# 18 YO sinus bradicardia anigma



## Tal (Dec 3, 2010)

20:00 a new 18 yo recruit come with his platoon's medic to my base's clinic with the complain of a general weakness. 
the kid is cold and snuffled and very weak, skin look good. 
V/S: fully alert, no breathing problems b.p 130/70, pulse 50 (athlete), SpO2 97. 
I decide to watch him for an hour.

hout later vital signs:
fully alert, no breathing problems b.p 130/70, SpO2 97 and a pulse of 36.
ECG: Sinus bradicardia 36, normal pr int' and everything, but leads V1-V3 showing a negative T wave.
same complain same everything, no chest pains during any pose, no fever in the last few days, only the good all boot-camp trainings and food.

I got an IV access, O2 mask, monitoring (LP 10 without pacing abilities) and a to the ER we go. I only know he was hospitalized for sevrel days.

what do you think could be the cause of this?

my comnder (MD) and I trying to conect the unit that he was hospitalized in to get the full pic. when I'll know, I'll share.


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## bstone (Dec 3, 2010)

Wow. That's really unusual for such a young guy to have such heart troubles. Labs would be really interesting to see.


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## boingo (Dec 3, 2010)

Top of my list would be electrolytes, K and Na specifically.


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## mikie (Dec 3, 2010)

Could it be a congenital condition...since it's appearing at such a young age?


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## MSDeltaFlt (Dec 4, 2010)

A few questions. 
1. What was his temp?
2. What was his FSBS?
3. What was he doing for the hour when his H R dropped to 36
4. Can you post ECG?

A young, athletic male with a H R of 36 (I think he's resting at that speed) without CP, only weakness, it might not be cardiac. 

Not enough information to tell


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## Tal (Dec 4, 2010)

MSDeltaFlt said:


> A few questions.
> 1. What was his temp?
> 2. What was his FSBS?
> 3. What was he doing for the hour when his H R dropped to 36
> 4. Can you post ECG?



1. 37.0 PO
2. sadly we dont own this in our base
3. only lying down
4. i'll try


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## Jay (Dec 10, 2010)

Negative T-Wave, PVC's, etc. w/ Sinus Braycardia in such a young person would make me think that it's dehydration along with an electrolyte imbalance. The slow rhythm is not that unusual but in conjunction with the above would make me think it could be a number of things electrolyte related such as +/- Mg, Ca, K, etc. Also, was he on any meds (which could be a cause)? Finally, it could be congenital but did he have a Hx of such a condition? 

If I had to put my money on it, I would say dehydration w/ electrolyte imbalance. Let me know if you find out, I am curious. Beseder.

Kol Tuv!


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## zmedic (Dec 10, 2010)

are we talking about an "enigma," or "angina?"


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## Akulahawk (Dec 11, 2010)

Dehydration w/ electrolyte imbalance easily could cause the brady you noticed. Athletes tend to "run" a bit brady anyway, but you might see either a 1*AVB or a long but normal PRI in them. Since this new recruit is fairly new and still going through boot, I would wonder if he's truly an athlete at this point. Why? His PRI is normal. I'd be guessing that he's not drinking enough water nor is he eating enough of the right foods. Given the environment, how often does he have to urinate, and what color is it? Urine can be a wonderful indicator, but it's often a lagging one. 

I would also wonder if he's been taking any dietary supplements that aren't for post-workout recovery...

I used to be a MUCH more active person than I am now. My HR still gets into the low 50's or high 40's when I'm at rest. It took a LONG time to get my heart to go that slowly. Many world-class athletes do brady down into the 30's and 40's at rest. Getting the heart to increase it's stroke volume to the point where cardiac output isn't adversely affected at such low rates doesn't happen overnight. Given his age and likely recent introduction to heavier exercise bouts than he's likely used to makes me think this isn't a congenital thing.


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## clibb (Dec 11, 2010)

Hypothyroidism? I know that would be a VERY fast onset for that, but just thought I'd throw it out there.

If he's in boot camp you might want to keep depression in mind. Ask his fellow recruits if he's been depressed. Check his blood too for any depressant drugs.


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## mgr22 (Dec 11, 2010)

Akulahawk said:


> I would also wonder if he's been taking any dietary supplements that aren't for post-workout recovery...



Hmmm...GHB?


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## Commonsavage (Dec 11, 2010)

*18 yo Bradycardia*

I'm having a hard time getting around the issue of your service not having basic glucometry available.  Nonetheless, an initial bolus of IV fluid would help in narrowing the differential diagnosis. Heck, give the young man some oral glucose, or some matza with honey! However, with a HR of 36 (were there U-waves?) at such a young age, I will go with congenital coronary sinus disease.<_<


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## MSDeltaFlt (Dec 11, 2010)

A young athletic male with a resting HR of 36 would not get me wound up unless there was something obvious on ECG or other clinical assessments.


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## abckidsmom (Dec 11, 2010)

MSDeltaFlt said:


> A young athletic male with a resting HR of 36 would not get me wound up unless there was something obvious on ECG or other clinical assessments.



I agree.  

I am 31, mother of five, and a new runner.  I had a minor surgical procedure yesterday and my resting heart rate was 48.  I was so proud!  All this hard work is paying off.


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## para1medic (Dec 28, 2010)

Tal said:


> 20:00 a new 18 yo recruit come with his platoon's medic to my base's clinic with the complain of a general weakness.
> the kid is cold and snuffled and very weak, skin look good.
> V/S: fully alert, no breathing problems b.p 130/70, pulse 50 (athlete), SpO2 97.
> I decide to watch him for an hour.
> ...




I would NOT pace this kid.  He's got a good blood pressure, he's awake, alert, and oriented. He's an athlete at rest, that could be his resting heart rate. Do NOT pace an asymptomatic patient.


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## sdadam (Dec 29, 2010)

Sick Sinus Syndrome


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## 18G (Dec 29, 2010)

Sounds like a case of treat the patient and not the monitor. He was asymptomatic of the slow rate, had a good blood pressure and was perfusing well. 

As far as cause.... could be his normal rate and the t-wave inversion in those leads could very well be normal for him. I would be interested to see what serial 12-leads showed and if they had the same t-wave inversion with new electrodes applied.


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## usafmedic45 (Dec 30, 2010)

sdadam said:


> Sick Sinus Syndrome


Sheep, not zebras.


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## Tal (Jan 6, 2011)

So, the kid comes back with some checks done and after he saw a cardiologist:
all heart enzymes came back normal, CPK, Troponin the works.
the blood test for Q-fever, which is my comending MD main guess of what cause this, hav'nt come back yet.
he was hopitalized for suspected URTI.

the cardiologist said that the kid was a 10 years basketball player and still is an athlete, the extreme bradi is normal because his pulse rises while exercising.



MSDeltaFlt said:


> A young athletic male with a resting HR of 36 would not get me wound up unless there was something obvious on ECG or other clinical assessments.



Personaly and with all due respect I really having a hard time accepting HR of 36 as *normal*. I've know that HR's of athlets is low, I can accept HR's of 50-40 but, 36 is 4 beats too low for not getting me high alert on the Pt. 

What cause this will probably remain a mystery for us, I dont belive it's normal baketball-player HR.
maybe Q-fever will be it...who knows

p.s I didnt mange to get the ECG.


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## Commonsavage (Jan 6, 2011)

*36 BPM is NOT normal!!!*

Tal, you are absolutely correct.  A heart rate of 36 is not normal.  As medics, we are never in a position to make a diagnosis of any brady less than 50, much less 40 bpm as normal under any circumstances.  Basic ventricular rate is 20 to 40 and indicates nodal dysfunction.  To not refer this patient to a cardiologist violates a basic standard of care.
So, the cardiologist was fine with this...OK.  They ran a battery of tests to rule out pathology.  I'm sure that the cardiologist would not have blown this kid off with only a field exam and assessment.  Unfortunately, many medics take on a completely inappropriate cavalier attitude that can kill patients.  If one believes that this is not an issue, they really need to go in for retraining.
Tal, thanks for the follow-up.


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## MSDeltaFlt (Jan 8, 2011)

Tal said:


> So, the kid comes back with some checks done and after he saw a cardiologist:
> all heart enzymes came back normal, CPK, Troponin the works.
> the blood test for Q-fever, which is my comending MD main guess of what cause this, hav'nt come back yet.
> he was hopitalized for suspected URTI.
> ...



Cardiologist, remember he/she is a specialist with a lot more knowledge and trading than we have, wasn't saying it was normal. I'm taking this as that rate might not be all that abnormal for this particular patient.  I've seen heart rates that low in extremely healthy pts with pleuritic pain.  Those pts were in a benign state and everybody got tunnel vision And panicked.  Never say never. Never say always.  Assess your patient with an open mind and look at the big picture and you'll be amazed at what you'll find and learn.


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## usafmedic45 (Jan 8, 2011)

> Personaly and with all due respect I really having a hard time accepting HR of 36 as normal. I've know that HR's of athlets is low, I can accept HR's of 50-40 but, 36 is 4 beats too low for not getting me high alert on the Pt.



Nice to know that I would have gotten a lights and sirens transport from you.  I used to have a resting heart rate in the upper 30's when I was training for a marathon.  It used to also freak out people that would take my vitals because I also ran a very low BP (80/70 was not unusual).  I've met several people with resting heart rates in the low 30s or even upper 20s.  



> Tal, you are absolutely correct. A heart rate of 36 is not normal. As medics, we are never in a position to make a diagnosis of any brady less than 50, much less 40 bpm as normal under any circumstances. Basic ventricular rate is 20 to 40 and indicates nodal dysfunction. To not refer this patient to a cardiologist violates a basic standard of care.



Unless the patient knows their body and tells you "That's normal for me".  With most endurance athletes, this is case, just like how most diabetics can tell you where they normally run in terms of their blood glucose levels.  I once had a paramedic student try to give me atropine after I was shown on the monitor at 48 with "chest pain".  I told him he would be having that prefill removed from his rectum if he even tried it.  It's normal to have chest pain after broken ribs from being kicked in the chest by a horse after all.



> So, the cardiologist was fine with this...OK. They ran a battery of tests to rule out pathology. I'm sure that the cardiologist would not have blown this kid off with only a field exam and assessment. Unfortunately, many medics take on a completely inappropriate cavalier attitude that can kill patients. If one believes that this is not an issue, they really need to go in for retraining.



Ever heard of defensive medicine?  Chances are the doc didn't suspect there was anything wrong and was simply covering his ***.  It doesn't sound like they did a "battery of tests" beyond what anyone walking in with vague potentially cardiac symptoms would have gotten.


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## Aidey (Jan 8, 2011)

usafmedic45 said:


> Nice to know that I would have gotten a lights and sirens transport from you.  I used to have a resting heart rate in the upper 30's when I was training for a marathon.  It used to also freak out people that would take my vitals because I also ran a very low BP (80/70 was not unusual).  I've met several people with resting heart rates in the low 30s or even upper 20s.



I had all sorts of fun when I was admitted to the hospital last year. My vitals run low normally, and I was stuck in bed on a morphine PCA. I have sinus arrhythmia, and had a rate of 44-64 and a BP in the 80s. Every time someone checked my vitals I had to tell them it was perfectly normal.


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