Critical Cases - Bradycardia Emergency!


  • 87 yo male hx of htn, afib on warfarfin, AAA s/p endovascular repair, CAD s/p CABG presents after a syncopal event on the toilet
  • Pt fell and struck his head with confirmed LOC
  • Wife found him down and called EMS
  • Patient denies any chest pain, dyspnea, abdominal pain, nausea/vomiting, but does endorse acute onset diarrheal illness preceding the syncopal event
  • Denies any recent medication changes


T 98.8 BP 154/68 HR 32 Pox 96%

  • Head: +abrasion above R eye
  • Neck: no c-spine tenderness
  • Lungs: clear bilaterally
  • Heart: bradycardic, no murmurs
  • Abdomen: soft, nontender, no pulsatile masses
  • Extremities: atraumatic, distal pulses intact






ECG Interpretation: Atrial fibrillation (possible flutter waves in V1), AV dissociation with complete heart block, with wide complex ventricular escape rhythm at 30 bpm


DDx for bradycardia:

  • Acute ischemia
  • Cardiomyopathy (ischemic or nonischemic)
  • Medications (beta blockers, calcium channel blockers, digoxin, clonidine)
  • Hyperkalemia
  • Hypothermia
  • Hypothyroidism
  • Sarcoidosis/Amyloidosis
  • Infectious (Lyme disease)
  • Elevated Intracranial Pressure

Management of complete heart block:

  • For acutely unstable patients: initiate transcutaneous pacing (patient will require sedation and pain control)
  • Ventricular escape rhythms are inherently unstable, these patients must have a temporary transvenous pacemaker placed while awaiting permanent pacemaker placement
  • For a comprehensive post on transvenous pacemaker placement, check out this fantasic review

Patient management and outcome:

  • Pacer pads placed on patient's chest, but no pacing initiated given lack of hypotension, chest pain, altered mental status, or other indications of hypoperfusion
  • STAT CT head and cspine negative for trauma
  • Labs demonstrated negative hsTN and no electrolyte derangements to explain bradycardia
  • While setting up for transvenous pacemaker placement, pt had a brief episode of asystole with associated loss of consciousness, this resolved after ~10 seconds of chest compressions
  • Transvenous pacemaker placed, but pt's ventricular rhythm increased to 70 bpm (accelerated idioventricular rhythm) with blood pressure of 170 systolic so pacing was not initiated
  • Patient admitted to CCU and received a permanent pacemaker later in the day


Take home pearls:

  • Complete heart block with ventricular escape rhythms are likely to decompensate and require emergency transvenous pacemaker placement, even if seemingly stable at first
  • Periodic review of the steps to perform this complicated procedure is a must for the EM physician....again check it out here!