you have it, otherwise, IVx2, oxygen, monitor, mellow transport.Also, his QTc might be a smidge long, which could be a problem if someone does manage to speed up his ventricular rate


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