# Low HR/Good BP



## planetmike (Jul 6, 2015)

Had a call a while ago, 82 year old female, chief complaint: "just not feeling right”. Vital signs: Pulse: 39, bp: 132/78; respiration rate: 18; SpO2: 95% on room air. Scheduled for bladder surgery (cancer) in two days time. As a basic, what to do as treatment while en route to hospital ten minutes away? I’m sorry, but I don’t remember which meds she was taking. NKDA.


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## STXmedic (Jul 6, 2015)

As a basic, transport and have a nice conversation.

As a medic, probably transport and have a nice conversation.


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## DesertMedic66 (Jul 6, 2015)

STXmedic said:


> As a basic, transport and have a nice conversation.
> 
> As a medic, probably transport and have a nice conversation.


This. Even though her HR is low she is still profusing good. Not much to do.


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## Carlos Danger (Jul 6, 2015)

Lots potentially going on with an 82 year old cancer patient.The fact that she isn't feeling well could be evidence that she actually is not perfusing well. I'd be concerned that she is in a dysrythmia. Is her pulse regular? Does the pleth look normal?

As a basic, I'd take a nice easy ride to the hospital if it's not far. But if ALS can get to us significantly quicker than I can get to the ED, I think this is a legit indication for ALS assessment.

As a paramedic, I'd get an EKG right away.


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## ERDoc (Jul 6, 2015)

I think a 12 lead and monitor would be appropriate.  A 3rd degree heart block might change your destination.


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## stethoscope (Jul 6, 2015)

planetmike said:


> Had a call a while ago, 82 year old female, chief complaint: "just not feeling right”. Vital signs: Pulse: 39, bp: 132/78; respiration rate: 18; SpO2: 95% on room air. Scheduled for bladder surgery (cancer) in two days time. As a basic, what to do as treatment while en route to hospital ten minutes away? I’m sorry, but I don’t remember which meds she was taking. NKDA.


As a basic, I'd probably focus on the o2 sats. Not that 95% is terrible, but it could be better. Especially with 18 breaths per minute. Her medications would have been significant. For a cancer surgery, she's probably on a good bit of heavy meds.


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## DesertMedic66 (Jul 6, 2015)

stethoscope said:


> As a basic, I'd probably focus on the o2 sats. Not that 95% is terrible, but it could be better. Especially with 18 breaths per minute. Her medications would have been significant. For a cancer surgery, she's probably on a good bit of heavy meds.


Except that anything >94% is considered normal and many guidelines and protocols say that it does not require supplemental oxygen


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## stethoscope (Jul 7, 2015)

DesertMedic66 said:


> Except that anything >94% is considered normal and many guidelines and protocols say that it does not require supplemental oxygen


I wouldn't necessarily give her oxygen -- but I'd ask how her quality of breathing is and check perfusion. Being barely normal is enough to at least make me consider investigating further. As a basic, there's not much else to do.


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## phideux (Jul 7, 2015)

How is she acting? Is she hurting anywhere, any SOB? Does she look in distress? What meds does she take? Put her on the monitor and take it from there. I'd pop in a line during the ride, treat her if she needs treating, If not, have a nice talk with the old lady on the ride in, who's probably just not feeling good because she's a little lonely, little scared about her surgery, probably normally on the bradycardic side, and by the time you get her to the hospital feels 100% better just from your talking with, and fussing over her.


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## MonkeyArrow (Jul 7, 2015)

stethoscope said:


> As a basic, I'd probably focus on the o2 sats. Not that 95% is terrible, but it could be better. Especially with 18 breaths per minute. *Her medications would have been significant. For a cancer surgery, she's probably on a good bit of heavy meds*.


BTW Two days pre-op, she is probably actually on very little medication. Most docs discontinue *most* meds this close to surgery, except for bridging with anti-coagulants if critical.


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## Tigger (Jul 7, 2015)

stethoscope said:


> As a basic, I'd probably focus on the o2 sats. Not that 95% is terrible, but it could be better. Especially with 18 breaths per minute. Her medications would have been significant. For a cancer surgery, she's probably on a good bit of heavy meds.


For many people, 95% on room air is normal, just plain normal. 

Check out the Oxyhemaglobin Dissociation curve. There is little difference in 95 and 100% saturation in terms of PO2 (which is what we really care about).


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## EMSComeLately (Jul 7, 2015)

Skin condition for possible vasoconstriction reaction to cardiogenic shock?  While it may seem like asymptomatic bradycardia and only 10 minute transport, I hope an ALS provider didn't simply hand over the pt to avoid an assessment that could give the hospital a jump on potentially dangerous issues assuming a split crew.  A line and lab draw would have been appropriate as well as monitor and 12 lead.


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## chaz90 (Jul 7, 2015)

EMSComeLately said:


> Skin condition for possible vasoconstriction reaction to cardiogenic shock?  While it may seem like asymptomatic bradycardia and only 10 minute transport, I hope an ALS provider didn't simply hand over the pt to avoid an assessment that could give the hospital a jump on potentially dangerous issues assuming a split crew.  A line and lab draw would have been appropriate as well as monitor and 12 lead.


Even if she is shunting a little bit, she's still perfusing all vital organs and the brain with that perfectly adequate BP. Vasoconstriction as a compensatory mechanism isn't particularly effective in the elderly population anyway. 

Let's not overthink this from a pre-hospital perspective. I don't think anyone is suggesting making this a BLS transport if ALS is available. A 12 lead, saline lock, and lab draw is absolutely indicated on a likely easy, low key ALS transport.


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## Ewok Jerky (Jul 7, 2015)

Not sure what their actually is to treat?

Asymptomatic bradycardia? Barring a 12-lead, which most BLS cannot do, I don't think there is any indication for, well, anything.


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## Clare (Jul 7, 2015)

She is not compromised so no specific treatment.  I have seen little old nanas with BPs of 90 and running round fine so just because she has a HR of 40 doesn't mean anything needs to be done. 

A 12 lead ECG is a definite but again, more to exclude something sinister that will either (a) change what you do or (b) change where you go.  If her bradycardia was the result of an MI involving the SA node or something, then she needs to go direct to a pPCI centre for example.


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## Brandon O (Jul 7, 2015)

Tigger said:


> Check out the Oxyhemaglobin Dissociation curve. There is little difference in 95 and 100% saturation in terms of PO2 (which is what we really care about).



Little change in oxygen carrying capacity, I think you mean.


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## Carlos Danger (Jul 8, 2015)

MonkeyArrow said:


> BTW Two days pre-op, she is probably actually on very little medication. Most docs discontinue *most* meds this close to surgery, except for bridging with anti-coagulants if critical.



Actually, with the exception of anticoagulants (and even that depends on lots of factors - they aren't always discontinued), most meds are continued through the morning of surgery these days. There are a few common exceptions, but they tend to depend on the preferences of the surgeon or anesthesia policies. Where I work the only thing that is routinely ordered held is metformin.


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## coolidge (Jul 25, 2015)

I was curious, what was the patient's diagnosis?
Thanks


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## planetmike (Jul 27, 2015)

I never found out, we rarely, if ever, get any final disposition of our patients.


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## EMT11KDL (Aug 17, 2015)

BLS: Have a nice drive and talk, depending on transport time, Meet with ALS, but with less than 10 min transport its a toss up, if ALS is outside the door and can meet you within a few minutes than yes, but if it is going to take more than 5 mins to meet them, than no.  

ALS: Have a nice drive and talk while doing a 12 lead to confirm she is not in a block or arrhythmia, and ask her what her HR normally is, maybe she is brady all the time.


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## Akulahawk (Aug 17, 2015)

Given the 10 min transport time...

BLS: have a nice talk, paying close attention to mental status. Figure out what meds she's on and if she knows why her heart rate is so slow. Transport to ED. 

ALS: Have a nice talk while acquiring a 12-lead, start a saline lock, nice quiet transport to ED with patient on monitor, and if she decompensates, well, we have options at our disposal and vascular access because of that lock...

In either case, patient is likely mostly asymptomatic, so a nice calm atmosphere is a good idea.


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## Medicbob (Sep 29, 2015)

ERDoc said:


> I think a 12 lead and monitor would be appropriate.  A 3rd degree heart block might change your destination.



Yup, I'd go with some sort of heart block.


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## NTXFF (Oct 1, 2015)

Tigger said:


> For many people, 95% on room air is normal, just plain normal.
> 
> Check out the Oxyhemaglobin Dissociation curve. There is little difference in 95 and 100% saturation in terms of PO2 (which is what we really care about).


I must say I always enjoy your responses.  You're one smart tater tot!


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## NTXFF (Oct 1, 2015)

Oh and I'd be doing a 12 lead in the house or facility, wherever I was at.  I've had an asymptomatic 3rd degree heart block with a chief complaint of I don't feel right.  It's something that will take 15 seconds to apply and run which could help you better prepare for what could go wrong.  As many of you know 10 min can feel like 45 if a routine call takes a turn that you didn't at least consider.


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## Tigger (Oct 1, 2015)

NTXFF said:


> I must say I always enjoy your responses.  You're one smart tater tot!


I have learned much from this very site. Hopefully it contributes to me ending up a half decent paramedic.


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## Ensihoitaja (Oct 1, 2015)

Remi said:


> Where I work the only thing that is routinely ordered held is metformin.



Is that because they're fasting or is there another reason?


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## Brandon O (Oct 2, 2015)

Ensihoitaja said:


> Is that because they're fasting or is there another reason?



Risk for causing lactic acidosis.


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