Complete heart block
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Location: Emergency Room
Vitals: BP: 80/50 mm Hg; HR: 40/min; RR: 24/min; Temp: N
C.C: Lightheadedness A 55 years old male victim of a motor vehicle accident is brought to the ER by ambulance. He was a unrestrained driver of a car that hit a tree due to poor visibility on that foggy night. The patient complains of mild generalized body ache, severe chest pain and lightheadedness. He remembered his chest having struck against the steering wheel. However, there was no history of head injury, headache or loss of consciousness. . The patient was feeling uncomfortable with the Miami-J collar put by the EMS team around his neck at the site of the accident.
1. IV access, stat- 2 large (18 G) IV bore needles
2. Start IV fluids: Normal Saline, bolus
3. Continuous BP, HR monitoring BP- 80/50 mm Hg; HR- 34/min
4. Pulse oximetry, stat 95% on room air
5. Order examination: General appearance: Well-built, white male, in severe pain, holding on to his chest with his right hand. ; Cardiovascular - Bradycardia, variable intensity of S1 and S2; no murmurs, rub or gallop.
11. EKG, 12 lead, stat shows complete heart block, ventricular escape rhythm with a rate of 40/min, QRS duration of 140 msec. No evidence of ischemia or injury except nonspecific ST/T changes.
12. Chest-X ray, PA portable Fracture of the left 3rd and 4th ribs. No pneumothorax or effusion. Heart and mediastinum are normal in size and configuration.
13. X-ray cervical spine,
14. IV Fentanyl or Ketorolac, bolus
15. Atropine 0.5 mg IV stat
16. Put patient on transcutaneous pacemaker
17. Consult Cardiology, stat (for transvenous pacemaker placement)
18. Consult Orthopedics, stat (to rule out cervical spine injury and get rid of Miami-J collar)
19. Make NPO
20. CBC with differential, stat
21. BMP, stat
22. PT/aPTT, stat
23. Check the BP and HR
24. Transcutaneous pacemaker paces at rate of 80/min, BP-90/60
25. Patient's lightheadedness and chest pain is better
26. Order complete examination WNL
33. Continuous HR and BP monitoring
34. Continue NPO
35. Continue NS
36. CK and MB, stat
37. Troponin T, stat N
38. Echocardiogram, stat EF=55 - 60, no wall
39. Cardiologist takes the patient to the cardiac cath lab for a temporary transvenous pacemaker insertion.
40. If case continues further, may need permanent pacemaker insertion.