HPI:

• 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

PE:

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

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!