-- ABCs: if unstable (low SBP, AMS, chest pain, SOB), give atropine1mg q3-5 mins up to 3mg, start transcutaneous pacing (give fentanyl or midazolam first), give epi if need for pressors, and get to ICU; glucagon if c/f beta blocker toxicity
-- Chart Check: prior EKG, echo; meds; prior heart disease or surgeries
-- Can't Miss: ACS, complete heart block, BB toxicity, hyperK
-- Admission Orders: telemetry, CBC, BMP, TSH, trop, EKG, echo,
-- Initial Treatment to Consider: oxygen, ACS pathway if needed, atropine, pacing, etc.
-- History: *** meds (BB, CCB, opioids), hypothyroid
-- Clinical/Exam: *** unstable (BP, AMS, chest pain, SOB), evidence of overload c/f CHF,
-- Data: *** EKG, Echo, TSH
-- Etiology/DDx: *** physiologic (athlete, sleeping), heart block, SSS, ischemia/ACS, increased vagal tone (OSA, pain, carotid hypersensitivity), inflammation (infection, amyloid, sarcoid, malignancy, autoimmune), infection (lyme, sepsis, endocarditis), meds (BB, CCB, amiodatone, opioids, SSRI), metabolic (AI, hypothyroid, hyperK, hypoCa), Cushing’s (increased ICP), hypothermia
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
-- f/u EKG, place on continuous telemetry, consider echo
-- CBC, BMP, trop, TSH; lyme serology if in the right context
-- unstable - atropine 1mg q 3-5mins (up to 3mg) --> pressor (dopamine 5-20 mcg/kg/min vs epinephrine 2-10 ug/min) --> transcutaneous pacing --> transvenous pacing (ICU)
-- glucagon if c/f BB toxicity
-- consult to EP if e/o heart block or SSS
-- Permanent Pacemaker (PPM) indications - symptomatic sinus brady (+/- pauses), complete heart block, symptomatic second-degree heart block, syncope 2/2 bradycardia
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Unstable bradycardia (SBP <90, AMS, chest pain, SOB) needs acute management with atropine and escalation as needed. The underlying etiology should be investigated - top of mind should be heart block, ACS, and BB toxicity. Some processes are reversible, but in certain cases a pacemaker will be needed, so get the EP consultants involved.