Scenario Data: You are part of an ambulance crew on site at the home of a 65 year old male who has complaints of “passing out” before your arrival and now complains of general weakness. He states he has no chest pain or discomfort. You have attached the monitor to the patient. There is an advanced life support ambulance in route. Assessment:

Skin: Pale/Warm/Dry
Cardio: HR 40, BP 82/55
Resp: RR 16; CTA in all lung fields
CNS: alert and oriented
Monitor: (see below)

What is the patient's rhythm?

The patient’s symptoms appear to be related to his slow heart rate. You apply oxygen by nasal cannula and start an IV. TCP (transcutaneous pacing) is not available at this moment but should be available as soon as the advanced life support ambulance arrives. What is your first intervention?

You give 1 mg atropine IV, but it has no effect. The patient continues to have weakness with HR of 40. TCP is still not available. As you consider your next option, the patient complains of increased weakness. The monitor shows the following:

What is the patient's rhythm ?

Since the atropine had no effect and TCP is not yet available what will you do now?

Your epinephrine is infusing at 5 mcg/min by infusion pump. The advanced life support ambulance has now arrived, and you have full ACLS support. The epinephrine infusion has not changed the complete block (3rd degree block). And the patient is worsening. What should you do at this time?

As you connect the transcutaneous pacing (TCP), the patient becomes unconscious and his rhythm changes.

What is the patient's rhythm?

With the patient now in VF what is your next intervention?

You shock the patient with 120 J. What is your next intervention?

You complete 5 cycles of CPR. What should you do now?

You check the rhythm and the patient remains in pulseless VF. What is next?

After the shock what should your next intervention be?

You complete 5 cycles of CPR and then perform a rhythm check. The patient remains unresponsive. The pulse check reveals a palpable carotid pulse and the rhythm on the monitor is as follows:

HR is 36 and BP is 78/36. What is the rhythm?

As the patient remains symptomatic in a second degree block, what is your next intervention?

You attempt TCP and get capture. The patient now has a palpable radial pulse with a rate of 60/min. A repeat BP is 95/65. The patient is breathing spontaneously at 14/min. You transport the patient to the ER for more definitive care.

When treating bradycardia with atropine, what is the maximum total dose you can give in a 24 hour period?

Congratulations, the patient is stable and being transported to a higher level of care.

(True or False): If bradycardia is related to acute ischemia, the patient should be paced at a lower heart rate to minimize oxygen demand on the heart.