Differential Diagnosis

* Mnemonic: HE DIES* Hypothyroidism* Elevated intracranial pressure (ICP)* Cushings reflex* Bradycardia* Increased blood pressure* Irregular breathing* Drugs* Beta blockers* Calcium channel blockers* Digoxin* Ischemia* Electrolytes* Especially potassium!!!* Sick Sinus Syndrome

Approach to Bradycardia

* Step 1: Get an EKG* Ischemia?* Heart block?* 1st degree = PR interval >200ms (5 small boxes)* 2nd degree type 1 = PR gradually prolongs until dropped beat* 2nd degree type 2 = Intermittent dropped beats* 3rd degree = None of the atrial beats result in a ventricular beat* Evidence of hyperkalemia?* Step 2: Determine if patient is SYMPTOMATIC* Hypotension* Chest Pain* Syncope* Lightheadedness* Note: Many patients have benign and asymptomatic resting bradycardia (I’ve seen as low as 30s!) and this does not necessarily require aggressive treatments/IV medications* Step 3: If patient is having symptoms… Give atropine!* Typical dose is 0.5mg IV atropine* Step 4: If patient still having symptoms… Give epinephrine!* Step 5: If patient still having symptoms… Cardiac pacing!* If symptoms are minimal or resolved, patient can sometimes wait for permanent pacemaker with cardiology* Transcutaneous pacing* Sometimes difficult to get mechanical capture* Transvenous pacing* Place through the right internal jugular vein

Additional Reading

* How to Read an EKG (EM Clerkship)* Transcutaneous Pacing Procedure (EM Clerkship)