Bradycardia emergencies are uncommon, but these cases can go sideways fast. An appropriately aggressive approach is needed to avoid cardiac arrest. Sometimes the answer is as simple as the appropriate epinephrine dose.
-
The IBCC chapter is located here.
- The podcast & comments are below.
Follow us on iTunes
The Podcast Episode
Want to Download the Episode?
Right Click Here and Choose Save-As
Electrophysiologist Michael Katz left a series of comments on twitter that were really useful. I've reproduced them here:
I think you’re “underselling” how necessary the panic button on the TVP box is. When floating the wire, I use this button. Unless you are VOO/DOO, your hand motions and wire movements will make TVP inhibit and you won’t know when you actually have capture.
— Michael Katz (@MGKatz036) October 14, 2018
This is a nice pearl. On a related note, if you're floating a transvenous pacemaker and the person holding the pacemaker generator doesn't know how to use it you can just ask them to hit the panic button.
thank you, agree. was afraid to go full-out against atropine because in some settings (e.g. ward) atropine may be the only immediately available drug and it may be more likely to help than harm. personally I don't think atropine has a role in an ED/ICU where epi is available
— 𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊 (@PulmCrit) October 14, 2018
I'm still struggling with the atropine issue a bit. Dumping atropine from the algorithm completely would go against AHA/ACC guidelines. I'm open to this, but would like some more evidence first.
My other comment is philosophical… and maybe to be added to section on “why bradycardia is bad”….
— Michael Katz (@MGKatz036) October 14, 2018
When a patient is bradycardia, the mechanism of death is rarely hypotension until they are on the spectrum of PEA/peri-arrest bradycardia… the mode of death is pause dependent Torsade and polymorphic VT/VF….
— Michael Katz (@MGKatz036) October 14, 2018
… this being said, bradycardic pts tend to look, well fine.
But if you look at their uncorrected QT, it’s probably like 680 if HR is in 20-30s…. One PVC away from dead.
— Michael Katz (@MGKatz036) October 14, 2018
Therefore, taking a holistic view, TCP —> TVP should be aggressively offered with extreme bradycardia, even in hypertensive pts.
— Michael Katz (@MGKatz036) October 14, 2018
https://twitter.com/MGKatz036/status/1051272811854131201
92 yo p/w CP and K 3.3. pic.twitter.com/cq3q0sF7DK
— Michael Katz (@MGKatz036) October 14, 2018
Closer look at escape: pic.twitter.com/Vdjf5t1TtZ
— Michael Katz (@MGKatz036) October 14, 2018
This is an interesting issue that I wasn't aware of. I've added this concept to the main chapter including the rhythm strip above.
- Pulmcrit wee: The cutoff razor - April 15, 2024
- PulmCrit Blogitorial – Use of ECGs for management of (sub)massive PE - March 24, 2024
- PulmCrit Wee: Propofol induced eyelid opening apraxia – the struggle is real - March 20, 2024
Great chapter as always. What about dobutamine instead of isoproterenol? A lot of cardiologists don’t want us to put the patients on a temporary pacer, they just want to keep them monitored until they get a slot for their permanent one. They say if we insert the temporary one, we mess up with the patient’s own sympathetic tonus which keeps them “stable”. And if the pacer stop sensing / pacing they don’t have this sympathetic rescue tonus anymore (“they get lazy”). I think this is bullshit, the patient has some rescue sympathetic hypertonus and they can decompensate in any second.… Read more »
thanks! a couple thoughts: 1) You’re not the only person to ask about dobutamine so I’ve added a new section about doubtamine to the chapter. I should have put it in before but hey, that’s what post-publication peer review is for: https://emcrit.org/ibcc/bradycardia/#other_medications 2) If a patient is planned to get a permanent pacemaker, I don’t see how putting in a temp wire would hurt them (even if it did suppress their sinus node, they’re going to get a permanent pacer anyway). If you’re that worried about the patient’s heart stopping, that should be an argument *for* placing a wire (not… Read more »
Great summary.
Small note; the algorithm has “success” spelt incorrectly. Cheers, JC.
might leave that one in there, purely for the sake of irony
Great chapter! Really enjoyed it, especially the essential learning about the honey badger. 😀
Thoughts on orciprenaline (don’t know if it’s even available in the US)?