Bradycardia

[JMedic]

Just looking for some input on a patient I had yesterday.

We were dispatched to a residence for someone in a "weakened condition". We arrive to find a 94 year old feeling "tired". She was blind, and had a history of CHF. The vitals were stable,,except for the pulse. a 3 lead EKG was attached indicating a rythm of 36 and holding throughout. Upon recieving the 12 lead, there was narrow complexes, but no apparent P waves or anything else. You were able to determine notches in some of the complexes, but nothing else. Fluid therapy of 650cc's Saline did not work, and Atropine was not administered because of no certain P-waves.

The patient was transported to a Heart Center 15 mins away where the ER had some trouble making out the rythm.

I went with a form of heart block where maybe the P's were buried in the complexes, but I'm very interested in seeing whether or not anyone else agrees, or disagrees. I'm open for opinions.

Thanks!

[paramedicmike]

Got a copy of the strip you can post? That would help immensely.

[Kiwiology]

There is some ventricular innervation by the vagus nerve, although less than atrial so I would still try some atropine.

If it's not effective our guideline is to either pace or mix up an adrenaline drip.

Could be a junctional rhythm with some non conducted PACs?

[JakeEMTP]

I'm kinda going with Kiwi here. Pacing would work nicely with this pt. if Atropine didn't. I'd may have tried 0.5mg of Atropine first prior to pacing. Either way, a HR of 36 is not good and it would be considered bad form to show up @ the hospital with just a fluid bolus that didn't fix the problem.

W/o a strip though I can't tell you exactly what I think it might be.

Kudos for asking for opinions though!

[JMedic]

Here is the strip. Every once in a while there are some uncertain ectopic beats, but this ekg itself took hours to upload and im not bothering with the other one.

Let me know what you think.

[Kiwiology]

Cool story bro .... looks like AF with a bundle branch block

[BushyFromOz]

ECG wont download

[paramedicmike]

It looks like Afib. But it's too regular to be Afib.

And the download file is huge. No wonder it took "hours" to upload it.

[NYCEMS9115]

It's some sort of Supraventricular Brady-Escape Rhythm. Without a clearer strip; we can't fully interpret the Rhythm... You have to look at all variables which may have caused the Artifact. Was there fine muscle movement? Were you in the Ambulance with the engine running? Was someone in the house operating an electric powered appliance? Was there ointment or gel on the skin? Was the skin dry? Did you press on the electrodes due to diaphoresis or dry/flaky skin? Have you notice the Monitor to have Artifactky isoelectric lines on other patients? Maybe it needs service...

Remember she's approaching 100y/o... If her complaint was just feeling tired and the only finding was this bradtcardia; Pharmaco-Intervention could wait until you get to the ER.... How was the rest of her presentation? Mental Status? What was her RR and BP (You said stable but stable is subjective)? SpO2? PMH and Medications (Prescribed, OTC, Herbal, Recreational)? Who let you into the house? Bystanders/family/friends; any story? So many factors to take into consideration before the bolus of 650cc NaCl... BLS intervention: when in doubt, do. ALS intervention: when in doubt, don't do, for the most part (Unless it's ECG, SpO2, ETCO2, & IV)...

I'm just saying... I wasn't there; I'm sure your Interventions were appropriate... Thank you for sharing...

[JMedic]

94 year old female at home, AOx3, Blind, non-ambulatory, no orthostatic changes, Resps 18, BP 120/76. SPO2 99%RA, Medical Hx of one episode similar, which the hospital found was secondary to electrolyte imbalance, but never did anything about it, including no pacemaker, hx of CHF, L/S clear all areas throughout. Family reports that pt's urine has smelled foul the past couple of days. Not acting right, wanted her checked out. So I know possible factors of the rythm, but what is it that's actually DIRECTLY causing the rythm seen on the strip.

Thanks guys. Hope That Helps.