Treatment of high 2º heart block and 3º heart block

[Doczilla]

Is giving Atropine here (given the right circumstances) probably the right thing to do? Yes.

Would it be really difficult to justify in court if something bad were to happen as a result of that choice? Hell yes.

Remember that while medicine is a "practice" and an "art," our slice of it as paramedics is extremely limited. Before you start blurring the lines, make sure you know your environment well and are acutely aware of the potential consequences of such a choice. It is naive to think that just because your choice was medically defensible that it will be supported by the powers that be when the chips fall on a call gone wrong. Worth thinking about...

Atropine is a recognized treatment for bradycardia, even that caused by heart block. ACLS teaches this nation-wide. It is part of prehospital protocols in many jurisdictions. It would not be difficult to defend in court at all.

You should be buried alive if you administer Atropine for 3rd degree block. There are cases of Atropine induced VF in 3rd degree block, and if you think about it, Atropine will increase the atrial contraction rate, thus decreasing pO2 in RCA and decreasing available oxygen for the ventricles. If you administer Atropine for 3rd degree block you are in essence malpracticing medicine, as it offers no benefit whatsoever, and causes side effects associated with Atropine, and further endangers the health of the patient.

This statement is closed-minded, dogmatic, intentionally inflammatory, and wrong. It is not malpractice, and I don't know who convinced you of that. As illustrated in previous posts, there are clinical indications for atropine in heart block.

Lets stick to Atropine. Logically speaking, we all agree that for a complete heart block, i.e no signal transduction between SA or AV node and ventricles is occuring, Atropine will have no benefit. Further, we all can agree that by administering Atropine, you allowing sympathetic nervous system to accelerate the atrium, perhaps increasing the atrial kick, which I will agree is a beneficial thing.

However, in literature I've reviewed, the Atrial tachycardia actually decreased cardiac output and blood pressure, thus decreasing perfusion to the ventricles. It was in part due to the ventricular tachycardia that followed, thus decreasing the inotropic effectiveness. In the case of a 3rd degree block, you are not affecting the ventricles, but you are increasing an atrial kick, but considering you only increasing cardiac preload, do you really benefit the cardiac output? Simultaneously you have a drop in pO2 in the RCA and in conjunction with an ischemia and ectopic centers in the ventricles you will aggravate the situation.

Bottom line is, to me, transcutaneous pacing has always been the best treatment modality. You cause pain thus increase the sympathetic response causing vasoconstriction, inotropic, dromotropic, chronotropic effects on the pump, and most importantly restore the blood flow via ventricular stimulation.

Its like a symphony of the cadence of life. It just works. Atropine, on the other hand, is a very dangerous alternative therapy. Just my humble opinion. In truth, I like to be in control. By external pacing you are taking over the functions of the SA or AV node, thus establishing yourself to be in charge, and having the pads already on the patient will let you cardiovert should the need arise. In the cases of acute MI, which can cause the heart block in question, the biggest concern is deterioration into VF/VT. Having pads already on the patient will let you rectify that possibility, and free up your hands to draw up Amiodarone or Lidocaine. To me its never about just one condition, its anticipating what will follow next and being ready for it right now and not once the condition presents itself.

Intentionally causing pain to elicit a physiological response is a draconian way of practicing medicine. If you want to increase sympathetic tone, you can administer a sympathomimetic agent, like dopamine or dobutamine or norepinephrine or epinephrine, which I see as far better than torturing the patient. Increasing sympathetic tone, by drugs or by causing pain, carries the same risks that you ascribe to atropine of increasing myocardial oxygen demand. And so will TCP. I've given quite a bit of atropine, and I do not see it as "dangerous" in the proper clinical setting, and is very well tolerated overall. TCP carries issues as well, if the patient is in such severe pain that they are trying to rip the pacer pads off their chest, then it's not "more efficient" than atropine.

That is all fine, but its not our job to sit there and figure out the diagnosis. We manage symptoms, and most efficient way to manage the bradycardia is transcutaneous pacing. You can spend an entire hour there trying to figure out H's and T's and that is fine, but its a job best left for the clinical setting.

Then why do any treatment at all? Just load them in the truck and take them to the hospital if that is the way you want to go. Your differential diagnosis must guide therapy. You have to think critically about what is causing the patient's condition and act accordingly.

'zilla

Edited September 6, 2010 by Doczilla

[speedygodzilla]

What I don't get is why many are saying they would give Atropine while "setting" up pacing. For the patient in the survey sedation is contraindicated since patient is unstable. Also it takes longer to spike a bag, start an IV, push Atropine, etc than to start pacing.

I have been taught not to give Atopine with 2nd Degree type two and 3rd Degree Heart Block due to increase work that it would place on the atria without helping the overall problems. In my understanding in a since Atropine increase P waves which is not going to help a 3rd degree block since the P and QRS are not married. As for the 2nd degree type two it makes more sense to possibly work but it is likely to increase number of blocks or "missed" beats.

[Inf]

Hey INF, how about trying this: After you have actually administered atropine to 10-15 patients, you can come in here and tell us all about it.

What does that even mean? I could walk before you were even a sperm in your drunk daddy's balls.

This statement is closed-minded, dogmatic, intentionally inflammatory, and wrong. It is not malpractice, and I don't know who convinced you of that. As illustrated in previous posts, there are clinical indications for atropine in heart block.

Are you being intentionally dense? First of all you keep talking about Atropine like it is used for any heartblock. I don't know what they teach you in the Caribbeans, but here in the states we prefer evidence-based medicine. Atropine in 3rd degree blocks is well documented to cause a cardiac arrest.

Edited September 7, 2010 by Inf

[chbare]

Your ignorance is astounding and only works to fuel your arrogance. I hope you enjoyed your short tenure on this site.

[ERDoc]

What does that even mean? I could walk before you were even a sperm in your drunk daddy's balls.

Are you being intentionally dense? First of all you keep talking about Atropine like it is used for any heartblock. I don't know what they teach you in the Caribbeans, but here in the states we prefer evidence-based medicine. Atropine in 3rd degree blocks is well documented to cause a cardiac arrest.

Would you mind providing evidence (from a legitimate journal) that shows how well documented this risk of atropine is? It seems that the American Heart Association disagrees with you. The package insert does not list it as a contraindication. An article from Critical Care Resusication recommends catecholamines, ATROPINE, aminophylline and temporary pacing as intial first line interventions. Before you ask, no, I did not go to any foreign medical school. I graduated from a NY medical school and did residency there also.

[Just Plain Ruff]

Guys, Chbare and ERDoc, haven't you read the book "Arguing with idiots" I think you are doing just that.

INF, if you can cite journals as to why atropine is so dangerous why don't you? If you just spout off your "humble opinion" you will be proven wrong.

But maybe we are too dense to understand why Atropine is so bad.

I've found nothing that marks Atropine as a absolute contraindication for any bradycardia. Have you?

Paramedic (Inf) arguing with two of the docs on this site 20 bucks

Paramedic being handed his butt on a plate - 100 bucks

Paramedic being laughed off the site - priceless

Funny thing is, I've given Atropine to several type 2 and 3 heart blocks and it's never caused cardiac arrest like Inf says it will. Sometimes the patient even got better. Not the 3rd degree block patients but the 2nd degree type 2 have gotten better.

Why do you wish to cause pain to any of your patients. That's not what we are supposed to do.

[ERDoc]

To be fair, there was a study that showed an increase in mortality to heart transplant pts who were given atropine. Maybe there are a large number of heart transplant pts running around NYC and that is why it is being taught. The funny thing is that the NYC REMAC protocols say that atropine should be used in compete heart block when the pt is bradycardic and symptomatic (see page D.20). Inf, you may want to let your medical director know that you know something they don't.

Off topic-When looking for the NYC protocols, I came across the FDNY website FAQs and question number 8 is, "Can and EMT or paramedic promote to firefighter?" A little insulting, no? Is it really a promotion?

[HERBIE1]

Seems like most are in agreement here. I agree, Atropine first, while getting ready to pace. However-

Based on the vitals, by definition this person IS unstable (hypotensive, altered LOC), which means in my system, TCP is the treatment of choice. That said,

in similar situations I have pushed atropine first, and it sometimes works- at least in the short term, but I ALWAYS would apply the pacing pads next, just in case.

It also depends on the patient- some folks can tolerate that BP very well, and altered LOC could mean they are a bit weak or sleepy. You could have a patient who can tolerate those vitals for a surprising amount of time, or they could be rapidly decompensating right before your eyes. Clearly you would be more aggressive(pacing first) in those situations.

I've had patients who call for general weakness, and upon exam, we find they are walking around with a complete heart block, possibly for a day or more. Would I immediately strap them down and start pacing? No- one step at a time. Evaluate and treat the patient, not just their stated problem.

Obviously it can also depend on how many hands you have, but unlike trauma, medical/cardiac calls are situations where we really can make a difference.- We can at least stabilize the patient and buy some time for the hospital to get their ducks in a row- notify cardiology, get an internal pacer ready, notify the interventional cardiology suite and/or OR, notify family, etc.

As was noted, medicine is an art, and yes, protocols are guidelines, but sometimes there's more to what we do than simply cookbook medicine. Experience gives us judgment and perspective, and we need to use that. To me, that is a defining characteristic of a good provider- balancing book smarts with common sense.

[Just Plain Ruff]

Besides, no one here is arguing that Atropine is the treatment of choice for high degree blocks, They are just arguing that it's a viable alternative.

No one here is saying don't pace these people.

No one is saying that you should cause pain to your patients to get a response you want, no wait a second, I think Inf was arguing that he prefers to make people suffer because he gets the response he wants. Kind of creepy if you ask me.

[ERDoc]

Besides, no one here is arguing that Atropine is the treatment of choice for high degree blocks, They are just arguing that it's a viable alternative.

No one here is saying don't pace these people.

No one is saying that you should cause pain to your patients to get a response you want, no wait a second, I think Inf was arguing that he prefers to make people suffer because he gets the response he wants. Kind of creepy if you ask me.

Besides the saddism in the post, I also don't like to see totally false medical information being given. People come here to learn and it would suck for them to learn and spread the wrong information.