Tom, our Editor-in-Chief, and David, an Associate Editor, are gone on vacation. As a send-off, I am presenting the following case. I hope you enjoy it!
It is just after 3am when you are called to intercept a BLS unit on scene with a 54 year old female with a low heart rate.
Upon your arrival, you find two EMT-Basics attending to a small woman lying in bed, who appears acutely ill.
The patient is alert, oriented, and answers all of your questions appropriately. She states that she woke up not feeling well and called 911 when she could not get out of bed.
Past Medical History: hysterectomy, cholecystectomy, breast cancer
Medications: Ambien and Zoloft (she denies depression)
Allergies: Aspirin gives her heartburn
You ask her if anything else is going on and she states that her chest, “feels funny”.
Onset: woke her up from her sleep
Provocation/Palliation: nothing makes it better or worse
Quality: she points to the middle of her chest as the source of the funny feeling
Radiation: when asked, she mentions her left leg is tingling
Severity: repeated questioning only elicits, “it isn’t that bad”
Time: 20 minutes
Her vital signs are reassessed in the Trendelenburg position.
Pulse: 44, regular, no radial pulses present, however weak brachials are palpable
Respirations: 12, unlabored, bilaterally clear breath sounds
BP: 54/0, unable to accurately auscultate the diastolic
SpO2: 96% on O2 via NRB at 15 L/min
Besides her cold, ashen gray skin, her physical examination is unremarkable.
The cardiac monitor is attached.
A 12-Lead ECG is acquired.
A final 12-Lead ECG is acquired as you arrive at the receiving facility.
What is your interpretation of the initial 3-Lead and 12-Lead? How would you treat this patient?
Given the final 12-Lead, does this change your interpretation?
See Also:
Awesome discussion everyone!
Just to clarify, I was thinking more along the line of dissection than AAA with my LE pulse checks. AAA is possible for a patient who’s sick as all get-up, but there’s a particular reason why I’m considering dissection (and also a few reason why I think it’s not likely, but I’d look anyway).
Anytime someone has the combination of a torso complaint and anything neurologically, dissection should be considered because when the dissection picks off arteries leading leading to any area of the body, it can present with numbness, tingling, or weakness. Also, a dissection could run back into the coronary arteries, usually the RCA, and cause all the problems of an RCA occlusion, including a tendency to develop blocks.
That being said, in this case, I think it’s highly unlikely that she has dissected all the way from the root of the aorta down to her left iliac to give the rather distant results of a heart block and left leg tingling. If this was indeed caused by a dissection, I’d be much more convinced if she presented with the heart block and facial numbness, tingling, or droop, since the carotid arteries are so close to the coronaries coming off the aorta. Arm numbness, or even the classic bilateral BP or pulse differential would also be possibilities, but as I said, hitting a coronary and an iliac is a pretty wide swath of aorta to dissect.
I work in the UK and I agree that this is type 3 (complete) heart block. Atropine is not contraindicated within our guidelines for complete heartblock, it is infact indicated where there is a high risk of asystole; mobitz type II, complete heart block WITH wide QRS, and ventricular pauses >3 secs. I would certainly give a primary dosage (within our guidelines of symptomatic bradycardia – 500mcg, max of 3 doses), record multiple 12 leads and treat the low BP with fluids (aiming for a systolic of around 90).
This is a great discussion, I believe our guidelines across the pond in the UK are somewhat different and I find it incredibly interesting that there’s so many different methods of treating this case yet all aiming for the same outcome!
TO me it sounds like a complete heart block. fluid rescus and pacing with caution will do! although the ECG is with artifacts n the baseline.. its hard to give proper answer!
I’m going with 3rd degree block. I’d skip the atropine, get pads on in preparation to pace, and do a fluid bolus. I’m not rushing into dopamine because with any luck, pacing will improve her pressure. Depending on her pressure after the fluid bolus(es), I may or may not premedicate, but I would then begin pacing and treat changes appropriately.
third degree block dopamine will do just as well as pacing, pt is alert and is going to mind being electrocuted