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What are the main players in symptomatic brady?
- Atropine
- Epi
- Dopamine
- Trancutaneous Pacing / Transvenous Pacing
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Patient presents with HR < 60.
Brady recognized.
WHAT IS THE KEY TO MANAGEMENT?
Is the patient having SYMPTOMS caused by bradycardia?
- Ssx of bradycardiaChest sx
- Sob
- Altered
- Weak/fatigue
- Lightheaded/dizzy
- Presyncope/syncope
- Hypotensive or orthostatic hypo
- Pulm congestion/edema (on cxr or exam)
- CHF
- Freq PVC, VT
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patient has HR < 50, and altered....
next move
BLS ABC'S
- Check
- Airway : open? head tilt and chin lift
- Breathing: adequate? need to intubate? put on bag mask
- pt has trach..is it plugged?
- Circulation: pulse?
- put pt on monitor, check for working IV access
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pt HR < 60, altered
ABC's intact, now what
Check monitor: what kind of brady is pt in?
- *if sinus brady or 1st degree block:
- give Atropine 0.5 mg IV (rpt 3-5 min, up to 3 mg, 6 doses)
- if 2 degree Mobitz Type II AV block or 3 degree block, start TCP!
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pt HR < 50, altered...
ABCs checked
1st doses of Atropine not working...
start pacing or if still waiting for pacer
- consider INFUSIONS of epi or dopamine
- at 2-10 micrograms/min infusion.
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Pt HR < 50, altered
Atropine, Epi and Dopamine not working
- Get that TCP started!
- Call cardiology for consult on TransVenous pacing.
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Patient stabilized...
How do you know?
- Check for improved clinical status.
- Second, improved heart rate.
- Patient not HR 65 on TCP.
- More alert, no CP.....
- You win :)
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Why is symptomatic brady dangerous?
These pt are PRE-CARDIAC ARREST!
- When the HR falls, the unstable ventricle may have escape rhythms that often fails to drugs.
- Ventricle rhythms can become WIDE COMPLEX and turn into VT/VF then ASYSTOLE.
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What is the first line Tx in pts with symptomatic bradycardia without evidence of heart blocks?
Symptomatic Brady first line treatment
- Atropine 0.5 mg IV q 3-5 min
- May repeat x 6 doses for max of 3mg.
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What are Unstable pt with symptomatic Brady?
WHat are these first line tx?
Unstable Pts are
- 2nd Degree Mobitz type II AV block
- 3rd Degree AV Block
- Wide QRS
- Must start TCP first.
- Atropine wont help (pt has heart blocks, increasing HR wont do no good)
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Atropine Precaution in
- ACS or AMI pts.
- These pts have injured myocardium.
- Atropine will increase HR and worsen ischemia.
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TRANSCUTANEOUS PACING
is really the tx of choice.
Atropine just buys you time.
What does TCP do?
TCP paces the heart, like a temporary pacemaker.
TCP delivers pacing impulses to heart thro skin using cutaneous electrodes.
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Indications for TCP
- *Hemodynamically Unstable Brady Pts
- (decrease BP, altered, angina, pulm edema)
- *High degree heart blocks
- (2nd degree Mobitz II or 3rd degree AV blocks)
- *New L, R or alternating BBB
- *Bifascicular Blocks
- *Sympt Brady with Ventricular Escape Beats
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Always give what with TCP
- Pain meds or Benzos in stable pts
- TCP hurts
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TCP: How do you do it?
- 1. Place electrodes
- 2. Turn on
- 3. Set demand rate 60/min (can adjust)
- 4. Set current output: 2mA above dose where consistent capture observed
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Where should you not check for TCP capture?
- Do not check carotid pulse for TCP capture.
- Electrical stimulus can cause muscle jerks that look like a pulse.
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Standby TCP pacing for
Anticipate clinical DETEROATION in pts with AMI and
- *symptomatic brady
- *Asympt 2nd degree Mobitz II and 3rd degree AV block
- *New L, R or alternating BBB
- *bifascicular blocks in setting of AMI.
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Brady tx in a nutshell
- 1. ABCs!
- 2. Does pt have ssx of adequate perfusion? Brady causing these symptoms?
- If no and no worrisome EKGs : monitor
- If yes with worrisome EKGs
- TCP
- if yes with no worrisome EKGs
- Atropine 0.5 mg IV q 3-5 min, up to 3mg
- Start TCP
- consider adding Epi or Dopamine if above fail or still waiting for TCP
- dose (2-10 microgram/kg/min)
Cardiac consult for Trans Venous Pacing!
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