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Treatment of high 2º heart block and 3º heart block


RomeViking09

Your treatment  

19 members have voted

  1. 1.

    • 1mg Atropine IV/IO
    • Pacing
    • 1mg Atropine IV/IO while attempting to pace
    • IV fluids, consider Dopamine or Epi drip
      0


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Is giving Atropine here (given the right circumstances) probably the right thing to do? Yes.

Would it be really difficult to justify in court if something bad were to happen as a result of that choice? Hell yes.

Remember that while medicine is a "practice" and an "art," our slice of it as paramedics is extremely limited. Before you start blurring the lines, make sure you know your environment well and are acutely aware of the potential consequences of such a choice. It is naive to think that just because your choice was medically defensible that it will be supported by the powers that be when the chips fall on a call gone wrong. Worth thinking about...

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Is giving Atropine here (given the right circumstances) probably the right thing to do? Yes.

Would it be really difficult to justify in court if something bad were to happen as a result of that choice? Hell yes.

Remember that while medicine is a "practice" and an "art," our slice of it as paramedics is extremely limited. Before you start blurring the lines, make sure you know your environment well and are acutely aware of the potential consequences of such a choice. It is naive to think that just because your choice was medically defensible that it will be supported by the powers that be when the chips fall on a call gone wrong. Worth thinking about...

but on the other hand Fiznat, if it's in your protocols to do a trial run of atropine while you get the pacer ready then you did not deviate from your protocols and you are in essence covered. Can you still be sued for a adverse event, yep but your protocols do offer you some protection.

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You should be buried alive if you administer Atropine for 3rd degree block. There are cases of Atropine induced VF in 3rd degree block, and if you think about it, Atropine will increase the atrial contraction rate, thus decreasing pO2 in RCA and decreasing available oxygen for the ventricles. If you administer Atropine for 3rd degree block you are in essence malpracticing medicine, as it offers no benefit whatsoever, and causes side effects associated with Atropine, and further endangers the health of the patient.

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You should be buried alive if you administer Atropine for 3rd degree block. There are cases of Atropine induced VF in 3rd degree block, and if you think about it, Atropine will increase the atrial contraction rate, thus decreasing pO2 in RCA and decreasing available oxygen for the ventricles. If you administer Atropine for 3rd degree block you are in essence malpracticing medicine, as it offers no benefit whatsoever, and causes side effects associated with Atropine, and further endangers the health of the patient.

Ok, so then we should all be buried alive if we administer Adenosine because there have been cases of Adenosine induced Asystole in SVT and since that further endangers the health of the patient then we should not give it by your line of reasoning.

I've looked all over on reputable drug references and do not see any Absolute contraindications to Atropine administration in relation to heart blocks.

Just sayin

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Dunno there inf. There are studies and literature supporting the use of Atropine. Conversely I'm sure with little effort, you can find the same discouraging the use of Atropine.

Here is but one article I found supporting it's use, with credit going to the Merck Manuals at Merck.com

There is no electrical communication between the atria and ventricles and no relationship between P waves and QRS complexes (AV dissociation). Cardiac function is maintained by an escape junctional or ventricular pacemaker. Escape rhythms originating above the bifurcation of the His bundle produce narrow QRS complexes, relatively rapid (> 40 beats/min) and reliable heart rates, and mild symptoms (eg, fatigue, postural light-headedness, effort intolerance). Escape rhythms originating below the bifurcation produce wider QRS complexes, slower and unreliable heart rates, and more severe symptoms (eg, presyncope, syncope, heart failure). Signs include those of AV dissociation, such as cannon a waves, BP fluctuations, and changes in loudness of the 1st heart sound (S1). Risk of asystole-related syncope and sudden death is greater if low escape rhythms are present.

Most patients require a pacemaker (see Table 4: Arrhythmias and Conduction Disorders: Pacemaker CodesTables). If the block is caused by antiarrhythmic drugs, stopping the drug may be effective, although temporary pacing may be needed. Block caused by acute inferior MI usually reflects AV nodal dysfunction and may respond to atropine Some Trade Names

ATROPEN

ATROPINE-CARE

SAL-TROPINE

Click for Drug Monograph

or resolve spontaneously over several days. Block caused by anterior MI usually reflects extensive myocardial necrosis involving the His-Purkinje system and requires immediate transvenous pacemaker insertion with interim external pacing as necessary. Spontaneous resolution may occur but warrants evaluation of AV nodal and infranodal conduction (eg, electrophysiologic study, exercise testing, 24-h ECG).

Most patients with congenital 3rd-degree AV block have a junctional escape rhythm that maintains a reasonable rate, but they require a permanent pacemaker before they reach middle age. Less commonly, patients with congenital AV block have a slow escape rhythm and require a permanent pacemaker at a young age, perhaps even during infancy.

Last full review/revision January 2008 by L. Brent Mitchell, MD

Content last modified January 2010

I have used Atropine in the very scenario provided in the opening post. My Medical Director didn't bury me. The pt. may respond to the Atropine, so why wouldn't you try it before using electricity?

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Ok, so then we should all be buried alive if we administer Adenosine because there have been cases of Adenosine induced Asystole in SVT and since that further endangers the health of the patient then we should not give it by your line of reasoning.

I've looked all over on reputable drug references and do not see any Absolute contraindications to Atropine administration in relation to heart blocks.

Just sayin

Lets stick to Atropine. Logically speaking, we all agree that for a complete heart block, i.e no signal transduction between SA or AV node and ventricles is occuring, Atropine will have no benefit. Further, we all can agree that by administering Atropine, you allowing sympathetic nervous system to accelerate the atrium, perhaps increasing the atrial kick, which I will agree is a beneficial thing.

However, in literature I've reviewed, the Atrial tachycardia actually decreased cardiac output and blood pressure, thus decreasing perfusion to the ventricles. It was in part due to the ventricular tachycardia that followed, thus decreasing the inotropic effectiveness. In the case of a 3rd degree block, you are not affecting the ventricles, but you are increasing an atrial kick, but considering you only increasing cardiac preload, do you really benefit the cardiac output? Simultaneously you have a drop in pO2 in the RCA and in conjunction with an ischemia and ectopic centers in the ventricles you will aggravate the situation.

Bottom line is, to me, transcutaneous pacing has always been the best treatment modality. You cause pain thus increase the sympathetic response causing vasoconstriction, inotropic, dromotropic, chronotropic effects on the pump, and most importantly restore the blood flow via ventricular stimulation.

Its like a symphony of the cadence of life. It just works. Atropine, on the other hand, is a very dangerous alternative therapy. Just my humble opinion. In truth, I like to be in control. By external pacing you are taking over the functions of the SA or AV node, thus establishing yourself to be in charge, and having the pads already on the patient will let you cardiovert should the need arise. In the cases of acute MI, which can cause the heart block in question, the biggest concern is deterioration into VF/VT. Having pads already on the patient will let you rectify that possibility, and free up your hands to draw up Amiodarone or Lidocaine. To me its never about just one condition, its anticipating what will follow next and being ready for it right now and not once the condition presents itself.

Edited by Inf
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You do realise atropine also inhibits the action of acetylcholine on M2 muscarinic receptors? We also have M2 muscarinic receptors in the AV node. Inhibiting the parasympathetic nervous system here can increase conduction through the AV area of the heart and may actually work in some cases of complete heart block.

In addition, as Doczilla stated, there are many different types of pathology that can cause a high grade heart block and some of them may respond to atropine.

Again, I see no problem with a trial of atropine while we are setting our patient up for external pacing.

Take care,

chbare.

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You do realise atropine also inhibits the action of acetylcholine on M2 muscarinic receptors? We also have M2 muscarinic receptors in the AV node. Inhibiting the parasympathetic nervous system here can increase conduction through the AV area of the heart and may actually work in some cases of complete heart block.

In addition, as Doczilla stated, there are many different types of pathology that can cause a high grade heart block and some of them may respond to atropine.

Again, I see no problem with a trial of atropine while we are setting our patient up for external pacing.

Take care,

chbare.

That is all fine, but its not our job to sit there and figure out the diagnosis. We manage symptoms, and most efficient way to manage the bradycardia is transcutaneous pacing. You can spend an entire hour there trying to figure out H's and T's and that is fine, but its a job best left for the clinical setting.

And sure, 0.5 - 1.0 mg of Atropine right before TCP is not going to hurt the patient, provided you restore the ventricular contractions right after you administer it by pacing

Edited by Inf
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That is all fine, but its not our job to sit there and figure out the diagnosis. We manage symptoms, and most efficient way to manage the bradycardia is transcutaneous pacing. You can spend an entire hour there trying to figure out H's and T's and that is fine, but its a job best left for the clinical setting.

And sure, 0.5 - 1.0 mg of Atropine right before TCP is not going to hurt the patient, provided you restore the ventricular contractions right after you administer it by pacing

So, EMS care occurs outside the clinical setting?

I fail to the how giving atropine while we set the patient up for TCP is somehow less efficient? It's okay if you would not personally give atropine; however, I can see nothing wrong with giving it. Again, giving atropine while setting up for TCP discussed in ACLS literature.

Take care,

chbare.

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