Asymptomatic bradycardia

[EMTinNEPA]

We get dispatched last night for SOB/near syncope. Arrive on scene, patient is an approx. 75 yo male. No chief complaint. Completely asymptomatic. So we walk him out to the ambulance. While the medic is getting a PMH, I start taking vitals. BP = 128/50. I take the patient's pulse. His pulse was 20. Yes, 20. I said to myself "That can't be right." Threw the monitor on him... 20. Yet he was CAOx4. I don't remember any of the other vitals because 1) I wasn't crew chief and 2) I was too floored by the fact that this guy didn't code, let alone was up and walking around. Anybody else ever run into something like this?

 

[daedalus]

20 bpm? He must have a strong heart because cardiac output= ejection fraction X HR. With a heart rate of 20, ejection fraction would have to be much higher than normal to keep a pressure like that?
128/50 is a perfusable pressure with a MAP of 76.

Very interesting. Paging VentMedic.

 

[MedicPrincess]

You walked him, all the way to the truck? Does your stretcher not have wheels that could be taken into the house? A quick check of the radial pulse while talking to him would have found that, before you had a pt who called for an ambulance with a complaint of SOB and near Syncope walk out to the truck.

Im still new at this, but if he had already complained of SOB and near Syncope his body had already had some symptoms. As for why he isn't complaining of anything now, perhaps he wasn't being completely honest. How often do your pts say everything is fine, or the chest pain is better, or down play everything.

I've seen it once before. Little old lady, called us because she had felt a little bad earlier. No other symptoms. Normotensive. HR of 20. 12led ECG- Great Big Inferior MI. She was dead by the next morning.

Are you a BLS unit? Did you call for ALS? How did your partner treat it?

As for the how/why? Easy answer seems to be the bodys ability to compensate.

The older, much more expierienced Medics will be here soon to explain it.

 

[Melbourne MICA]

We get dispatched last night for SOB/near syncope. Arrive on scene, patient is an approx. 75 yo male. No chief complaint. Completely asymptomatic. So we walk him out to the ambulance. While the medic is getting a PMH, I start taking vitals. BP = 128/50. I take the patient's pulse. His pulse was 20. Yes, 20. I said to myself "That can't be right." Threw the monitor on him... 20. Yet he was CAOx4. I don't remember any of the other vitals because 1) I wasn't crew chief and 2) I was too floored by the fact that this guy didn't code, let alone was up and walking around. Anybody else ever run into something like this?

Could you give a little more information on the context for the bradycardia? it goes without saying this is not a normal HR for a 75yo. Establishing a HR of 20 during vitals should have rung alarm bells immediately as any number of serious pathologies may have been associated, such as arrhythmias like 3rd degree HB, infarct, a neurological event etc.

If you'll forgive me for saying, walking such a patient was a bad idea. He should have been immediately monitored, layed supine, oxygenated, IV access established and some anti-arrhythmica drugs drawn in prep with a bag of fluid slung as well.

Vitals can indentify clincial signs indicative of primary organ dysfunction that may not be associated with symptomology the pt can talk about at least in the short term whilst compensatory mechanisms are active. Adding additional workload to the pt may well have become the straw that broke the camels back and created a more complex situation than there needed to be.

To answer your question directly, pts can certainly display no outward signs of deficits (though this pt already had - the collapse) but this may not reflect the underlying progression of a disorder.

The greatest successes of pre-hospital management are acheived when operators intervene effectively at key points in the cycle of illness or injury in so doing checking the trend towards deterioration and thus permitting at least temporary, homeostatic stability until definitive managements of underlying pathologies are addressed in hospital.

Personally speaking I would have used pharmacological interventions to increase HR is this pt very early on in the piece and certainly prior to transfer. Even the fittest of athletes record HR's in the forties or low thirties some even a little lower. But a 75yo is no olympian.

For an elderly male a HR of 20 will have only one direction to go eventually - downwards to 0/min!

MM

 

[EMTinNEPA]

You walked him, all the way to the truck? Does your stretcher not have wheels that could be taken into the house? A quick check of the radial pulse while talking to him would have found that, before you had a pt who called for an ambulance with a complaint of SOB and near Syncope walk out to the truck.

Im still new at this, but if he had already complained of SOB and near Syncope his body had already had some symptoms. As for why he isn't complaining of anything now, perhaps he wasn't being completely honest. How often do your pts say everything is fine, or the chest pain is better, or down play everything.

I've seen it once before. Little old lady, called us because she had felt a little bad earlier. No other symptoms. Normotensive. HR of 20. 12led ECG- Great Big Inferior MI. She was dead by the next morning.

Are you a BLS unit? Did you call for ALS? How did your partner treat it?

As for the how/why? Easy answer seems to be the bodys ability to compensate.

The older, much more expierienced Medics will be here soon to explain it.

1. Walking him wasn't my call. There were three of us on the truck that night. I was out in the truck setting things up for the medic. The other EMT made the call to walk him.

2. SOB and near-syncope could be anything. We treat patients, not dispatches. If the patient doesn't have any complaints, what are we supposed to do? If he was lying, sucks to be him when he codes and leaves his wife a widow because he wouldn't be honest.

3. ALS unit. No need to call for ALS.

4. As for treatment, we laid him supine, oxygenated, established IV access, and ran a 1000 bag NACL wide open. We arrived at the hospital before we had a chance to push any anti-arrhythmic meds.

 

[EMTinNEPA]

If you'll forgive me for saying, walking such a patient was a bad idea. He should have been immediately monitored, layed supine, oxygenated, IV access established and some anti-arrhythmica drugs drawn in prep with a bag of fluid slung as well.

As I stated in my last post, walking the patient wasn't my call. I never even made it inside the house. Treatment-wise, we did all of the above except anti-arrhythmic meds due to time constraints.

 

[MedicPrincess]

1. Walking him wasn't my call. There were three of us on the truck that night. I was out in the truck setting things up for the medic. The other EMT made the call to walk him.

2. SOB and near-syncope could be anything. We treat patients, not dispatches. If the patient doesn't have any complaints, what are we supposed to do? If he was lying, sucks to be him when he codes and leaves his wife a widow because he wouldn't be honest.

3. ALS unit. No need to call for ALS.

4. As for treatment, we laid him supine, oxygenated, established IV access, and ran a 1000 bag NACL wide open. We arrived at the hospital before we had a chance to push any anti-arrhythmic meds.

But, Did he have SOB and Near Syncope prior to calling?

As for the "Sucks to Be Him" attitude.... Wow! That is part of the problem. Part of your job as the medical care provider to to ask question to get answers. If you were dispatched for SOB and Near Syncope and now they are saying they have none of that, then you should be asking them if they WERE SOB before you got there. Ask the widow he will be leaving behind. Especially if she is the one that called.

Try being your patients advocate instead of taking the Sucks to Be Him stance.

 

[Melbourne MICA]

Not your call

As I stated in my last post, walking the patient wasn't my call. I never even made it inside the house. Treatment-wise, we did all of the above except anti-arrhythmic meds due to time constraints.

Fair enough. I would be interested to know why your colleague didn't use drugs to treat the brady straight up if allowed. Is fluid filling for a brady/normotensive part of your protocol?

Given the brady has ALS drug management implications do you still think you did'nt need to call for ALS? Perhaps it wasn't practical given your time frame to hospital.

Cheers

MM

 

[boingo]

2. SOB and near-syncope could be anything. We treat patients, not dispatches. If the patient doesn't have any complaints, what are we supposed to do? If he was lying, sucks to be him when he codes and leaves his wife a widow because he wouldn't be honest.QUOTE]


Could be anything? Heres a little clue, a heart rate of 20 would be top of my list of causes, now the question is, why is his heart rate 20? Near syncope/SOB IS a complaint.

 

[Sasha]

Fair enough. I would be interested to know why your colleague didn't use drugs to treat the brady straight up if allowed. Is fluid filling for a brady/normotensive part of your protocol?

Given the brady has ALS drug management implications do you still think you did'nt need to call for ALS? Perhaps it wasn't practical given your time frame to hospital.

Cheers

MM

Why would he call for ALS if it's an ALS unit?

 

[Sasha]

2. SOB and near-syncope could be anything. We treat patients, not dispatches. If the patient doesn't have any complaints, what are we supposed to do? If he was lying, sucks to be him when he codes and leaves his wife a widow because he wouldn't be honest.QUOTE]


Could be anything? Heres a little clue, a heart rate of 20 would be top of my list of causes, now the question is, why is his heart rate 20? Near syncope/SOB IS a complaint.

Have you never had a patient who calls in and tells you hey, nothings wrong! Did you feel dizzy? No. Do you or did you feel like you were having trouble breathing or couldn't catch your breathe? Nope.

Some people DO have low resting heart rates. We've had people who call in, don't even know the patient and claim they look like they can't breathe, etc.

 

[EMTinNEPA]

2. SOB and near-syncope could be anything. We treat patients, not dispatches. If the patient doesn't have any complaints, what are we supposed to do? If he was lying, sucks to be him when he codes and leaves his wife a widow because he wouldn't be honest.QUOTE]


Could be anything? Heres a little clue, a heart rate of 20 would be top of my list of causes, now the question is, why is his heart rate 20? Near syncope/SOB IS a complaint.

Yes, because I'm always going to automatically assume that every patient who I run into (as the third medical professional to make contact with them on the call) has a heartrate of 20 despite being asymptomatic. I guess I was sick the day they covered "clairvoyance" in EMT class.

 

[EMTinNEPA]

But, Did he have SOB and Near Syncope prior to calling?

Oh, you got me. I guess I was sick the day they covered "History of Present Illness" too!

 

[boingo]

Have you never had a patient who calls in and tells you hey, nothings wrong! Did you feel dizzy? No. Do you or did you feel like you were having trouble breathing or couldn't catch your breathe? Nope.

Some people DO have low resting heart rates. We've had people who call in, don't even know the patient and claim they look like they can't breathe, etc.

No one has a normal resting heart rate of 20. I can understand a patient denying any complaint, however someone called for him with a reported complaint of near syncope/SOB, certainly consistant with a heart rate that low. Are you suggesting that the treatment rendered was appropriate? I believe you are in medic school now, how would you run this senario?

 

[EMTinNEPA]

Fair enough. I would be interested to know why your colleague didn't use drugs to treat the brady straight up if allowed. Is fluid filling for a brady/normotensive part of your protocol?

Given the brady has ALS drug management implications do you still think you did'nt need to call for ALS? Perhaps it wasn't practical given your time frame to hospital.

Cheers

MM

Is fluid filling in the ALS protocols? No idea. I do what the medic tells me unless it exceeds my scope of practice and/or comfort level.

And I WAS part of the ALS unit. It wasn't practical to push meds even though we WERE an ALS unit since we were so close to the hospital.

 

[Sasha]

Don't get rude now, Archie :[

 

[boingo]

Yes, because I'm always going to automatically assume that every patient who I run into (as the third medical professional to make contact with them on the call) has a heartrate of 20 despite being asymptomatic. I guess I was sick the day they covered "clairvoyance" in EMT class.

You didn't assume he had a heart rate of 20, you are the one who took his pusle, and then confirmed his hr with an EKG. You do routinely conduct a physical exam and obtain vitals BEFORE walking elderly folks to your ambulance, no? If not, and he had no complaint, why even take him?

 

[Sasha]

No one has a normal resting heart rate of 20. I can understand a patient denying any complaint, however someone called for him with a reported complaint of near syncope/SOB, certainly consistant with a heart rate that low. Are you suggesting that the treatment rendered was appropriate? I believe you are in medic school now, how would you run this senario?

I believe I don't analyze and criticize other people's calls, becuase I wasn't there.

He should have gotten some Atropine and/or epi, but maybe there's some reason the medic didn't start with that immediatly that we don't see. Is his b/p normally in the 120s or is he normally hypertensive? Did he look dehydrated? Good skin turgor? Was his pulse thready and weak? You don't know, weren't there, can't judge.

 

[EMTinNEPA]

You didn't assume he had a heart rate of 20, you are the one who took his pusle, and then confirmed his hr with an EKG. You do routinely conduct a physical exam and obtain vitals BEFORE walking elderly folks to your ambulance, no? If not, and he had no complaint, why even take him?

Do you read? I never even made it into the house. I was out in the truck setting up for the medic. The other EMT made the call to walk him.

 

[EMTinNEPA]

Don't get rude now, Archie :[

I sowwy Sashy-poo