From the September 2013 issue of Emergency Medicine Practice, “Evaluation And Management of Bradydysrhythmias in the Emergency Department.” Reprinted with permission. To access your EMRA member benefit of free online access to all EM Practice, Pediatric EM Practice, and EM Practice Guidelines Update issues, go to www.ebmedicine.net/emra, call 1-800-249-5770, or email ebm@ebmedicine.net.
- “The initial ECG looks fine, and I'm not that impressed with the history. I'm sure the patient is fine.”
Many bradydysrhythmias are transient and intermittent in nature. Upon initial evaluation, it is not uncommon to have a normal ECG and an asymptomatic patient. Don't make any final decisions based on a single ECG. Two ECGs are better than one, and continuous monitoring in the ED is even better. - “I know she passed out at home, but she looks fine now, and she really wants to go home.”
It can be tempting to discharge an asymptomatic patient home, especially if she is eager to leave. Remember that the absence of symptoms now does not mean there will be no recurrence. Make sure that there is a clearly identifiable (and reversible or avoidable) cause of symptoms if you plan on discharging a patient home. - “I didn't check the medical record because he said this has never happened before.”
With the pervasiveness of electronic health records, it is becoming difficult to justify failure to review a patient's records of previous encounters. Patients may not be able to accurately answer whether they have had dysrhythmias in the past. A quick review of the record may uncover additional history that can make a big difference. - “I was so focused on the bradycardia that I totally missed the ST changes in the inferior leads.”
Inferior ischemia and myocardial infarction are frequently associated with bradydysrhythmias. Don't forget to scan through the inferior leads of the ECG to make sure the patient doesn't need emergent revascularization. - “It looks like second-degree type II block on the ECG. We can probably admit him to the floor.”
Even if the patient appears asymptomatic now and a majority of the beats are being conducted, remember that, in certain settings, second-degree type II blocks can rapidly degrade to complete heart block. Strongly consider admitting the patient to an intensive care unit for closer monitoring. - “I didn't even think to ask about travel history or tick bites.”
Infectious causes of bradydysrhythmias, including Chagas or Lyme disease, may not be common if your ED is not within an endemic area; however, for patients who have lived in or traveled to endemic areas, asking about this may identify the underlying cause. - “We were so busy focusing on the therapy that I overlooked the fistula in the patient's arm.”
Clues to the underlying cause of the conduction abnormality may be evident on examination. Make sure you look for evidence of dialysis catheters or fistulas if you are considering the likelihood of hyperkalemia. - “He said he had been on the same digoxin dose for the past few years, so I didn't check.”
In the setting of digoxin therapy (which is known to cause bradydysrhythmias), don't forget to check drug levels. If recognized as the offending toxin, antibody antidote therapy may be the only treatment for the dysrhythmia. - “A heart rate of 45 beats/min in a 25-year-old? I can't find a reason for her to have any cardiac disease.”
Not all causes of bradydysrhythmias are cardiac in nature. Don't overlook intra-abdominal pathology as a potential cause. Broaden your differential to include these reflex-mediated syndromes. - “I was so pleased I could explain the patient's syncope with the sinus bradycardia that I completely missed the other injuries.”
Although the evaluation and identification of syncope are important to signal bradydysrhythmia as a potential factor in trauma, do not overlook other injuries the trauma patient may have sustained. Especially in the elderly, be sure to evaluate for extremity fractures, head trauma, and other injuries following syncope and falls.