BRADYCARDIA

Family Medicine Team B Dr. David Lanum, Attending Deborah Liu, D.O. R3 My-Linh Truong, D.O. R1 Jacqueline Ryan, MS IV

Case presentation

CC: Diarrhea & vomiting x 5days HPI: 58 yo Caucasian female presented for TB testing at her board and care. She was found to have a low heart rate and sent to the ER for evaluation. Pt main complaint was diarrhea, nausea, vomiting x 5 days. Denies bloody or black stools. + fever of 101 3 days ago, none since then. + abdominal pain in lower quadrants + Abx use of Clindamycin x 2 weeks 2/2 tooth infection c/o weakness, no syncope or ALOC. + dizziness. SOB on occasion with exertion

Case continued

PMHx: HTN, R lateral meniscus tear, Asthma PSHx: C-section, appendectomy, cholecystecomy Meds: Zofran, Advair, Ibuprofen, Norco, Robaxin, Famotidine, Fluoxetine, Vasotec, Tramadol, Clindamycin, Atenolol Allergies: Codeine (upset stomach) Social hx: + Smoke 3ppd x 20 years, quit 6 months. + Etoh 6 beers/night & 6 shots of tequilla. Denies IVDA or drug use. FamHx: HTN, DN, CAD, Breast CA

Case continued

ROS:

Positive: fatigue, dizziness, abdominal pain, nausea, vomiting, diarrhea, depression Negative: chest pain, wheezing, coughing, weight loss, neurological deficits

Physical Exam

Vitals: T 98.1 P 45 R 20 BP 129/62 Gen: NAD, A&O x3 Eyes: PERRLA, EOMI ENT: WNL, poor dentition, no lesions, no abscess in the mouth, no LAD, no JVD CV: bradycardic, regular rhythm, S1/S2, no murmur/clicks/rub/gallops Pulm: CTAB, no wheeze/rales/rhonchi GI: soft, nondistended, mild TTP in B/L lower quadrants Ext: no edema Neuro: CN 2-12 grossly intact Psych: very tearful and cries intermittently over unknown triggers Osteopathic exam: B/L thoracic paraspinal fullness

ER course
Glucagon 5mg IV x 3 Reglan Bendaryl NS bolus x 1

EKG: Sinus bradycardia

EKG: Sinus bradycardia w/1st degree AV block

Labs
Na 153, K 3.6, Cl 99, CO2 26, BUN 21, Cr 1.3, Glu 101 WBC 5, Hgb 13, Hct 36.6, plt 164, N55, B0, L30 CE: CPK 89, Trop < 0.01 EKG: sinus bradycardia with NO ST changes, pulse 38 CXR: NAD Echo 5/19/10: EF 60%, no global dysfunction

Assessment
Symptomatic bradycardia exacerbated by B-blocker r/o sick sinus syndrome HTN Asthma Diarrhea likely 2/2 antibiotic induced Chronic renal insufficiency Depression with psycho-social dysfunction (pt homeless)

Plan

CALL CARDIOLOGY STAT!!

Stop all B-Blockers & HTN meds IVF boluses C.diff toxin x 3 (r/o C.diff colitis from Clindamycin NEG) Slowly reintroduce BP meds once HR is more stable (started Adalat & Vasotec) Continue all other home medications

Recommended: give Atropine if HR < 35 and transfer to ICU. Start dopamine (inc HR) & dobutamine (contractility) gtt. Get pacer to bedside and call cardiology! Doubted it was sick sinus syndrome given her age and no signs of tachycardia, recommended outpatient holter monitor x 24h

Pathogenesis of Bradycardia

Normal Heart (absence of disease)

During sleep At rest in people under age 25 Athletes Some elderly people

Pathophysiologic Sinus Brady

Drugs Beta blockers - negative chronotropic effect, causing slowed heart rate - also depresses conduction through the AV node

Other drugs
Parasympathomimetic agents Cimetidine Digitalis Calcium channel blockers Amiodarone/other antiarrhythmics Lithium

Sick Sinus Syndrome

SA nodal dysfunction causing one of a number of syndromes, which may include persistent bradycardia Occurs more commonly in the elderly Patchy fibrosis of SA node and cardiac conduction system Other conditions: sarcoidosis, amyloidosis, Chagas disease, cardiomyopathies

EKG: Sick Sinus Syndrome

Tachycardia

Bradycardia

Exaggerated Vagal Activity

Vasovagal response causing brady due to increased parasympathetic activity and sympathetic withdrawal on the SA node Stimuli for vagal activity: - pressure on carotid sinus - vomiting, coughing - valsalva - sudden exposure of face to cold water - prolonged standing (Bezold-Jarisch reflex)

Other causes
Increased ICP Acute MI (esp. inferior wall MI) Obstructive Sleep Apnea Hypothyroidism Hypothermia

Treatment of Bradycardia

Treatment of Sinus Bradycardia

First steps: ABCs

Maintain airway Assist breathing and give oxygen Monitor heart rate, blood pressure and oxygen saturation Obtain and review EKGs Initiate IV access Focused H&P for reversible causes

Treatment of Sinus Bradycardia

Asymptomatic or symptomatic? Symptomatic presentation:

Shortness of breath Chest pain Weakness Fatigue Light-headedness Syncope, presyncope Decreased level of consciousness, Hypotension/shock Acute MI Congestive Heart Failure

Treatment of Sinus Bradycardia

Identify and treat underlying causes:

Hypovolemia, Hypoxia, Hydrogen ion, acidosis, Hypo/hyperkalemia, Hypoglycemia, Hypothermia Toxins, Tamponade, Tension pneumothorax, Thrombosis, Trauma In patients with sinus bradycardia secondary to therapeutic use of digitalis, beta-blockers, or calcium channel blockers, discontinue drugs and monitor Treatment for B-blockers/CCBs overdose: Administer Glucagon 3.5-5mg IV x 1, can repeat x1 if no response in 10 minutes

Treatment of Sinus Bradycardia

If asymptomatic and adequate perfusion

If symptomatic and poor perfusion

Observe and closely monitor

Prepare transcutaneous pacing, immediate use in patient with Morbitz type II second degree and third degree block First-line drug: Atropine 0.5 mg IV q 3-5 min to maximum dose of 3 mg, if ineffective, begin transcutaneous pacing Infusion of dopamine 2-10 ug/kg per minute or epinephrine 2-10 ug/kg per minute If pacer is ineffective, prepare transvenous pacing

Prognosis
HR improved to 50-60s Outpatient holter monitor Vasotec & Adalat cc restarted Atenolol discontinued Prozac dose increased to 40mg QD improved mood, less teary C.diff toxin neg x 2, Abx discontinued diarrhea resolved Patient given bus ticket and sent back to homeless shelter

References

Ferrer, MI. The sick sinus syndrome in atrial disease. JAMA 1968; 206:645. Ferrer, MI. The Sick Sinus Syndrome. New York, Futura Press, 1974. McPhee, SJ, and Papadakis, MA. Current Medical Diagnosis & Treatment. New York, McGraw Hill Medical, 2009. Ko, DT, Hebert, PR, Coffrey, CS, et al. Adverse effects of beta-blocker therapy for patients with heart failure: a quantitative overview of randomized trials. Arch intern Med 2004; 164:1389. Arnsdorf, MF, and Ganz, FI. Sinus bradycardia. 12 Dec. 2008. 16 July 2010. <www.uptodate.com>.