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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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And to think, I miss all this inflammatory crap. Wow! A question turned into such drama.

I’m not going to discount what anyone has offered, however, I am just saying what I would do and what I was taught.

In this exact situation, I would immediately pace. I’m sure IV access on someone in this circulatory compromised state, would be difficult. I’m not about to waste time looking when I can pace within 30 seconds.

On the topic of atropine itself, I was taught that is was actually contraindicated in high degree heart blocks, as it could cause significantly worsened rebound bradycardia. But I guess if the pacer is there, it doesn’t matter huh? I’d have to go back to my 10 year old pharmacology book to see if it’s actually listed as contraindicated.

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The real question here is why is your patient in a heart block in the first place.... Is it because they had an Acute MI or is it because they have taken too much medication & they have blocked down. If you can figure out what the cause is then you can address it. In any case I would do the following for this Pt: 1) Consider Causes + IV/IO Fluid Bolus 500 ML x1. 2) 0.5 mg Atropine IVP x1 3) Applying Pacer Pads 4) PACE 5) Additional Fluids and/or Dopamine Titrated to SBP of 90.

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Go to you tube and search for John Bielinski.

He has all kinds of awesome cardiology lectures that are easy to understand.

He confirms what I was taught. Atropine usually will not work on blocks below the AV node. In a 2nd or 3rd degree heart block, atropine is considered IIb, meaning it probably won't work, but it probably won't hurt either.

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Atropine is a recognized treatment for bradycardia, even that caused by heart block. ACLS teaches this nation-wide. It is part of prehospital protocols in many jurisdictions. It would not be difficult to defend in court at all.

Interesting. That isn't the case here, at least for EMS. My protocols specifically say that "atropine is not indicated for 3rd degree or mobitz II heart blocks."

That's why I said it would be difficult to defend in court, because even though atropine may be used in this way elsewhere in the country, it is absolutely not here, and to do so would directly contradict our standing orders. We may not like it sometimes, but the fact remains that paramedics practice protocol-based medicine. Not ACLS-based medicine, not evidence-based medicine, not "they do this everywhere else-based medicine." It should be no surprise that people have different estimations of this atropine thing, because protocol differs widely from region to region. HERE, if a patient suffered an adverse outcome after being given prehospital atropine in the setting of a high degree block, it could potentially be very difficult to explain, and the paramedic would most likely be found at fault.

Edited by fiznat
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  • 2 months later...

Hey.

couple of questions:

Do you have isoprenalin in the states ?

Are there any evidence that atropin could induce VF in AV block 3 ?

Best regards

/

Swedish-medic

We do have it. Here it is called isoproterenol, under the brand name Isuprel. We don't use this much anymore in symptomatic bradycardias, preferring instead to use dopamine, dobutamine, or epinephrine if you're going to start a drip to fix severe bradycardia. Isuprel used to be pretty common on the ambulances here, but got dropped by most places in the early-mid 1990s.

'zilla

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