Third Degree AV Block

The usual... HPI, OPQRST, SAMPLE, initial vitals, all that happy stuff...

Rx = oxygen, IV NSS KVO, apply the pacer pads just in case the patient decompensates, serial 12-leads, repeat vitals every 5 minutes, continuous reassessment, obtain blood samples if the system permits, treat additonal complaints as they arise, and transport. I'd also probably get out the versed and the atropine and have the unopened meds sitting on the bench seat next to me and at least unzip the compartment that the airway kit is in... no such thing as too prepared.
 
I would do 12 leads, 1 sitting still, the rest enroute(you can do multiple while transporting, try to do it on smooth parts of the roads, and if you have transported to that hospital, you know where it is smooth); 2 IV's, Cath Labs need 2 and if the patient crashes, it is great to have 2. O2, 4 l/m NC, transport non emergent.
Atropine doesn't help on 3rd deg blocks, I would have pace pads out, and ready to connect, but not open or on the patient.
 
With a heart block as described, while atropine would be on my mind, I'd still prefer to go to TCP over atropine. Out here, atropine @ 0.5mg is protocol for all bradycardias, and this would "qualify" under that protocol... the guy is otherwise asymptomatic, so Sacramento County would have the medics wait and watch.

Sacramento County doesn't break down the rhythms. It's a functional result: Bradycardia, narrow complex tach or wide complex tach w/ pulses...
 
Akulahawk said:
With a heart block as described, while atropine would be on my mind, I'd still prefer to go to TCP over atropine.
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Same here, which is why the pacer pads would be on but the atropine, while out of the bag, would still be in the box. I'm still figuring out whether I like electricity or I like chemicals, though.
 
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I actually talked this over with the medical director and he agreed with my course of action. He said in a case like this that he would have basically done exactly as I did but he would have given 0.5 mg of Atropine, especially with it being a narrow complex rhythm.

As I said, the receiving ER physician did try Atropine without any success. This patient did ultimately get a pacemaker and went home the next day. I only know what the newspapers reported as he was the mayor of one of the three towns in our county. He conversed just fine during transport. Only thing that changed was that he began to complain of slight difficulty breathing (difficulty taking a deep breath) upon arrival and that his BP rose a bit during transport, I think it went up to around 160/70ish. That surprised me because I kept waiting for it to fall.
 
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Great resources

Thanks for the articles! Our protocols tell us not to give atropine in 2 degree type II or 3rd degree blocks - yet when we get to the ER the MD asks why we didn't give it, but never explains why we should. Now I understand!

Whitey



EMTinNEPA said:
http://www.americanheart.org/presenter.jhtml?identifier=564

The American Heart Association includes atropine in their treatments for third degree AV block.

http://emedicine.medscape.com/article/758454-treatment

According to this document by Drs. Levine and Brown, atropine is likely to be ineffective in wide complex third degree AV blocks. Paccookie described a narrow complex third degree AV block.
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