Hypotensive Bradycardia

[hammerpcp]

I am curious as to how many of you would treat the rate immediately and how many of you would administer fluid therapy first to see what happened. Also, if you opted for fluid bolus, how long would you wait until treating the rate? Assuming there is no improvement with the pts condition of course. What is a reasonable amount of time to hold off other treatment to see the effectiveness of fluid alone?

BBT = be back tomorrow

[Lithium]

That's another reason why I do feel this is more of a volume problem rather then rate. The beta blockers are working more on his rate then on vessel size/diameter. We all know HR x SV = CO. So yes, even tho his HR is fairly low which could correlate to the lowered BP, if we start pacing him, all you're gonna be doing is speeding up the pump, but if all his vessels are huge, you're not going to see much difference.

Add in some dopamine, get some vasoconstriction, his BP will rise, CO will increase, perfusion to the brain will allow his mental state to return to normal, and I still don't need to mess around with sedation (which has the possibility of lowering BP once again) and I haven't caused him any pain by actually pacing.

Remember Hammer, your protocols are guidelines. If you have access to a medication (ie. dopamine) and you feel it will be beneficial, even though it's not one of your protocols for unstable bradycardia (just bolus, atropine/pacing) patch! Depending on your relationship with the MD, how well you present your case, you'll probably get the order. Just don't get sad when they switch over your primitive dopamine drip set up with a buretrol over to an infusion pump ...

Edit: didn't see your post!

Id go ahead with a fluid bolus first, it's the least amount of harm I can do. I'd start it on scene, and depending on where we are, how long extrication takes from where he is, reassess once I got down to the ambulance. If 500 mls isn't enough to cause an increase in his mental state or atleast get a palpable BP, I'd move to atropine and wait 5 minutes, then onto dopamine.

[becksdad]

OK, I'm an EMT playing with Paramedics here, but my first impression is that this is very likely a medication interaction. The anti-Parkinson meds - Levodopa and Levocarb - isn't it very common to induce orthostatic hypotension? And isn't Trihex used as an adjunct with these meds? The Amiodirone and Metoprolol - they will keep HR low, correct? Compound these effects with the fact that patient just had wine - initially induces vasodilation, correct? Further compound that if he took any of his NTG (or Viagra as someone pointed out - dirty old man!).

You said lungs are clear, no resp. distress. The fluid challenge sounds good, but honestly, the first thing I would do is to lay him down and see what changes. Is that stupid?

[Shelbmedic]

well 12 lead is good pupils er and hand grips are fine after I gave him his inital bouls of 250cc I would move him to the stretcher place him in the trendenlenburg position move him to the unit . Then do vitals again if no change I would bolus 250 again and if that didn't work I would do another 12 lead and if that doesn't show any changes I think about atropine 0.5mg repeat till 1mg if needed then try dopamine drip.

Just one last thought how long has he had parkins? Is at the end stage ?? Has he been taken his meds the way is supposed to?

[Ridryder 911]

You guys have some great responses, but I believe we are over analyzing this a little bit. Let's keep this simple..

I too believe it is a rate induced problem, there is not clinical evidence of failure, i.e. CHF, etc..indicating otherwise. Sure, the rate may not be that low for a mid twenty year old, but for a post. inferior AMI in a middle age patient it should be raising red flags.. and is of concern. Remember, treat the rate if ...."the patient is symptomatic".. sure, give a fluid bolus, but doubtful it is going to help. Usually with afterload problems you will see clinical findings of such before sudden hypotensive.

Dumping more fluid than 500ml is not going to help him other than to drown him, it is probably a pump problem and his rate is affected. Time to pace the patient. Worrying about a "possible side effects" and trying to treat an overdose of medication without really knowing that is the real primary source is going to bite you in the butt... while your patient is dying. It really does not matter.. you have to treat the immediate reaction at the time on this one.

Try pacing and see if perfusion increases, if it does not, then use some form of vasopressors in conjunction.

If you have capture and still no increase in perfusion, then you have identified the problem... and the patient is in need IABP... or has another horrible etiological problem..

R/r 911

[nsmedic393]

You said lungs are clear, no resp. distress. The fluid challenge sounds good, but honestly, the first thing I would do is to lay him down and see what changes. Is that stupid?

Thats not stupid. Actually its the first thing I thought of when reading the initial post. Lay him down with his feet up. O2, IV and fluid bolus, 12 lead, atropine, pacing and then finally dopamine if all else fails.

[bassnmedic]

I think some postural changes would be my first line treatment and try putting the patient in trendelenburg along with a fluid bolus of say 250 -300 cc. Since the rhythm is a sinus brady and no block is indicated, I'd try .5mg Atropine IVP, if the fluids didn't help. TCP and or Dopamine may be in the cards for this gentleman if the Atropine and fluids failed to help with his perfusion.

Take care,

Todd

[Paramagic14]

02 15Lpm via NRB, POC high fowlers,continous cardiac monitoring,12 lead with a repeat after a few minutes, check blood glucose---> if low give D50/no iv access?----> glucagon IM, IV 18gauge,fluid challenge 250mL NS--->checking lung sounds before and after,reasses,consider second 250mL fluid challenge, quick neuro exam,seizure hx?,consider atropine if no change consider second dose or pacing,possibly dopamine, rapid transport code 3

[hammerpcp]

Alrighty, the general concensus seems to be to try a fluid bolus prior to addressing the rate. So we administer 250cc over 5-10 min or so. Pt's BP is 78 systolic. Now what?

[Paramagic14]

give a second fluid challenge if lungs are still clear.....consider dopamine...reasses pts mental status......perfusion status