Pucker Up: Bradycardia


History of Present Illness:
Upon arrival the patient was laying on the walkway to the beach. FD stated that she was AAOx3. Her husband stated that she had a brief loss of consciousness. The patient denied any pain, but felt weak and short of breath. During transport the Zoll pacemaker was not functioning, it read "poor pad contact". A new set of pads was tried without success. The patient's perfusion status was rapidly declining, and we became unable to obtain a BP. Her ventricular rate slowed to about 10 BPM, and Epinephrine was given. The Epinephrine brought the HR up, Dopamine was then started. With the 3rd set of pacer pads the pacemaker began to get capture. The Dopamine was stopped after 1min. of administration. The patient's perfusion status improved. Versed was administered for conscious sedation. Verbal report was given to the ER physician and care was transferred.

This was a call that I ran. The epi was a quick decision and luckily, it worked for as long as I needed it to. This wasn't the most perfect scenario, but I improvised, adapted, and overcame the situation. Top ECG in first image shows initial rhythm, complete heart block. This is why Atropine wasn't considered. Since Atropine Sulfate works on the vagus nerve, and the nerve is located in the atria, AV disassociation would impair the function of the med.

As you can see, the second strip, bottom of first image, and third strip on the top of second image are both post-epinephrine. Finally, the pacemaker was fixed and electrical capture is shown in the final strip. The patient's pulse reflected full capture.

I would be happy never running a call like this again!

Just want to make it clear that this is not our protocol, and is not in any way endorsed by AHA. Read RM's comment on administering Epinephrine to a cardiac patient. It is dangerous and was not something I wanted to do. At the moment, I felt the patient was going to code faster than I would have managed an infusion. Had I planned better and conquered the pacer problem faster, this could have been avoided.


Anonymous said...

It's a good thing you have three sets of combo pads ! Don't you find that this is JUST the kind of call that really tests you, though ?

Adam Thompson, EMT-P said...

I believe it wasn't the pads. I had the firefighter that was riding in with me connect the first two sets. After the call I replicated what I thought the problem was. The connector was inverted. The pads shouldn't connect this way and it takes more effort to connect them, but they will connect without working properly.

Another tip:
If you have a hairy-chested, UNRESPINSIVE patient, you can use your pediatric pads to do a little wax job before connecting your adult combo pads.

Rogue Medic said...

Why the bolus of epinephrine? Is that the way your protocols are written?

The ACLS guideline on Bradycardia indicate that the dose of epinephrine should be 2 - 10 mcg/minute. Not a 500 mcg bolus (0.5 mg bolus). Or dopamine at 2 - 10 mcg/kg/minute. There are a bunch of other things that should come first.

I don't even like the idea of giving 0.5 mg epinephrine IM for anaphylaxis. I can always give more. If the patient needs more epinephrine, they will not be concerned about another IM injection. Determining if they need more is based on a good assessment.

We should not be giving epinephrine boluses to live patients. Especially not patients with moderate symptoms that are possibly due to an MI. Depending on the difficulty breathing, this patient may not meet unstable criteria.

How does she respond to supplemental oxygen? If her lungs are clear, how does she respond to a fluid challenge? What is her blood sugar? It is not uncommon for patients to become bradycardic as a symptom of hypovolemia or as a symptom of hypoglycemia. What medication is she taking?

RVI tends toward bradycardia. For EMS, RVI is best treated with fluids.

FD stated that she was AAOx3. Her husband stated that she had a brief loss of consciousness. The patient denied any pain, but felt weak and short of breath.Pacing is something that often involves operator error. We do not do a good job of educating people in how to pace. There are pacer simulators out there that work well, but part of the problem can be the way the equipment is connected, as appears to have been the case here.

We need to include simulations like this in EMS training/refresher classes. These are not rare problems. We should anticipate that any time the pacer or the cardioverter are used, that there will be a problem that is due to operator error. These problems should be expected. We should regularly practice with simulators to maintain a level of comfort with our equipment.

Adam Thompson, EMT-P said...


I think you missed the HR of 10 part. At first she was mildly symptomatic, and I was in normal treatment mode. I should have questioned the operator with the second set of pads. You are correct, regarding the protocol. We give an infusion if brady, if we make it that far down the list. At the point of treatment, I considered this patient pre-arrest.

Giving the Epi was the last thing I wanted to do, given the probability of AMI. Even less, I didn't want her to code. May not have been the perfect choice. I ended up pushing 0.5mg, very slow with a wide open line. I don't think I would have had time to get the drip mixed with as fast as she declined(I would have had time, if I would have planned for no capture). Needless to say, I would have ran this call differently if I could go back.

I completely agree with the operator error statement, and training statements you made. The next shift, at the station, me and the guys all went over the use of our monitor. They use a Phillips, and we use Zoll so this incident was a perfect motivator to do this stuff.

Lungs said...

with a pulse of ten, no palpable BP altered mental status, she is almost PEA, or agonal. you made a good call, im sure your PT thanks you.

Shaggy said...

A little anatomy lesson. The left vagus nerve does reach the AV Node. The right reaches the SA node. This is why you will see junctional escape rythms with a complete heart block, because the block is at the AV node or usually before the Hundle of His. When it is below this area is when we see the ventricular escape rythms.

Now about criticizing your call:
It is easy to blast you from the comfort of an easy chair in front of a computer with easy access to the AHA guidelines. Yes, the guidelines do state epi infusions OR dopamine if Pacing OR atropine does not work. I remember the ACLS texts always stating the epi infusions are considered for prearrest conditions. You had a prearrest condition.
I do think it may not have been too difficult to mix as putting 1mg in a 500cc bag will give you a concentration to give 2mcg per ml, or 1 drop a second with a microdrip or one every 6 seconds for a macro. That is thinking off the top of my head.
Now for reality. Your pads did not work for you, for whatever reason. You could not use atropine, and working in the back alone, even if you had someone assisting with airway, etc., you were at a disadvantage. Isoproterenol may work but we normally don't carry that anymore and the AHA saves that way down there for the denervated hearts. The quickest thing to think of at that moment, with your patient crashing fast, was what you did. With your patient crashing fast, taking the time to mix and hang the drug may have appeared to take too long of a process for you. It may or may not have been, but I was not there, and you did what you had to. It seemed to have worked.
The problem I have with giving the bolus of epi for a bradycardic patient is it is not advocated anywhere in the literature that I have seen. What would be a safe dose? You guessed without data to support your decision. Personally, and as much as I admire him, RM can say what he wants; You guessed right considering the situation you were in.
I remember back in the early 90s, when the new LP10s were still not universal, I was on a truck that only had an LP5. My patient was found unresponsive with idioventricular rythm in 20s. I gave a whole 1 mg of atropine with minimal results and I got orders for an epi drip. Before I could even mix it, my patient arrested. Me being a brand new medic and thinking I had a clue when I really didn't sure did not help much.

Adam Thompson, EMT-P said...


Thanks for clearing up why I didn't give Atropine. I touched on it, guess my explanation wasn't too clear.

Just a timeline to give a picture of what I was dealing with:

-on scene for 2min when AVB was recognized

-2 more min. the patient was on the stretcher and in the truck with first set of patches

-I am trying to assist the firefighter with the monitor for about 5 min, and I tell my partner to start driving

-At this point I tell him to try another set of pads and I go for an IV. This takes about 4 or 5 more minutes

- After I get the IV and I am spiking a bag, the firefighter is still working on the pacer, and I recognize a rapid deceleration in HR.

- I opened the fluids up, and grabbed the epi when I saw a HR of 10.

I did not actually pick a dose. I just pushed it very slow with my line still running until I witnessed an acceleration in the HR. Once I got the HR up enough to breath I grabbed my Dopamine.

As I said before, this was the wrong route to go. Sure it worked, but like you said it isn't supported. I can defend myself and my decision if need be, but it is very simple for a call like this to go the wrong way.

Anyhow thanks for the reply Shaggy. RM is right though, unfortunately, haha.

Shaggy said...

Yeah, he is right, sitting in front of his computer playing armchair medic, and maybe he would have done something different, but I was actually envious that I did not consider it. I really think under the circumstances you made an effective move.
So, now in hindsite, what would you do differently, considering the rapid decline of your patient?

Shaggy said...

By the way, I am also envious of this cool site! You also have the coolest contributers too, especially TomB and RM.

Rogue Medic said...

Shaggy and Adam,

I have for a long time discouraged the use of epinephrine, except in anaphylaxis (IM or SQ, not IV) or as a slow drip for bradycardia.

My opinion is that epinephrine is as close to a heart attack in a syringe as we have, although some people have norepinephrine. :-)

One of the best ways to prepare for this kind of situation is to plan for what you would do if your equipment fails. At some point, I have had just about every piece of equipment fail. Having already thought through what to do in that situation makes it much easier to remain calm and just move on to the next step in treating the patient.

Not that I haven't made mistakes.

I wrote these about epinephrine over a year ago -

Epinephrine in Cardiac ArrestDead VT vs Not Quite Dead, Yet VT.More on Epinephrine in Cardiac Arrest.

Shaggy said...

Thanks RM, I was wondering what the others were alluding to regarding your comments on Epi. I take it you are not a big fan of family members getting epi pens to give prophylactically any time one of their loved ones gets stung by something.

Rogue Medic said...


Thanks RM, I was wondering what the others were alluding to regarding your comments on Epi. I take it you are not a big fan of family members getting epi pens to give prophylactically any time one of their loved ones gets stung by something.

I have no problem with a person at risk for anaphylaxis receiving an EpiPen.

Epinephrine for anaphylaxis is a life saving intervention. Kids getting an IM shot of epinephrine do not have the bad outcomes that adults do, so it is significantly safer in children, than adults. Nowhere near risk-free, just safer.

One unnecessary shot with an EpiPen and the kid will never let that adult touch him/her again with anything. Nausea, vomiting, palpitations, tachycardia, hypertension, chills, agitation, . . . . If you are near death, this is not a bad alternative and the epinephrine symptoms often act to counteract the opposite effects from the anaphylaxis. That is the whole reason for using epinephrine. Therefore, with a real anaphylactic reaction, the epinephrine is generally not a problem.

Cardiac arrest is a different story. If this is a primary cardiac event, then is there a worse drug than a bolus of epinephrine? Resuscitating a patient to a tachycardia, that is pure epinephrine, is not good for the heart. Epinephrine is also not good for the brain.

The two organs we are most worried about in cardiac arrest are the heart and brain. Epinephrine is generally toxic to both. Small, slowly administered doses of epinephrine are indicated, but only when less aggressive treatments are not effective.

I see that the links I posted all ran together. It seems that Blogger is formatting differently in the past month. Here they are with separators:

Epinephrine in Cardiac Arrest.

. . . . . . . . . . .

Dead VT vs Not Quite Dead, Yet VT.

. . . . . . . . . . .

More on Epinephrine in Cardiac Arrest.