A 78-year-old man is brought to the emergency department after a brief episode of syncope. Since yesterday, he has been fatigued and lightheaded. The patient has no chest pain or palpitations. He has a history of hypertension, stable coronary artery disease, type 2 diabetes mellitus, and hyperlipidemia. The patient's blood pressure is 82/44 mm Hg. He appears mildly lethargic but answers questions appropriately. Lungs are clear on auscultation. The patient's extremities are cold and capillary refill is 3 seconds. ECG is shown in the image. Which of the following is the most appropriate next step in management of this patient?

Question

A 78-year-old man is brought to the emergency department after a brief episode of syncope.  Since yesterday, he has been fatigued and lightheaded.  The patient has no chest pain or palpitations.  He has a history of hypertension, stable coronary artery disease, type 2 diabetes mellitus, and hyperlipidemia.  The patient's blood pressure is 82/44 mm Hg.  He appears mildly lethargic but answers questions appropriately.  Lungs are clear on auscultation.  The patient's extremities are cold and capillary refill is 3 seconds.  ECG is shown in the image.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d17a_b740_bc81_df48a02d7ca3_MD0003_00 This patient's symptoms and ECG findings are consistent with symptomatic sinus bradycardia (heart rate <60/min with regular rhythm and a constant PR interval). The normal resting heart rate is usually 60-100/min. Sinus bradycardia can occur normally in adolescents and younger adults, in well-conditioned athletes, and in some elderly patients, especially during sleep. Pathologic causes include sick sinus syndrome, myocardial ischemia or infarction, obstructive sleep apnea, hypothyroidism, increased intracranial pressure, and medications. Most patients with sinus bradycardia are asymptomatic, but some can develop fatigue, dizziness, light-headedness, hypotension, syncope, angina, and/or congestive heart failure. The first step in symptomatic patients is to identify and treat reversible causes, followed by administration of intravenous (IV) atropine for initial treatment of the bradycardia and hypotension. In patients with an inadequate response, further treatment options include IV epinephrine or dopamine, or transcutaneous pacing. (Choice A) Adenosine causes a transient block of impulse conduction at the level of the atrioventricular (AV) node, which is useful in identifying (and in some cases, terminating) supraventricular tachycardia. It can potentially worsen bradycardia. (Choice B) Amiodarone is an antiarrhythmic used in many cases of supraventricular and ventricular tachyarrhythmias. Amiodarone can lead to slowing of impulse generation and/or conduction in sinoatrial and AV nodes and can potentially worsen symptoms. (Choice D) IV glucagon increases the intracellular levels of cyclic adenosine monophosphate and has been effective in treating beta blocker and/or calcium channel blocker toxicity. Its use should be considered in patients with suspected medication overdose. (Choice E) Norepinephrine is indicated for treatment of severe hypotension and shock (eg, septic shock). It is not indicated for treatment of bradyarrhythmias. Educational objective: Patients with symptomatic sinus bradycardia should be treated initially with intravenous atropine. In patients with inadequate response, further treatment options include intravenous epinephrine or dopamine, or transcutaneous pacing. References: Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. (http://www.ncbi.nlm.nih.gov/pubmed/20956224)

A 78-Year-Old Man Is Brought to the Emergency Department After