2nd degree heart block - does it warrant code 3 return to the hospital?

[ParamedicStudent]

Question above. Obviously, treat the pt, not the monitor. But there are also times in which I've had asymptomatic patients, or "little" sick ones, with a cardiac complaint - SVT, Vtach, LVAD problem, which all warranted code 3 returns.
I've never seen a 2nd degree before out in the field. Would a 2nd degree (I/II) warrant a code 3 trip?

 

[DesertMedic66]

If their vitals are stable then personally no however I rarely transport code 3 (lights and sirens).

 

[Akulahawk]

If the problem is going to be immediately lethal, by all means, bring 'em in Code 3. If it's not going to be immediately lethal, Code 2 and just prepare for (anticipate) the need to perform immediately lifesaving procedures.

I had patients come into my ED within the past week that were brought in Code 3. More than one of them probably didn't need the Code 3 run, especially if the crew had been more aggressive with the treatment given.

 

[StCEMT]

No.

 

[Gurby]

Mobitz type I (Wenckebach) is often a normal variant and seen in individuals with a high vagal tone without evidence of structural heart disease. However, this rhythm can result from inferior myocardial ischemia, medication toxicity (AV nodal blocking agents), hyperkalemia, cardiomyopathy (Lyme disease), or following cardiac surgery.

Mobitz type II is rarely seen in patients without structural heart disease. It is often associated with myocardial ischemia and fibrosis or sclerosis of the myocardium. This rhythm often progresses to third-degree atrioventricular block.

https://www.ncbi.nlm.nih.gov/books/NBK482359/

If I incidentally found a 2nd degree type 1, I'd probably ask a little bit about cardiac history and things that could cause it, but not worry too much.

If you found a 2nd degree type 2, you probably want to have a high index of suspicion. If you're doing a 12 lead on them they probably have some complaint and aren't completely asymptomatic... If it could be related to a heart issue in any way shape or form, I probably take them lights + sirens, unless when asking about their history it turns out that they've had this rhythm for a while.

 

[mgr22]

Sometimes we over-do treatment by mechanically following algorithms or policy -- e.g., atropine for bradycardia, code 3 for potentially unstable patients. If someone's in a stable arrhythmia, I think the first priority should be to not make it worse. I'd be happy to get any comfortable, asymptomatic pt to the ED just as healthy as I found him/her. Transporting with lights and sirens adds risk -- not only for the pt, but for the crew.

 

[Akulahawk]

https://www.ncbi.nlm.nih.gov/books/NBK482359/

If I incidentally found a 2nd degree type 1, I'd probably ask a little bit about cardiac history and things that could cause it, but not worry too much.

If you found a 2nd degree type 2, you probably want to have a high index of suspicion. If you're doing a 12 lead on them they probably have some complaint and aren't completely asymptomatic... If it could be related to a heart issue in any way shape or form, I probably take them lights + sirens, unless when asking about their history it turns out that they've had this rhythm for a while.

You don't run someone in Code 3 based solely on having a "high index of suspicion." If a patient has otherwise stable vitals and otherwise appears OK, bring 'em in Code 2 and be ready to implement an appropriate treatment should the patient's rhythm changes to CHB and the patient becomes actually unstable.

 

[Gurby]

You don't run someone in Code 3 based solely on having a "high index of suspicion." If a patient has otherwise stable vitals and otherwise appears OK, bring 'em in Code 2 and be ready to implement an appropriate treatment should the patient's rhythm changes to CHB and the patient becomes actually unstable.

Maybe this scenario is too abstract -- there are so many variables to consider. The likelihood that we find a Mobitz 2 in an asymptomatic patient is basically 0%. Somehow somebody called 911 and we were suspicious enough to put patient on the monitor...

I guess it comes down to are we absolutely, positively, bet-your-license-on-it sure that the patient is not having an MI? I don't want to sit in traffic for an hour with this patient hoping I didn't miss something subtle on the 12-lead.

 

[gotbeerz001]

I’m not sure I would categorize SVT or Vtach as “little sick”... especially as a student. Stable or unstable, these are not sustainable rhythms and require intervention.

Or maybe you are generalizing “little sick” off of your initial impression? In that case, I would encourage you to refrain from making that decision until you have finished your assessment.

 

[rescue1]

With the exception perhaps of vtach, I don't think there's a single cardiac rhythm that means, by itself, that you must transport lights and sirens. Even vtach doesn't mean that, but I think most people would be forgiven for transporting emergently with that patient.

Mobitz type 1 is almost always benign and does not warrant you going L&S. Yes, technically it can cause a symptomatic bradycardia. But do you go L&S for every old person in a-fib because they could throw a clot and stroke out at any minute? Do you transport every young person with early repolarization hot because it could be a STEMI? Of course not.

Mobtiz 2 and SVT will likely not require L&S either. If these patients are very symptomatic (hypotensive, altered mental status, etc)--treat them. If you've broken SVT with atropine/CCBs/BBs or cardioversion there is no longer an emergency. If a Mobitz (or any bradycardic rhythm, it doesn't matter) patient is symptomatic enough to be unstable/hypotensive then yes, they may warrant lights and sirens, but if you can bring them back to a decent pressure with atropine or pacing you should consider how much difference the time saved is going to make.


As a general rule of thumb, if the doctor isn't getting up and coming into the ED room quickly to see the patient or a specialty team isn't waiting for you at the doorway, you probably didn't need to go lights and sirens. Unfortunately given the limited time window that we see patients, we have a very poor idea of what makes a stable or unstable patient outside the extremes (trauma alerts and codes vs toe pain and upper respiratory infections). Most (90% or more) ALS patients will not be impacted by waiting an hour for definitive care--even STEMI patients have 90 minutes to go to the cath lab from when they hit the ER. If you're in an area where mechanical thrombectomy is done, stroke patients may have up to 24 hours to have clot retrieval depending on the hospital. The ten minutes you save in the field isn't going to change anything in that patient's outcome. It's safer for you and your patients to take your time and drive normally unless the patient truly needs it.

Remember there has never been a study that showed that lights and sirens improved patient outcomes--all of them show it makes no difference, and you likely save much more time getting to the ED by limiting your on scene time as opposed to trying to beat traffic.

 

[Gurby]

even STEMI patients have 90 minutes to go to the cath lab from when they hit the ER. If you're in an area where mechanical thrombectomy is done, stroke patients may have up to 24 hours to have clot retrieval depending on the hospital. The ten minutes you save in the field isn't going to change anything in that patient's outcome.

At a quick glance, there appears to be a mountain of evidence suggesting that shorter door-to-balloon times are associated with better outcomes. 10 minutes can make a difference. Just because you have 90 minutes until Medicare dings you or whatever doesn't mean faster isn't better for those patients.

https://www.ncbi.nlm.nih.gov/pubmed/29437704

 

[rescue1]

At a quick glance, there appears to be a mountain of evidence suggesting that shorter door-to-balloon times are associated with better outcomes. 10 minutes can make a difference. Just because you have 90 minutes until Medicare dings you or whatever doesn't mean faster isn't better for those patients.

https://www.ncbi.nlm.nih.gov/pubmed/29437704

I'll have to read the full study when I get a chance, but the abstract specifically only mentions less than 90 minutes and greater than 90 minutes.

Regardless (and you're probably right--and faster is probably better in clot retrieval too), I would argue that you'd save considerably more time by streamlining on scene time prehospitally than by running lights and sirens in all but the most congested areas, since most of the data suggests you only save 3-5 minutes in urban areas.

 

[Peak]

I think that in a lot of cases like this experience will change your opinion. What I would consider stable when I was a new medic is very different than now.

In my opinion patients very rarely deconpensate in an unpredictable manner, but rather in ways that are more subtle and we get better at assessing over time. I also think that with experience we become more comfortable with high risk presentations.

For example I don't think I would consider emergent transport for the majority of SVT cases. Only if they were hemodynamicly unstable and cannot be converted with adenosine or electricity would I consider emergent transport. My main job is in a referral center with one of our large programs being congenital heart disease. If a crew transported a somewhat unstable neonate in SVT I wouldn't hold it against them though.

Similarly I wouldn't automatically assume that an LVAD patient requires emergent transport every time, I'm not going to emergency transport a patient who injured their wrist but is otherwise stable just because they have an LVAD for example.

I have seen patients sit in a mobitz or wenckebach for days before converting back into a 1st degree or NSR. I've also seen pretty quick deterioration into 3rd degrees with very poor perfusion and end up real sick real quick.

I always think that you need to look at what benefit emergent transport actually brings as well. In the majority of cases emergent transport cuts off seconds at most, while increasing the risk of accidents and increasing the stress to crew and possibly the patient. Back when I was on fire we often transported traumas, patients in extremis, and codes without lights or sirens barring the last few turns right before the hospital (which was typically the only area of real traffic congestion).

 

[Akulahawk]

Maybe this scenario is too abstract -- there are so many variables to consider. The likelihood that we find a Mobitz 2 in an asymptomatic patient is basically 0%. Somehow somebody called 911 and we were suspicious enough to put patient on the monitor...

I guess it comes down to are we absolutely, positively, bet-your-license-on-it sure that the patient is not having an MI? I don't want to sit in traffic for an hour with this patient hoping I didn't miss something subtle on the 12-lead.

If you have a symptomatic Mobitz II patient and the patient has become unstable, then by all means run 'em in Code 3. Just be safe doing so and know that you'll only be "saving" a couple minutes or a few seconds over a Code 2 return most of the time. If the patient converts into a CHB and is unstable, that may warrant a Code 3 return but remember that ALS crews also are going to have the ability to do TCP. Sedate and pace, bring in Code 2 if stable, unless your protocols require a Code 3 return for that.

For me, I rarely consider Code 3 returns. Why do I NOT run most patients in Code 3? Because I have the tools at hand to continue working on stabilization and I'm not saving much time otherwise. This is a clinical decision that I make that is individual to each patient.

 

[medichopeful]

Obviously, treat the pt, not the monitor.

I'm guessing you're a medic student by your name, so I don't fault you for using this, but try to get this saying out of your vocabulary. It's not a good mindset to have.

I've never seen a 2nd degree before out in the field. Would a 2nd degree (I/II) warrant a code 3 trip?

Very, very few things actually need lights and sirens, especially at the ALS level. If you're not treating it in the field as a medic, a 2nd degree heart block absolutely doesn't need L&S. If you are treating it, it still probably doesn't need them.

Lights and sirens saves very little time in the majority of the cases, and should be considered a medical treatment.

 

[StCEMT]

I'm guessing you're a medic student by your name, so I don't fault you for using this, but try to get this saying out of your vocabulary. It's not a good mindset to have.

This I'll second. The longer I've been out of medic school, the more I dislike that statement.

 

[E tank]

This I'll second. The longer I've been out of medic school, the more I dislike that statement.

Then we need a new phrase to get that valid point across to the under-experienced. Treating numbers is pandemic in nearly all phases of care and it's most usually, tho not always, the new guys....

 

[StCEMT]

Then we need a new phrase to get that valid point across to the under-experienced. Treating numbers is pandemic in nearly all phases of care and it's most usually, tho not always, the new guys....

I don't think they need a new phrase as much as just understanding how to apply the information it gives. I could give them a reason to treat purely based on numbers and nothing hands on, but that falls back to putting pieces together into the big picture.

 

[Bullets]

This I'll second. The longer I've been out of medic school, the more I dislike that statement.

Funny because i feel the exact opposite. I find that ive been getting more requests by BLS to treat based on one aberrant number than ever before. I think its a good phrase to help newer providers actually look at the patient and emphasis the importance of laying hands on the patient rather than looking at a computer screen

 

[GMCmedic]

I don't think they need a new phrase as much as just understanding how to apply the information it gives. I could give them a reason to treat purely based on numbers and nothing hands on, but that falls back to putting pieces together into the big picture.

New phrase: "treat the big picture"