In this episode Dr. Julie Vieth and I discuss management options of complete heart block.
We start with a case where EMS responded to a call for an altered mental status. Glucose was normal, but when they checked vital signs they realized the patient was bradycardic. Patient was put on an external pacer and had improvement of symptoms.
Next we discuss a case where Dr. Vieth was called to the ICU to place a temporary transvenous pacer. She discusses the method she used to place the catheter, float the wire, and pace the patient.
Lessons learned from these cases are as follows:
- Does the patient require airway management
- Consider differential diagnosis (not diagnostic):
- Myocardial infarct/ischemia
- Myocarditis
- Medications (beta blockers, calcium channel blockers, digoxin, amiodarone, organophosphates, clonidine, etc)
- Hyperkalemia
- Hypothermia
- Increased ICP
- Consider trial of medications such as:
- Atropine: 0.5 mg IV repeated every 5 minutes up to 3 mg
- If you need vasopressors, consider one of the following:
- Dopamine: 3 mcg/kg/min, titrate up to 20 mcg/kg/min
- Dobutamine if heart failure: 5 mcg/kg/min titrate up to 20 mcg/kg/min
- Epinephrine: 2 mcg/min, titrate up to 10 mcg/min
- Glucagon if on beta blockers
- When you are changing the connection from the EMS device to your device in the Emergency Department, make sure you have the second device set up BEFORE you disconnect the patient!
- Temporary transvenous pacing
- The preferred site is the right IJ, if this is not available use the left subclavian.
- For a video walk through, visit the video created by Dr. Jess Mason with EM:RAP.
- Transfer to the appropriate care early and quickly!
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