Atropine in the presence of an MI.

[RocketMedic]

I hear rumors that patients can sustain asystole indefinitely.

 

[DrParasite]

I've never had a patient who crashed following an asystolic cardiac rhythm.

 

[Handsome Robb]

It is usually not that simple, from the archives of the EMS 12-Lead Blog:

Those phantom QRS complexes look pretty convincing. Especially when you get pseudo-fusion of a real complex and a paced complex!

Thanks for the read. That was definitely interesting. After reading that about the LifePaks I'm curios to see how our MRx does it. I'll have to look into it.

I hear rumors that patients can sustain asystole indefinitely.

I've never had a patient who crashed following an asystolic cardiac rhythm.

:rofl:


On a serious note, I've never personally given atropine, or paced for that matter. Seen both once and neither worked but the guy's K++ turned out to be 8.75 so I have a feeling that may have had something to do with it.

The ERP stopped attempting to pace at 100 mA but that was about the same time the lab values came back and he started treating the hyperK and the patient's condition approved.

I've always been taught to trial atropine if you have IV access while you are setting up for pacing but it seem to me that if you are pacing someone you are finding that out early on, before you have the access to give the atropine. That's my medic-school-intern take on it.

 

[TomB]

Interesting point. Dr. Smith and Dr. Weingart talked about that in a podcast last year and both recommended routing administration of calcium prior to pacing because hyperkalemia can be "the great imitator" and calcium is cheap and benign. When you've been burned with an atypical hyperkalemia (bradycardic but not as wide as you might have expected) it's a humbling experience!

 

[Aidey]

Interesting point. Dr. Smith and Dr. Weingart talked about that in a podcast last year and both recommended routing administration of calcium prior to pacing because hyperkalemia can be "the great imitator" and calcium is cheap and benign. When you've been burned with an atypical hyperkalemia (bradycardic but not as wide as you might have expected) it's a humbling experience!

We ran into that recently. Junction rhythm, wasn't wide and had normal T wave morphology. Rate of 30 and dropping when we got on scene. Pacing failed and she coded (briefly) at the ED. Potassium was over 7.

 

[OIFXGunner]

Pacing = faster heart-rate = more oxygen demand = wait... good for the heart?!

But you just said faster heart rates is bad for the heart

I believe his point was more along the lines of finding a happy medium between bradycardic hypoperfusion and exacerbating an MI in progress. Pacing just gives you more control.

 

[VFlutter]

I would be very suspect of bradycardia secondary to an inferior MI due the possibility of heart blocks. Giving atropine in a patient with a 3rd degree will probably do nothing but it may speed up the atrial rate resulting in worsening of the block.

 

[Farmer2DO]

Atropine also, in theory, increases conduction through the AV node.

 

[VirginiaEMT]

The biggest concern for me with the atropine would be the fact that the heart rate may go up in rate far more than you anticipated and pacing give you the control of the rate.

So a small debate started over in the BLS section in one of the topics and I thought an ALS section thread couldn't hurt us.

In school we are taught atropine = faster heart-rate = more oxygen demand = bad for infarcting heart.

But at the same time, symptomatic bradycardia can commonly present in conjunction with an MI especially in a more diseased heart. (I have met people who weren't bright enough to perform a 12 lead prior to initiating their treatment, with atropine.)

Now of course we should not be giving atropine to a patient who is otherwise stable. One person stated in the other thread that they recently fired someone at his/her company because they gave atropine to a patient with an inferior wall MI as well as a sinus rate of 45, bp 95/50. Without seeing this patient ourselves, we don't know how stable or unstable they may be. A number is just a general guideline after all not a definitive level for all patients.

Anyway, if you are presented with a patient experiencing an MI as well as symptomatic bradycardia, should we be giving a trial of atropine? Is it truly that detrimental to them or might it potentially help them? Should we be moving right to more aggressive means like fluid boluses, vasopressors, pacing?