ACLS Megacode 2: Bradycardia

A 72-year-old male presents to the emergency department with new onset altered mental status.

His wife states he complained of dizziness in the morning, but has subsequently become more confused throughout the day.

VS: 98.6 F / BP 84/58 / HR 44 / RR 18 / SaO2 90%

On exam, the man is oriented to person and place only. Cardiovascular exam reveals a slow rhythm with occasional skipped beats. No murmurs, rubs or gallops are appreciated. Distal pulses are weak. Lungs are clear to auscultation bilaterally. No pedal edema.

A 12-lead EKG reveals a gradually progressive prolongation of the PR interval leading up to a blocked sinus impulse.

It is determined the patient has Mobitz type I second degree AV block.

The patient’s wife confirms he does not take any anti-hypertensives that may affect the AV node. Bilateral IV access has been obtained.

A 0.5 mg IV bolus of atropine is delivered.

On EKG, his heart rate remains around 45 bpm. The patient’s clinical status is unchanged.

A second dose of 0.5 mg Atropine is delivered intravenously after 3 minutes.

Heart rate increases transiently to 58, but decreases back into the low 40s shortly after.

Transcutaneous pacing is initiated, without improvement in the patient’s vitals or symptoms.

An epinephrine infusion is started at 3 μg/min.

There is mild improvement in the patient’s vitals, however he remains symptomatic. Cardiology consult has been called.