Symptomatic bradycardia

Diagnosis: The symptomatic complete heart block — the syncope (the collapse), the rate of 32, the wide QRS escape (the infranodal/ventricular escape), and the hypotension (the systolic 84). This is the haemodynamically compromising bradycardia and the emergency.^[1]

Assessment: ABCDE, the oxygen, the IV access, the continuous monitoring, the 12-lead ECG, the pacing defibrillator at the bedside. The bloods: the electrolytes (the potassium, the magnesium, the calcium), the troponin (the ischaemia), the TSH, the digoxin level, the drug history (the beta-blocker, the calcium-channel blocker), the magnesium. The search for the reversible cause.^[1]

Management — the atropine is futile: The complete heart block does not respond to the atropine (the block is below the AV node, the vagal tone is not the limiting factor). The patient goes straight to the pacing.^[1]

1. The transcutaneous pacing — demand 70-80/min from 30 mA, the sedation and the analgesia given, and the capture confirmed by pulse or arterial pressure (ECG alone may mislead). A short-term bridge to transvenous pacing.^[1][2]
2. The concurrent IV infusion — the adrenaline (2 to 10 micrograms per minute) or the dopamine or isoprenaline per ANZCOR second-line dosing to support the blood pressure and the rate.^[2]
3. The definitive transvenous pacing — the cardiology placement of the temporary transvenous wire, more reliable and less painful than the transcutaneous.
4. The reversible-cause treatment — the ischaemia (the troponin, the PCI), the electrolyte correction, the drug review. New-onset block on chronic stable AV-nodal blockers often does not resolve — continued surveillance for recurrence.^[1]

Disposition: The coronary care or the intensive care, the continuous monitoring, the cardiology referral for the permanent pacemaker (the complete heart block is the indication).^[1]