Note: Your progress in watching these videos WILL NOT be tracked. These training videos are the same videos you will experience when you take the full ProACLS Recertification program. You may begin the training for free at any time to start officially tracking your progress toward your certificate of completion.
In this lesson, we're going to let you play the role of team leader during a cardiac emergency – bradycardia. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations.
In this scenario, you've been presented with a 78-year-old female patient who is pale and diaphoretic. She tells you that she is feeling dizzy and weak and also that she began feeling this way about 3 hours ago. She also tells you that her condition seems to be getting worse.
She is conscious and alert, which means that at the moment she's stable. And since she doesn't seem to have any life-threatening conditions, you determine that the first step should be to get a good set of vitals, which you have instructed an assistant to get.
Your initial assessment recap:
- 78-year-old female
- Pale and diaphoretic
- Feels dizzy and weak
- Conscious and alert
Your assistant tells you that the patient's vital signs are:
- Respiratory rate: 20
- Pulse rate: 48 and irregular
- Blood pressure: 78/40
- SPO2: 94 percent
Based on these vital signs, you don't need to start oxygen immediately. However, the patient is obviously bradycardic and hypotensive. And in order to know if the patient's hypotension and bradycardia are related to her heart arrythmia or another cause, you decide to get an ECG reading.
The assistant attached the ECG monitor to the patient and takes a quick look at her rhythm. As you look at the monitor, you see narrow QRS complexes along with regular P-waves, until the entire QRS is dropped.
You recognize that this rhythm indicates 2nd degree, Mobitz type II heart block. And because this type of heart block is below the bundle of His, it could turn into complete heart block rather quickly.
Pro Tip #1: Since hypotension and bradycardia are a concern, you direct the assistant to start an IV in order to consider administering atropine to the patient. But if the patient was unstable, as in unconscious and pulseless, you would then begin with transcutaneous pacing instead.
However, since the patient is still responsive, you choose atropine as the first treatment option. You direct the assistant to give 1 mg of atropine via rapid IV push and wait for the assistant to repeat the order back to you, which she does. She follows the order and administers the atropine.
After a minute has passed, you recheck the patient's vital signs and find the following:
- Respiratory rate is still around 20
- Heart rate is still around 46, irregular, and weak
- Blood pressure has not improved and is 76/40
- The pulse oximeter is still reading 94 percent
Based on these new set of vitals, it appears that the atropine has been ineffective. As you come to this conclusion, the assistant tells you that the patient's heart rate and blood pressure just both went down, and now suddenly the patient just went unconscious.
You now have a situation where the patient has an unstable bradycardia, which means you need to begin transcutaneous pacing as quickly as you can. You direct the assistant to apply the pacing pads and turn the pacer on.
Pro Tip #2: Individual protocols will dictate specifics and vary from place to place. However, the American Heart Association guidelines recommend starting at 60 beats per minute and as the pacer is running, turn up the milliamps until the heart muscle is captured.
In our scenario, you achieve consistent capture at 70 milliamps. Once you have that consistent capture, you should then turn the machine's interval up 2 to 5 milliamps – just enough to keep the capture. In this scenario, you decide to turn it up to 75.
Pro Tip #3: Once you have consistent capture at 60 beats per minute, you turn up the rate until symptoms improve, which is typically between 60 and 70 beats per minute.
In our scenario, you turn the rate up to 68 beats per minute. You then begin to see the patient becoming responsive again. Upon checking her vitals once more, you have:
- Respiratory rate of 16
- Heart rate of 68 under capture with a transcutaneous pacemaker
- Blood pressure of 96/60
- Pulse oximeter up to 96 percent
Once the patient's perfusion improves, you need to continue to monitor the patient closely and work on improving perfusion further by trying to determine her cause of the bradycardia, and then treat it accordingly.
Warning: Keep in mind that transcutaneous pacing can be really uncomfortable for a conscious patient. You may want to consider some sort of pain management while also considering whether or not to move the patient to the next level of care for further cardiac treatment.
