Tasty Morsels of EM 039 BradyDysrhythmias

[Featured image via LITFL]

Approach to BradyDysrhythmias

EB Medicine Article [free via EMRA if you're a member. About 70 dollars a year. Well worth it.]

 

On a FOAMed note, it’s interesting that all the ECGs in the article are taken from LITFL. Another sign that FOAMed is not providing a marginal, niche resource, but a highly curated and high quality resource for all.

  • while usually thought benign, first degree block are more likely to develop AF and have a (moderately) increased rate of death [Cheng S, Keyes MJ, Larson MG, et al. Long-term outcomes in individuals with prolonged PR interval or first-degree atrioventricular block. JAMA. 2009;301(24):2571-2577. (Prospective analysis; 7575 patients)]
  • in sinus node dysfunction and in particular, tachy-brady syndrome most of the tachycardias will be AF (but not all)
  • sinus node dysfunction is seen in the oldies
  • pathological bradycardias in the context of ACS are typically associated with RCA occlusions. I have a vivid memory as a 1st year doc of seeing a bradycardic, diaphoretic guy with chest pain and the more senior doc coming down saying “what do you think? a nice big inferior?” with a grin on his face.
  • Some of the more interesting and esoteric causes of a pathological brady
    • hypothyroid
    • hyperkalemia
    • chagas disease (common world wide but not here)
    • Lyme disease
    • parvovirus or coxsackie (in the context of myocarditis)
    • syphillis (so it turns out that Amal Mattu might be wrong and it’s not just Hyperkalemia that is the syphilis of electrocardiography but syphilis itself is the syphilis of electrocardiography)
    • some chemo regimens (not in the article but I saw this last month…)
  • atropine is of course recommended but no surprise that it’s rarely effective. Given that most of the nasty bradys I see are third degree blocks then I find that it’s rarely helpful.
  • dopamine is also recommended but along with some other smart people I just use adrenaline for virtually all vasoactive situations as I actually know how to use it ;-)
About Andy Neill

EM Reg/Resident based near Dublin. Former anatomy lecturer, theology student and occasional musician @andyneill | + Andy Neill | Contact

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