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
