Atropine & Bradycardia

[Jon]

Hey - A couple of questions - what is the "over the counter nitro-type medication" - not familar with it, and would like to be, for future reference.

OK - 12 lead's normal... how about a 15 lead? Yeah, I know, no one does them... just asking.

My gut feeling would be to try the ACS algorythym - ASA, NTG x3, and re-evaluate from there. At that point, if pain is still significant and transport time is grater than a couple of minutes, I'd probably call Medical Control and discuss Atropine, and/or poss. MSO4. I don't see a need to give Atropine based on Chest Pain alone... although I'm somewhat swayed by the "paleness" statement.

 

[8jimi8]

the pallor is concerting because to me that is indicative that his body is vasoconstricting peripherally and shunting blood to vital organs; however there is no concurrent hypertension and the patient is bradycardic.

Again, I would not give the atropine based on the presentation, but it is worrisome.

any more info from the OP

 

[Melbourne MICA]

Symptoms

There's a difference between "symptomatic" and "hemodynamically unstable". Chest pain by itself does not qualify (please do not read me the AHA algorithm). The issue is whether or not the chest pain is being caused or aggravated by the bradycardia. What if this patient was having an acute inferior STEMI? Does the mere fact that STEMI is typically accompanied by chest pain qualify the patient for atropine?

Tom

Yes there is. But the chest pain and brady may well be the first indicators of his infarct and that's the worry and the point. We don't want him to become haemodynamically unstable. But he is already (at least on the balance of probabilities) heading in that direction. Not good.

And he does already have a compromised perfusion state. BP might be one of the big perfusion quantifiers but don't underestimate others at the same time. At the very least technically, he's getting a B+ for perfusion. And the brady may well be nothing to do with the pain. A guy at 45, even somebody as unfit as me could well tolerate a HR of 48 without getting ischaemic mainly because all my other compensatory mechanisms still work ( I hope!!!). If I keep my BP because my smoking hasn't completely clogged all my arteries then I should be OK - for now. But the brady may well be arrhythmic as well. As inferior STEMI's go

But this guy now has multi system and multi symptom involvement - has serious pain (a neuro response - maybe dermatome 4?)), skin perfusion changes (skin), a drop in his HR (CVS), feels decidedly unwell and all in the setting of physical exertion ( has really loaded up his myocardium just thr right time to expose any inherent weaknesses like clogged coronaries!!), his age and gender and other risk factors.

Pain is a always a warning sign of injury. And his haemodynamic status can change - really quickly if he's infarcting.

I'm still happy to try a cardiac meds regime and work the brady as well. Oh; and by the way his HR being 48/min, at least in my guidelines, GTN is out - contraindicated for HR<60/min. So all you guys who mentioned nitro - does this change your thoughts on treating this guy?

What does he get now? Aspirin - good stuff all round, O2 (no benefit really if his SPo2's are 100%) IV, Morph - ohhhh.....careful with that brady and a stretcher. We've lost one one of our first line cardiac trump cards - the GTN, the morph carries risks and we don't want to use the Atropine. Yep?

No offence intended to anyone. Just fluffing around a bit at the edges.

MM

PS I had a pt who could have been this 45yo's twin just a couple of weeks ago. He had a much better (nastier) prior cardiac history admittedly so the chopices were a bit clearer but I wanted to use atropine - his Hr was 48, he was pale andd sweaty with lots of chest pain. But my partner equivocated because his BP was 110/65 even though we had 12lead but it was not clear cut as an infarct.

Being the concilliatory type I bowed to his wishes and didn't give it. (I'm a big girls blowse after all). 5mins later he dropped his BP sub 100 and got much much worse. The I gave it - the Atropine that is - HR to 70/min and BP to 130sys. But how much damage had I done in the meantime whilst his obs were marginal at best?

Pt went to the cath lab - plasty etc infero=lateral Even my boss said why didn't I give it earlier. yeh why didn't I?

MM

 

[Veneficus]

Even my boss said why didn't I give it earlier. yeh why didn't I?

MM

Armchair quarterbacks

 

[dmiracco]

n o

 

[zzyzx]

Quote: "PS I had a pt who could have been this 45yo's twin just a couple of weeks ago. He had a much better (nastier) prior cardiac history admittedly so the chopices were a bit clearer but I wanted to use atropine - his Hr was 48, he was pale andd sweaty with lots of chest pain. But my partner equivocated because his BP was 110/65 even though we had 12lead but it was not clear cut as an infarct.

Being the concilliatory type I bowed to his wishes and didn't give it. (I'm a big girls blowse after all). 5mins later he dropped his BP sub 100 and got much much worse. The I gave it - the Atropine that is - HR to 70/min and BP to 130sys. But how much damage had I done in the meantime whilst his obs were marginal at best?

Pt went to the cath lab - plasty etc infero=lateral Even my boss said why didn't I give it earlier. yeh why didn't I?"

You didn't do any damage, and your boss is wrong.

 

[MrBrown]

My two cents are that in this situation blood pressure and perfusion status (or degree of compromise) are really independant of each other; I mean sure there is probably a link there (I ain't no physiologist!) but it's not a guarentee.

For example; if I go to a job where the patient is obviously compromised because of thier bradycardia (pale, cold, poor orentation/LOC) it wouldn't matter to me if thier blood pressure was 200/130 I'm gonna whip out some atropine.

Now in the setting of infarct a good question is raised; do we speed up the ticker and put more strain on an already buggered conduction system, risk growing the infarct and him dying on me or do we leave it a nick up to the cath lab on a priority 1?

We could ask the same of the opposite situation, an infarct throwing runs of PVCs and heading towards VT; do we just put the foot to the gas pedal or mix up some amiodarone?

MM; could this be something you would call "The Clinician" for? ... sounds like somebody who runs around in one of those blue jumpsuits MAS has with a red cape ...

 

[zzyzx]

C'mon dude, seriously? I think you are selling yourself short here, and you don't need a "clinician" to figure this out. Take a look at your textbooks, scratch your chin a bit, and I'm sure you'll figure this out for yourself.

 

[ScoopandSwoop]

Fair question.

No to Atropine. Stable. RX: O2, NTG, ASA and keep and eye on 12 lead and rate. You could always bounce the RX off of Telemetry Control. Personally, I wouldn't fiddle with his heart rate.

 

[MrBrown]

C'mon dude, seriously? I think you are selling yourself short here, and you don't need a "clinician" to figure this out. Take a look at your textbooks, scratch your chin a bit, and I'm sure you'll figure this out for yourself.

The "metro clinician" is the consultant level Paramedic that MAS have sort of like online contact but its to consult not ask for orders

 

[clibb]

What is the opinion of my fellow paramedics on this situation.

So, 45 year old patient. No medical history. No meds. No allergies. Chest pain started 45 minutes earlier while exercising at gym. Continued exercising. Went home and his wife gave him an over the counter nitro-type medication readily available in NYC and then called 911. Pain was a "tightness", 7 of 10, non-radiating, midsternal, constant pain. Reduced to a 3 after taking the medication. No change on palpation, exertion, inspiration. No cough. Denied muscle pull. Never had similar pain. Non-smoker. VS: 118 / 60, HR 48, RR 20, Pale (not normally pale per wife, less pale after taking medication), slightly moist, SaO2 98%. Lungs Clear. 3 Lead Sinus Brady at 48, 12 lead NSR neg ectopy.

Would you give atropine or not? I recognize and subscribe to the theory that atropine is generally for symptomatic bradycardic patients who are hypotensive or ams and that it increases oxygen demand. Would you consider this patient to be symptomatic based on the chest pain? It is an unstable dysrhythmia based on NYC REMSCO GOP guidelines.

Your thoughts?

I'm not a Paramedic, but I've got some questions.
Since you say he's an athlete; what kind of athlete? Does he play hockey, baseball, basketball, football?
I know that when I get hit in the chest at hockey, I won't think about until a couple hours to days after.
Muscle pulls at the gym, especially by the sternum you won't feel until some time after. But. constant pain would kind of rule that out since you get it when you do something that would trigger the pain like lift again or put your arms in a different way, right?
Also if he had an MI at the gym, would he be able to continue exercising or would he feel extremely weak?
Has he ever had broken ribs? My dad broke 2 ribs and he does feel chest tightness from that sometimes. - - - I know this would be under medical, but just good to know.

I was just asking that since you said non-radiating and constant chest pain.

 

[Tal]

Alltough the Israel MDA protocol suggest 0.5mg Atropine in stable pt, I've been taught that the delivery of good medical care is to do as much nothing as possible...so O2, monitoring and D65.

 

[usafmedic45]

Granted I'm only 21, but my resting HR is 52 and my dad, at 56yo, is in the low 50's as well.

When I was kicked in the chest by a horse when I was younger (19), the medic student who was on the call for me was panicking that I had a cardiac contusion and (I quote) "needed atropine like right now" because I had a resting heart rate of 40 something and BP of 84/60. Mongo the Super-Medic didn't bother to ask what my normal resting heart rate and BP were. Both those values were normal for me. It took me threatening to cram the pre-fill up where the sun don't shine if he didn't put it down to make him stop and listen to me and his preceptor (who had been an EMT class classmate of mine). I am a little surprised that my heart rate was not higher given how much the broken ribs and sternum hurt. ALWAYS ask if the person knows what their normal resting heart rate is, especially in athletes.

In this case, no, I would not have given atropine either.

 

[Akulahawk]

I'm not a Paramedic, but I've got some questions.
Since you say he's an athlete; what kind of athlete? Does he play hockey, baseball, basketball, football?
I know that when I get hit in the chest at hockey, I won't think about until a couple hours to days after.
Muscle pulls at the gym, especially by the sternum you won't feel until some time after. But. constant pain would kind of rule that out since you get it when you do something that would trigger the pain like lift again or put your arms in a different way, right?
Also if he had an MI at the gym, would he be able to continue exercising or would he feel extremely weak?
Has he ever had broken ribs? My dad broke 2 ribs and he does feel chest tightness from that sometimes. - - - I know this would be under medical, but just good to know.

I was just asking that since you said non-radiating and constant chest pain.

One of the questions I ask when dealing with a chest pain patient is if they can take one finger and point to exactly where it hurts... if they can't, then I start heading down the cardiac pathway. If the patient does indicate one specific spot, then I'll attempt to determine if it's musculoskeletal, pleuritic... and so on. What I will also want to know is what the patient was doing before the pain started. That can provide a clue as to what the problem is.

When I was kicked in the chest by a horse when I was younger (19), the medic student who was on the call for me was panicking that I had a cardiac contusion and (I quote) "needed atropine like right now" because I had a resting heart rate of 40 something and BP of 84/60. Mongo the Super-Medic didn't bother to ask what my normal resting heart rate and BP were. Both those values were normal for me. It took me threatening to cram the pre-fill up where the sun don't shine if he didn't put it down to make him stop and listen to me and his preceptor (who had been an EMT class classmate of mine). I am a little surprised that my heart rate was not higher given how much the broken ribs and sternum hurt. ALWAYS ask if the person knows what their normal resting heart rate is, especially in athletes.

In this case, no, I would not have given atropine either.

In my experience with athletes, they usually know what is normal for them. I've had my fair share of linemen that really had no clue... but most know what's normal.

usaf: I'd bet that you did sustain some cardiac and pleural contusion on top of your broken ribs, but given your likely fitness level at the time, it probably wouldn't have shown up (if at all) unless you were pushed near your max performance. Rib and sternal pain would have been your limiters before you reached a point where performance would have been impacted by any internal contusions.

What would I have done with you? Frankly, probably not much. ECG Monitor (watching for arrythmias and any ectopy). Consider O2 (certainly have it handy). IV TKO or Saline Lock if allowed by protocol (primarily for med access if you code). Piggy-backed on that is pain management measures, also if allowed by protocol or base order. Relatively frequent vitals at first and watch for a declining trend. Transport to facility of choice. Chat while en-route... with you and the ED.

And in my best "Soup Nazi" voice: "No Atropine for YOU!" (at least until you need it.)

 

[usafmedic45]

I'd bet that you did sustain some cardiac and pleural contusion on top of your broken ribs, but given your likely fitness level at the time, it probably wouldn't have shown up (if at all) unless you were pushed near your max performance.

Actually the pulmonary contusions were apparent on the CXR (I have a copy of it somewhere around here...I use it in presentations when I need to demonstrate rib fractures, sternal fracture or pulmonary contusion). They did an echo on me while I was in the hospital and there was no evidence of a cardiac contusion.

 

[Hellsbells]

Atropine

Yes there is. But the chest pain and brady may well be the first indicators of his infarct and that's the worry and the point. We don't want him to become haemodynamically unstable. But he is already (at least on the balance of probabilities) heading in that direction. Not good.

Yes he may be having an infarct, However, the chest pain was reduced from 7-3 with the "over the counter" Nitro, he doesn't have any significant ST changes ( although, of course a NSTEMI is possible), and has had the chest pain for at least 30mins (enough time to finish his workout and return home). Besides the slight bradycardia and chest pain there is no indication of impending haemodynamical collapse. For all we know the 48 may be his normal heart rate, although you strangely argue that his normal resting heart rate is irrelevent.

And he does already have a compromised perfusion state. BP might be one of the big perfusion quantifiers but don't underestimate others at the same time. At the very least technically, he's getting a B+ for perfusion. And the brady may well be nothing to do with the pain. A guy at 45, even somebody as unfit as me could well tolerate a HR of 48 without getting ischaemic mainly because all my other compensatory mechanisms still work ( I hope!!!). If I keep my BP because my smoking hasn't completely clogged all my arteries then I should be OK - for now. But the brady may well be arrhythmic as well. As inferior STEMI's go.

Where is the evidence its an inferior STEMI?

But this guy now has multi system and multi symptom involvement - has serious pain (a neuro response - maybe dermatome 4?)), skin perfusion changes (skin), a drop in his HR (CVS), feels decidedly unwell and all in the setting of physical exertion ( has really loaded up his myocardium just thr right time to expose any inherent weaknesses like clogged coronaries!!), his age and gender and other risk factors.

Pain is a always a warning sign of injury. And his haemodynamic status can change - really quickly if he's infarcting.

...and even faster if the bradycardia is a protective mechanism of the infarct. In an Infarcting heart there is always the risk that an increase in myocardial oxygen demand can increase the size of the infarct.

I'm still happy to try a cardiac meds regime and work the brady as well. Oh; and by the way his HR being 48/min, at least in my guidelines, GTN is out - contraindicated for HR<60/min. So all you guys who mentioned nitro - does this change your thoughts on treating this guy?

A good point, Nitro may be contraindicated in this pt, but that doesn't mean he should automatically be given atropine. Again, if his resting heart rate is normally slow, I may give Nitro. However, I would certainly give a drug that is proven to increase outcomes in MI-ASA.

What does he get now? Aspirin - good stuff all round, O2 (no benefit really if his SPo2's are 100%) IV, Morph - ohhhh.....careful with that brady and a stretcher. We've lost one one of our first line cardiac trump cards - the GTN, the morph carries risks and we don't want to use the Atropine. Yep?

Really, SATS of 100% and you think the pt may be having an MI, but 02 is of no benefit? I probably wouldn't give the morph- but again, this all rests on what the pts normal heart rate is, something that you have dismissed as unimportant. As far my Tx:
02 4LPM via N/C, ASA 320mg PO, IV- bolus of NaCl 250ml, Nitro 0.4mg SLx1- reasess Vitals pain, serial 12 leads, Patch to hosp

No offence intended to anyone. Just fluffing around a bit at the edges.

None taken, its a good discussion, but I think Atropine in this situation has more risk than you think, particularly if it an acute MI, as you argue. Let me ask you this, if one more spray of Nitro resolved the chest pain, but the vitals stayed the same, would you still administer the atropine?

 

[DwayneEMTP]

First time poster. Thank you for letting me participate.

To the OP. For me there are really only a couple of immediate considerations here.

1) Are we getting end organ perfusion?

2) Is this a cardiac even?

Why do we care if his heart is beating at all? Or adequately? End organ perfusion, and mentation is a very good indicator of this. In this pt we certainly show some perfusion compromise if we look no further than his pale/diaphoretic skin. But I'm much less concerned with his skin at this point than I am with his vital systems.

The chest pain/diaphoresis certainly raises concerns for a cardiac event. Bradycardia is sometimes a protective mechanism for cardiac eschema. Do we know that this is what is occurring? No, not based on the 12 lead, but we don't really need to know in this situation, as we're not forced at this moment to increase cardiac O2 demands based on our adequate end organ perfusion as indicated by normal mentation.

So it lines up for me like this. I'm not terribly concerned with a h/r in the 40's in an adequately perfusing person. I can push some Atropine because protocols may or may not say to do so, but there is a chance that if the bradycardia isn't normal for this pt, and is in fact protective, that we will increase h/r with the accompanying increase in O2 demand on an already hungry heart, yet not really gain anything except an increase in perfusion adequate to make him stop sweating. And sweating isn't terminal, though the presumed infarct might be.

My plan, ASA as the science is clear on it's benefit, withhold the Nitro for now, IV access TKO, as his b/p is adequate for his perfusion needs at this time per mentation, not high enough that I believe that I'll gain much by lowering preload, and I'm not terribly concerned by a 3/10 pain level at this point. O2 despite his SPO2 as his physiological markers tell me not to trust the pulse ox numbers in this pt. As well the O2 in my experience often offers a psychological calming benefit that may also help with cardiac O2 demand, withhold Morphine at this time simply based on the fact that I see no benefit to this intervention at this time.

Monitor pain level, mentation, watch his rate, lung sounds, serial/parked (non driving) ECGs, transport.

All of these decisions are subject to change of course based on new/changed s/s.

Have a great day all.

Dwayne

 

[LondonMedic]

I'd only consider atropine for symptomatic bradycardia.

Maybe I'm more conservative, but as far as I can see the only justification for atropine outside of an arrest is compromised bradycardia with a hypotension in the absence of pacing. Simple symptomatic bradycardia is not, in itself, an acute problem.

 

[atropine]

I wouldn't have... Pt wasn't AMS, decent BP, and clear lung sounds, so that would guide me away from atropine. The guy was just at a gym, so does he work out normally? Granted I'm only 21, but my resting HR is 52 and my dad, at 56yo, is in the low 50's as well.


Pain semi-relieved by vasodilators guides me more towards stable angina, but sadly without a pre-dose 12lead it doesn't make our jobs any easier.


Then again I'm the new guy so I'll wait for the more experienced ones.




What's interesting is the adrenergic caused appearance and him being in pain, but the heart rate still being low.

What did you do before there was any 12-lead?

 

[MrBrown]

You mean we should be using atropine in cardiac arrest?