VISIT US AT BOOTH # 116 AT THE ACEP SCIENTIFIC ASSEMBLY IN SEATTLE, OCTOBER 14-16, 2013 September 2013 Evaluation And Management Volume 15, Number 9 Of Bradydysrhythmias In The Author Nathan Deal, MD Assistant Professor, Section of Emergency Medicine, Baylor Emergency Department College of Medicine, Houston, TX Peer Reviewers Abstract Joshua M. Kosowsky, MD Vice Chair for Clinical Affairs, Department of Emergency Medicine, Brigham and Women’s Hospital; Assistant Professor, Bradydysrhythmias represent a collection of cardiac conduction Harvard Medical School, Boston, MA abnormalities that span the spectrum of emergency presentations, Charles V. Pollack, Jr., MA, MD, FACEP Professor and Chair, Department of Emergency Medicine, from relatively benign conditions to conditions that represent Pennsylvania Hospital, Perelman School of Medicine, University serious, life-threatening emergencies. This review presents the of Pennsylvania, Philadelphia, PA electrocardiographic findings seen in common bradydysrhythmias CME Objectives and emphasizes prompt recognition of these patterns. Underlying Upon completion of this article, you should be able to: etiologies that may accompany these conduction abnormalities are 1. Recognize the electrocardiographic features of common discussed, including bradydysrhythmias that are reflex mediated bradydysrhythmias. (including trauma induced) and those with metabolic, environ- 2. Consider a variety of pathologies that give rise to mental, infectious, and toxicologic causes. Evidence regarding the bradydysrhythmias. 3. Identify the emergent therapies for the unstable patient management of bradydysrhythmias in the emergency department with bradycardia. is limited; however, there are data to guide the approach to the un- 4. Be familiar with common antidotes for acute toxicities that stable bradycardic patient. When decreased end-organ perfusion is result in bradydysrhythmias. present, the use of atropine, beta agonists, and transcutaneous or Prior to beginning this activity, see the back page for faculty transvenous pacing may be required. disclosures and CME accreditation information. Editor-In-Chief Nicholas Genes, MD, PhD Keith A. Marill, MD Scott Silvers, MD, FACEP Research Editor Andy Jagoda, MD, FACEP Assistant Professor, Department of Assistant Professor, Harvard Medical Chair, Department of Emergency Michael Guthrie, MD Professor and Chair, Department of Emergency Medicine, Icahn School School; Emergency Department Medicine, Mayo Clinic, Jacksonville, FL Emergency Medicine Residency, of Medicine at Mount Sinai, New Attending Physician, Massachusetts Emergency Medicine, Icahn School Corey M. Slovis, MD, FACP, FACEP Icahn School of Medicine at Mount York, NY General Hospital, Boston, MA of Medicine at Mount Sinai, Medical Professor and Chair, Department Sinai, New York, NY Director, Mount Sinai Hospital, New Michael A. Gibbs, MD, FACEP Charles V. Pollack, Jr., MA, MD, of Emergency Medicine, Vanderbilt York, NY Professor and Chair, Department FACEP University Medical Center; Medical International Editors of Emergency Medicine, Carolinas Professor and Chair, Department of Director, Nashville Fire Department and Peter Cameron, MD Associate Editor-In-Chief Medical Center, University of North Emergency Medicine, Pennsylvania International Airport, Nashville, TN Academic Director, The Alfred Kaushal Shah, MD, FACEP Carolina School of Medicine, Chapel Hospital, Perelman School of Emergency and Trauma Centre, Associate Professor, Department of Hill, NC Medicine, University of Pennsylvania, Stephen H. Thomas, MD, MPH Monash University, Melbourne, Emergency Medicine, Icahn School Philadelphia, PA George Kaiser Family Foundation Steven A. Godwin, MD, FACEP Australia of Medicine at Mount Sinai, New Professor & Chair, Department of Professor and Chair, Department Michael S. Radeos, MD, MPH York, NY Emergency Medicine, University of Giorgio Carbone, MD of Emergency Medicine, Assistant Assistant Professor of Emergency Oklahoma School of Community Chief, Department of Emergency Editorial Board Dean, Simulation Education, Medicine, Weill Medical College Medicine, Tulsa, OK Medicine Ospedale Gradenigo, University of Florida COM- of Cornell University, New York; Torino, Italy William J. Brady, MD Jacksonville, Jacksonville, FL Research Director, Department of Ron M. Walls, MD Professor of Emergency Medicine Emergency Medicine, New York Professor and Chair, Department of Amin Antoine Kazzi, MD, FAAEM and Medicine, Chair, Medical Gregory L. Henry, MD, FACEP Hospital Queens, Flushing, New York Emergency Medicine, Brigham and Associate Professor and Vice Chair, Emergency Response Committee, Clinical Professor, Department of Women’s Hospital, Harvard Medical Department of Emergency Medicine, Medical Director, Emergency Emergency Medicine, University Robert L. Rogers, MD, FACEP, School, Boston, MA University of California, Irvine; Management, University of Virginia of Michigan Medical School; CEO, FAAEM, FACP Scott D. Weingart, MD, FCCM American University, Beirut, Lebanon Medical Center, Charlottesville, VA Medical Practice Risk Assessment, Assistant Professor of Emergency Inc., Ann Arbor, MI Medicine, The University of Associate Professor of Emergency Hugo Peralta, MD Peter DeBlieux, MD Maryland School of Medicine, Medicine, Director, Division of Chair of Emergency Services, John M. Howell, MD, FACEP Professor of Clinical Medicine, Baltimore, MD ED Critical Care, Icahn School of Hospital Italiano, Buenos Aires, Interim Public Hospital Director Clinical Professor of Emergency Medicine at Mount Sinai, New Argentina of Emergency Medicine Services, Medicine, George Washington Alfred Sacchetti, MD, FACEP York, NY Dhanadol Rojanasarntikul, MD Emergency Medicine Director of University, Washington, DC; Director Assistant Clinical Professor, Attending Physician, Emergency Faculty and Resident Development, of Academic Affairs, Best Practices, Department of Emergency Medicine, Senior Research Editors Medicine, King Chulalongkorn Louisiana State University Health Inc, Inova Fairfax Hospital, Falls Thomas Jefferson University, Memorial Hospital, Thai Red Cross, Science Center, New Orleans, LA Church, VA Philadelphia, PA James Damilini, PharmD, BCPS Clinical Pharmacist, Emergency Thailand; Faculty of Medicine, Robert Schiller, MD Francis M. Fesmire, MD, FACEP Shkelzen Hoxhaj, MD, MPH, MBA Room, St. Joseph’s Hospital and Chulalongkorn University, Thailand Professor and Director of Clinical Chief of Emergency Medicine, Baylor Chair, Department of Family Medical Center, Phoenix, AZ Suzanne Peeters, MD Research, Department of Emergency College of Medicine, Houston, TX Medicine, Beth Israel Medical Center; Senior Faculty, Family Joseph D. Toscano, MD Emergency Medicine Residency Medicine, UT College of Medicine, Eric Legome, MD Medicine and Community Health, Chairman, Department of Emergency Director, Haga Hospital, The Hague, Chattanooga; Director of Chest Pain Chief of Emergency Medicine, Icahn School of Medicine at Mount Medicine, San Ramon Regional The Netherlands Center, Erlanger Medical Center, King’s County Hospital; Professor of Sinai, New York, NY Medical Center, San Ramon, CA Chattanooga, TN Clinical Emergency Medicine, SUNY Downstate College of Medicine, Brooklyn, NY Case Presentations upon arrival or that they will become unstable during the course of their evaluation and treatment. It is about 20 minutes into your shift when EMS ar- While these scenarios may not occur on a regular rives with a pleasant 80-year-old woman who has had basis, emergency clinicians must be prepared to a syncopal event. She describes standing in her home provide emergent interventions, as needed, to sta- earlier today and becoming lightheaded and falling to the bilize these patients. Familiarity with resuscitation ground. She is now resting comfortably, and her vital techniques and medications as well as procedures signs are: blood pressure, 140/72 mm Hg; pulse rate, 74 (including transvenous pacer placement) is central beats/min; respiratory rate, 14 breaths/min; and oxygen to management. This issue of Emergency Medicine saturation, 99% on room air. You have just begun to take Practice provides a systematic review of the litera- her history when you are interrupted and called to your ture on bradydysrhythmias and presents recommen- next patient... dations based on the best available evidence. You approach the bedside of a 27-year-old woman who is pale, diaphoretic, and writhing in pain. The only Critical Appraisal Of The Literature history you are able to obtain is that she has had mild lower abdominal pain for a few days that acutely wors- A review of the literature on bradydysrhythmias ened today. Initial vital signs are: blood pressure, 70/40 proved to be challenging due to the vast number mm Hg; pulse rate, 58 beats/min; respiratory rate, 20 of articles mentioning relevant terms. The review breaths/min; and oxygen saturation, 99% on room air. was initially performed through PubMed and Ovid ® Your brief exam is significant for diffuse abdominal ten- MEDLINE , using the keywords bradydysrhythmias, derness and guarding. You then hear a flurry of activity sinus bradycardia, sick sinus syndrome, tachy-brady from the hallway... syndrome, sinoatrial block, sinus arrest, first-degree heart Your next patient is being rushed down the hall on a block, second-degree heart block, Mobitz type I, Mobitz stretcher. Brought in by a family member for intermittent type II, Wenckebach, third-degree heart block, complete lightheadedness and shortness of breath,