Asymptomatic bradycardia

[boingo]

Everyone is a Monday morning quarterback. I assumed, perhaps incorrectly, that by posting this case the OP was looking to generate some discussion. There is more than one way to skin a cat, plenty of differing opinions, and plenty of information not given in the original post. Not looking to offend anyone, although when posting on the internet, tone is lost, and for some reason when someone questions patient management those involved tend to become defensive, myself included.

 

[EMTinNEPA]

Everyone is a Monday morning quarterback. I assumed, perhaps incorrectly, that by posting this case the OP was looking to generate some discussion. There is more than one way to skin a cat, plenty of differing opinions, and plenty of information not given in the original post. Not looking to offend anyone, although when posting on the internet, tone is lost, and for some reason when someone questions patient management those involved tend to become defensive, myself included.

There's a difference between "discussion" and "question putting a band-aid on an ouchie". The reason there wasn't a lot of info in the original post is because I don't HAVE a lot of info to give you. Like I said, I never made it in the house. My participation in this call involved driving and helping the medic keep this guy from coding with his wife in the front seat. I wanted to see what everybody thought of the case, just because it struck me as unusual that somebody could have a HR that low and still be CAOx4. Plus, the treatments were ultimately the medic's call, and I'm not a paramedic, nor was I the crew chief. I can't defend decisions that weren't mine to begin with.

 

[VentMedic]

Very interesting. Paging VentMedic.

I believe the others are doing very well without my explanations.

I will say, I would not put too put much weight on the A&Ox3 stuff or even if the patient states "feeling great" if the patient was witnessed to be short of breath and near syncope especially with a HR of 20. Hypoxia/hypoxemia comes in different forms as cardiac output varies along with O2 uptake and consumption regardless of what a pulse ox tells you and can affect sensation and memory in different ways for both short and long term. Older people due to decreased sensation in various nerve pathways may or many not feel the text book pain even when experiencing an MI or other cardiac even. The same can be said for women who also experience pain differently.

 

[MedicPrincess]

The reason there wasn't a lot of info in the original post is because I don't HAVE a lot of info to give you. Like I said, I never made it in the house. My participation in this call involved driving and helping the medic keep this guy from coding with his wife in the front seat.

When you presented this to us, you presented it as though you were there. Naturally we will have additional question for you. You were never in the house, so you don't really know what the patients complaints were. You never had any real patient contact, so you don't have any real information. That is apparent... Now.

Getting rude and making snide comments is not the way to generate any sort of learning. You say your intrested in what could be, then stop all the childish snipes...

Do you read?

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

I guess I was sick the day they covered "clairvoyance" in EMT class.

and ask questions. Answer the questions you can. If you can't asnwer them, ask additional questions or seek the answer.

If you think we are tough and asking to many questions, you haven't seen anything yet when a patient that had "No complaints" ends up dead. Even as the third man on the truck whose job is to "do as told" you will get those questions, and they are a lot tougher than we could ever give.

As for no meds... how far was the ER? Did your medic do everything enroute once the HR of 20 was confirmed or did they play a little on scene and establish O2/IV/Monitor?

As for EPI for a HR of 20 in an adult..... Stick with the Atropine, unless its PEA at 20. And get the Pacer pads out.

 

[Sasha]

As for EPI for a HR of 20 in an adult..... Stick with the Atropine, unless its PEA at 20. And get the Pacer pads out.

Duh. Of course. My mistake!

 

[Laur68EMT]

I think this is an excellent thread. Certainly it helps a lot if folks don't become so defensive. Personally, I find feedback (neg or pos) to be an excellent learning tool, and I encourage people to talk to me about things I've done right or things I need to improve on. It's not personal with me.

When I don't understand something, want to know more about why something was done one way vs another, I question it. One reason is to learn, another is because if something is done that I know isn't correct, I'm going to state my objection because it's my butt on the line, too. Every tek or medic I've ever ridden with has been super about discussing the how's and why's of what they did.

Perhaps in the house this guy had a pulse that was in normal ranges but by the time he walked to the ambulance and you rechecked it, it had dropped down to 20. I also agree that he should not have walked himself to the rig. You were dispatched for SOB and syncope. That would raised a red flag all by itself but when you arrived and found him to be asymptomatic, that would have raised two for me.

Again, interesting thread. Thanks for posting it.

 

[Lin57EMT]

I guess I was sick the day they covered "clairvoyance" in EMT class.

I think maybe your crew members may have been sick the day they covered ABCs in class, though.

I have to agree with the majority. Dispatch info was sufficient to warrant the minimum of feeling a pulse while asking just how asymptomatic he was. Red flags are only useful if you watch for them. Any responder who summarily dismisses dispatch information is not making use of quality "think time" on the way to the call.

I think sometimes responders get a bit lax about the ABCs. They figure if they patient is up and talking, he's breathing and perfusing adequately. That's not always the case, and as at least one other person pointed out, asking the patient for physical exertion (walking to the ambulance) with a HR of 20 isn't good patient care.

Nothing takes the place of putting your fingers on the pulse of a patient, and I can't think of anyone who should have a pulse check done sooner than one who has had a near-syncopal episode. What causes fainting? Lack of O2 to the brain. What causes lack of O2? Poor perfusion. What can be a cause of poor perfusion in a patient not bleeding out from evisceration? Poor pump. And if you conclude there is a pump problem, you don't ask the pump to work harder. It doesn't get any more simple than that. Ask any BLS responder what they would have done and they'll (hopefully) tell you they would have checked the ABCs. packaged patient on a stretcher and hollered loudly for ALS for a possible cardiac event. Those were Basic skills that were overlooked by your crew.

And now for my soapbox: Adopting a "Joe Cool" attitude that is dismissive of dispatch information can be a dangerous thing for some patients (and responders as well). More than a few responders' halos have fallen because they adopted an "I won't believe it until I see it with my own eyes" attitude. So many times you hear a responder say "We treat patients, not dispatches" or "You can't save anyone with a PCR box" or something similarly foolish, only to have them eat their words in the end. Often it's the young newbies trying desperately to sound seasoned and hard, like the old guys who sit at the table (who aren't necessarily the ones you want to emulate). The end result might be that a responder stops utilizing one of his greatest tools - the ability to HEAR what a patient, bystander, relative or dispatch is trying to tell you. It's not enough just to listen.

On this call, I think you gotta admit there are some lumps to be taken. Not by you, necessarily, but it sounds like the other two may have treated this too casually and could have cost the patient dearly.

Secondary soapbox: A good responder makes use of his QA, not by arguing loudly against the overwhelming tide of opinion, but by re-evaluating the facts, assessing the situation as a whole, and honestly admiting that a different treatment plan may have been a better idea. That's how we all learn. EMS keep you humble, if nothing else.

 

[vquintessence]

To answer the earlier question about fluid bolus prior to atropine, yeah that's what the state wants, at least in Massachusetts. Now however, would I wait for the entire 250cc prior to atropine? Well, good skin turgor, normotensive, I believe I'd do it simultaneously. Just document it in the "correct order".

 

[boingo]

I don't think that is what the state wants. It is an option, but I believe atropine and TCP are on the top of that list.

 

[marineman]

Duh. Of course. My mistake!

Don't admit to a mistake sash, just say that you meant an Epi drip not just IV Epi

To the OP, I'm not criticizing you or your partners but I would have definitely confirmed that BP in the other arm (don't remember by now if you said your partner did or not). In Michael Phelps I might be able to get over a normal blood pressure at that heart rate but in an elderly patient I think I'd recheck on that. Outside of that like others said the Atropine, I would have the pacer paddles ready but if he is truly asymptomatic based on your assessment I would have them in place but not start just yet. If the Atropine didn't maintain a normal perfuseable rhythm I would be double checking with a doc but thinking about spiking a bag of epi or dopamine. Personally I don't want to use electricity unless I have to with a normal responsive patient even though the pacer is supposed to come before the epi or dopamine infusion.

Others that know more feel free to tear my post apart and tell me if I did something wrong. I've got thick skin. I'm in medic school and we know most of the ACLS algorithms but haven't technically gone through ACLS yet so maybe I'm missing a key piece of the puzzle or stepping out of bounds putting steps out of line like that.

 

[rhan101277]

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.

Maybe he wasn't given these because the medic wasn't sure if he was having a heart attack or not. Unless there was a 12 lead around, I think its tough to tell on a three lead unless its a stemi. Making the heart beat faster would be bad to do on a heart attack victim I would think.

 

[marineman]

Maybe he wasn't given these because the medic wasn't sure if he was having a heart attack or not. Unless there was a 12 lead around, I think its tough to tell on a three lead unless its a stemi. Making the heart beat faster would be bad to do on a heart attack victim I would think.

Technically can't confirm STEMI on a 3 lead anyway. But Epi and Atropine have nothing to do with MI, well not what's being discussed in this thread. You diagnose a symptomatic brady rhythm and I would think 20 is symptomatic regardless of what the pt says you need to do something to speed it up. Atropine is the primary drug for that in this case with an epi drip also being an option technically, some protocols may not allow that I don't know.

 

[artman17847]

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

I'd be curious to see this pt's meds. I have seen totally asymptomatic bradys caused by pt's who accidently OD i.e. dig toxicity.

MM

Our brady protocol goes like this--

1-if pt is in accute distress i.e. severe hypotension or impending cardiac arrest begin pacing immed.

2-Airway, O2, IV NSS, mointor and 12 lead

3-signs/symptoms of distress i.e altered loc, ongoing CP, poor perfusion then .5mg atropine IV up 3mg or begin pacing and sedate pt

4-if no signs/symptoms of distres i.e. stable vitals neg SOB or CP monitor and transport and contact medical command.

 

[vquintessence]

I don't think that is what the state wants. It is an option, but I believe atropine and TCP are on the top of that list.

Right, I'm not advocating going about options alphabetically and the state isn't mandating an order either. I guess I worded it wicked stupidly:sad:. Providing no AV blocks and relative stability, I just have typically started w giving the bolus simultaneously because stroke volume (specifically preload) is stuck in mind when thinking about churning up a guys rate with Atropine. Don't see much good in increasing the rate and myocardial O2 consumption if there is limited intravascular volume.

The documentation part was just a mention regarding CQI. Like getting questioned for not documenting "attempted vagal maneuvers" as part of your treatment for SVT.

 

[KEVD18]

per protocol, this call doesnt get worked in ma. the stp's state quite clearly that you dont fire up on asymptomatic patients.

me personally, i would probably have worked it up all the way edison and medicine, but the book says not unless that become symptomatic.

for reference:

1.4. BRADYDYSRHYTHMIAS​

Pathologically slow heart rates usually result from hypoxemia, acidosis,
hypothermia, toxic ingestion or exposure, damage to the cardiac conduction system
(e.g. infarct), and late shock. Bradycardia may be a late finding in cases of raised
intracranial pressure (ICP) due to head trauma, infection, or CNS tumor. Out of hospital
treatment is directed to the symptomatic patient only. In treating bradycardia, as in
treating tachycardia the admonition​

"treat the patient, not the monitor" should be
emphasized. REMINDER: EMS providers must be aware of the concept of "relative"
bradycardia, i.e., the patient's pulse rate in relation to the patient's BLOOD PRESSURE
and clinical condition.​

ASSESSMENT / TREATMENT PRIORITIES​

1. Ensure scene safety and maintain appropriate body substance isolation
precautions.
2. Maintain an open airway with appropriate device(s), and Administer oxygen using
appropriate oxygen delivery device, as clinically indicated.
3. Remove secretions, vomitus, etc., be prepared to initiate CPR and assist
ventilations as needed.
4. Determine patient's hemodynamic stability and symptoms. Continually assess level
of Consciousness, ABCs and Vital Signs.
5. Obtain appropriate S-A-M-P-L-E history related to event, including possible
ingestion or overdose of medications, specifically calcium channel blockers, betablockers,
and digoxin preparations.
6. Monitor and record vital signs and ECG.
7. Symptomatic patients will have abnormally slow heart rates accompanied by
decreased level of consciousness, weak and thready pulses or hypotension​

(systolic
BLOOD PRESSURE less than 100).​

8. Initiate transport as soon as possible, with or without Paramedics. Do not allow
patients to exert themselves and properly secure to cot in position of comfort, or
appropriate to treatment(s) required.​

TREATMENT
BASIC PROCEDURES​

NOTE: Inasmuch as Basic-EMTs are unable to confirm the presence of Bradydysrhythmias, check patient for
a slow and /or irregular pulse. If present, treat according to the following protocol.​

1. If pulse <60 and patient is symptomatic, and/or blood pressure falls below 100
systolic, place the patient supine, treat for shock.
2. Activate ALS intercept, if deemed necessary and if available.
3. Initiate transport as soon as possible with or without ALS.
4. Notify receiving hospital.​

Commonwealth of Massachusetts 7.04 Official Version OEMS​

CARDIAC EMERGENCIES 6/06/2008

​

INTERMEDIATE PROCEDURES​

NOTE: Inasmuch as EMT-Intermediates are unable to confirm the presence of Bradydysrhythmias, check
patient for a slow and/or an irregular pulse. If present, treat according to the following protocol.​

1.​

ALS STANDING ORDERS​

Advanced Airway Management if indicated.
Initiate IV Normal Saline (KVO).
If patient’s BLOOD PRESSURE drops below 100 systolic: Administer a 250 mL
bolus of IV Normal Saline, or titrate IV to patient’s hemodynamic status

​

PARAMEDIC PROCEDURES​

1.​

ALS-P STANDING ORDERS​

Advanced Airway Management if indicated.
Initiate IV Normal Saline (KVO).
Consider a 250 mL bolus of IV Normal Saline, or titrate IV to patient’s hemodynamic
status
If patient is symptomatic as defined in Assessment Priorities:​

•​

​

​

​

Transcutaneous Pacing (TCP).​

•​

​

​

​

While waiting for pacer set-up, consider atropine sulfate 0.5 mg IV/IO
push every three (3) to five (5) minutes up to total dose 3 mg. If
administered via ET, each dose is 2.0 mg, to max. 6 mg.​

NOTE: If Transcutaneous Pacing (TCP) is warranted, consider administration of​

midazolam 0.5 mg to 2.5 mg IV push.​

2. Contact​

MEDICAL CONTROL. The following may be ordered:
a. Additional Fluid Boluses of Normal Saline as indicated.
b. Dopamine 2 μg/kg to 20 μg/kg per minute. (Rate determined by physician)​

c.​

Epinephrine Infusion (mix 1 mg in 250 mL Normal Saline). Administer 2 μg
to 10 μg per minute​

d.​

Glucagon 1.0 to 5.0 mg IM, SC or IV for suspected beta-blocker toxicity.​

Calcium Chloride 10% 2 - 4 mg/kg maximum of 1 gram IV slowly over five (5)
minutes​

​

for suspected calcium channel blocker toxicity.
Sedation for transcutaneous pacing: administer midazolam 0.5 mg to 2.5 mg IV​

push

 

[Hastings]

If the patient is asymptomatic, transport without intervention.

If it's not broken, don't fix it. At that point, you can only make things worse.

 

[BossyCow]

Wait a minute... asymptomatic? The guy had a syncope or near syncopal episode, and had symtoms severe enough to trigger a call to 911. I think I would have asked a bunch more questions before determining this to be asymptomatic. I've found with a lot of elderly, you sometimes have to crowbar those symptoms out of them.

 

[Airwaygoddess]

Food for thought and practice.......

Food for thought, for any SOB, syncope or near syncope , I always will bring the the gurney to the patient, better to work safe and be prepared for the worst. With every call we will learn something from it. -_-

 

[Veneficus]

Technically can't confirm STEMI on a 3 lead anyway. But Epi and Atropine have nothing to do with MI, well not what's being discussed in this thread. You diagnose a symptomatic brady rhythm and I would think 20 is symptomatic regardless of what the pt says you need to do something to speed it up. Atropine is the primary drug for that in this case with an epi drip also being an option technically, some protocols may not allow that I don't know.

If I may just point out.

If you increase the heart rate (with atropine or epi) in somebody with a MI prior to an intervention to restore perfusion, you will probably kill the person. I have seen it more than once where overzealous providers were treating a protocol rather than a patient. There are also other conditions that could cause this, like PE, CVA, increased inter abd pressure from an AAA, etc.

With just the information posted I would think that
1. Asking this guy to walk anywhere was a very bad idea. (but even that may have exceptions, I had a guy with a ruptured appendix who said he would go to the hospital, but only if we didn't put him on the stretcher. Upon arrival when the doc saw me walking the patient in it started with a butt chewing, but later ended with a "very sorry, good work")

2. In the absence of diagnostic tests and clinical findings, with a short transport time adding pacing or atropine to the mix would have probably been a bad idea.

3. Discretion may have been the better part of valor. Without more thorough findings, like a 12 lead, hx, meds, clinical signs and symptoms, even a fluid bolus above 500cc (or less depending on the build of the guy) may have been a bad idea.

I don’t think there is enough information posted about this patient for us to really point fingers for bad judgment outside of the walking. For instance, it might even be possible that the guy didn’t remember or notice his near syncopal episode, making him A&O x3 rather than x4. If he was unaware of events, it may give away significant pathology.

I agree you have to take dispatch information with a grain of salt, but I don’t think it should ever be discounted totally.