Initial vitals:
T: 36.5, BP: 140/70, R: 22 P: 34, O2: 100%
What is your initial step in management?
Give atropine
Start epinephrine infusion
Provide supplemental oxygen
Initiate IV, monitor, and gather history
The patient is stable and currently asymptomatic. While the heart rate/bradycardia is concerning, at this point we have no idea the etiology or type of bradycardia the patient has. Avoid “treating a number”. You have time in this scenario to gather more information while continuously assessing the patient.
You appreciate the following rhythm:
What is the next step in management?
Transcutaneously pace the patient
Atropine 0.5mg
Synchronized cardio version
Adenosine 6mg
The patient is currently stable and demonstrates bradycardia, specifically second degree heart block, type I (Wenkebach). It is reasonable to give atropine to attempt to increase the heart rate. Cardio version is not indicated. Transcutaneous pacing can be attempted in unstable patients unresponsive to atropine. Adenosine is not indicated for bradycardia and could actually worsen symptoms as this is an AV nodal blocking agent which could potentially precipitate complete heart block or unstable bradycardia/arrest.
Patient begins to feel more light-headed and feels like she is going to pace out. Rhythm strip remains unchanged. Repeat vitals demonstrate a thready pulse and BP: 70/30.
What is your next step in management?
Transvenous pacing
Give atropine, transcutaneous pacing
Intubate
Initiate CPR
The patient demonstrates unstable bradycardia. Atropine 1mg can be given but patient has not responded to this and transcutaneous patient should be initiated. While the patient is unstable, ACLS emphasis is on CAB (circulation, airway, breathing). The patient is currently maintaining an airway and breathing and her main issue is the bradycardia causing poor perfusion.
Which medication can be started for treatment?
Dobutamine 5mcg/kg/minute
Amiodarone, 150mg bolus over 10 minutes
Diltiazem 5mg/hour
Epinephrine 2-10mcg/minute infusion
Atropine can be given as first line for bradycardia. Transcutaneous pacing should be attempted for unstable bradycardia. Can also give epinephrine 2-10mcg/kg/minute or Dopamine can be initiated at 2-20mcg/kg/minute. Diltiazem is a calcium channel blocker and AV nodal blocking agent which would worsen the scenario. Amiodarone is an antiarrhythmic used in treatment of certain tachycardias.
You attempt dopamine infusion but patient remains bradycardia. The patient now has become completely unresponsive and you are unable to palpate a pulse.
Rhythm strip demonstrates the following:
Give dopamine
Defibrillate
Cardovert
The rhythm strip demonstrates asystole. This is not a shockable rhythm. Initiate CPR and give 1mg epinephrine every 3-5 minutes, re-assessing after each round of CPR.
On re-evaluation, the monitor demonstrates the following:
Check a pulse
IV fluids
If transcutaneous pacing is unavailable or ineffective, an epinephrine infusion can be initiated in symptomatic bradycardic patients unresponsive to atropine. Alternatively, ACLS guidelines recommend dopamine infusion at 2-10 μg/min – which can be either added to epinephrine or given alone. Doses for each medication should be titrated to patient response, with continuous assessment of intravascular volume and support as needed.
Which of the following represents possible causes of PEA arrest?
Sepsis, myocardial infarction
Hypomagnesmia, hypocalcemia
Hypoxia, hypovolemia
Pulmonary embolism, hyperthermia
The “H’s and T’s” are causes of arrest that should be considered when treating cardiac arrest. H’s: Hypothermia, Hydrogen ion (acidosis), Hypoglycemia, Hypovolemia, Hypo/hyperkalemia. T’s: Thrombosis (myocardial infarction or pulmonary embolism), Tamponade, Tension pneumothorax, Trauma, Toxins.
Intubate, admit to the ICU
Start dobutamine
Send for cardiac catheterization
Oxygenate appropriately, maintain perfusion, consider therapeutic hypothermia
Once a patient regains a pulse, optimize oxygenation and perfusion. If the patient remains unresponsive but has a pulse, consider therapeutic hypothermia. If the patient regains consciousness, and if there is high suspicion of STEMI, the patient should go to catheterization. If there is not evidence of STEMI (in this case the initial rhythm was bradycardia but no ST elevation), then continued advanced critical care should be continued, maintaining oxygenation, perfusion and searching for underlying cause.
