CASE STUDY: Atropine & the Bradycardia Patient by ProQuest


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									                                                                                          By Stewart A. Stancil, NREMT-P

                                                                         Questioning the
                                                                        need for medical
                                                                          interventions is
                                                                       key to patient care

The 9-1-1 dispatcher reports a call from a female who says her 66-year-old mother “may
be having a heart attack, but is responsive.” On arrival, the crew finds the older female
can answer questions, but responds in a fashion the daughter says is abnormally slow and
                                                                                                                     Photo by Eddie Sperling

confused. The patient, Mrs. Jones, says she had a heart attack four months ago and is now
taking medication for heart failure. She has felt progressively tired over the past two weeks,
and feels dizzy when standing. Today, her chest started “feeling funny” about an hour ago,
with some pain at about 2 on a 10 scale. She has a history of hypertension. She is not
reporting shortness of breath, sweating or nausea.
                                                              EMS JUNE 2010       47
case review:

                  Initial physical exam reveals an elderly   mental status. She shows evidence of          capability. With regard to patient care en
               female with pale skin in no respiratory       poor perfusion and is still confused. Her     route, the physician frames the decision
               distress. Her vitals are: BP 90/55, pulse     daughter can’t provide any history of the     into three groups: (1) supportive care
               48 and irregular, RR 24 with slight bilat-    patient’s usual blood pressure, but in a      only, (2) give medication, (3) use elec-
               eral lower lobe crackles, pulse oximetry      patient with a history of hypertension, a     trical intervention.
               92%. Her pupils are equal, round and          blood pressure of 90/55 is almost certainly     Supportive care is appropriate if the
               reactive; blood glucose is 90; there is 1+    too low. Her heart rate is low, and she is    patient has been deteriorating and
               ankle edema, and the jugular veins are        not conducting the electrical impulses        transport has been directed to the nearby
               distended.                                    effectively and regularly. The patient        community hospital. In this case, the

  regard to
                  Oxygen is given by NRB at15 LPM; IV
               access and the initial lead II strip are
               obtained. Every third P-wave lacks a
                                                             shows signs that her vascular volume is
                                                             not compromised, with jugular venous
                                                             distention, lung crackles and leg edema.
                                                                                                           biggest assist to patient care would be
                                                                                                           maintaining the airway and oxygenation,
                                                                                                           as well as expediting the patient’s hospital
               subsequent QRS complex. All P-R inter-        To increase perfusion, the patient needs a    care by obtaining serial vital signs and
   patient     vals are 0.16 seconds and regular. The        heart rate higher than 48 beats a minute.     ECG printouts. With this short transport,
  care en      QRS complexes are 0.18 seconds wide           Questions the EMS crew will need to           the critical decisions involving invasive
               and upright in lead II. A 12-lead EKG is      consider are: How should the bradycardia      procedures are better made in the more
 route, the    obtained showing a left axis. The rhythm      be treated in light of a suspected left-      controlled environment of the emergency
 physician     disturbance noted in the 3-lead rhythm        sided bundle branch block and possible        department. The other case in which
               strip is confirmed. Lead V1 shows deep         MI? If this patient deteriorates, should      supportive care would be warranted is
   frames      QS waves and ST segment elevation             she be given atropine or have transcuta-      when the patient is maintaining perfu-
               (see Figure 1). These ECG findings point       neous pacemaking performed? In view of        sion. If bradycardia is present but the
     the       to the possibility of left bundle branch      these questions and how they will impact      patient has normal mental orientation
  decision     block. There are Q-waves in leads II and      the transport decision, medical control is    and function, then no invasive interven-
               III, which raises concerns for inferior or    contacted.                                    tion in the ambulance would be indicated.
 into three    right-sided infarction.                                                                       The second decision group involves the
  groups.”     CRITICAL DECISIONS                            TREATMENT OPTIONS
                                                                                                           use of medication. Atropine is commonly
                                                                                                           used for patients with symptomatic brady-
                 The nearest hospital with invasive        
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