Unstable Bradycardia Part 1 (Beta-blocker toxicity)

Beta-blocker toxicity


1210:  A 59 year old is brought in to the ER by EMS after he experienced a syncopal episode at work.   He has past medical history of hypertension, GERD, Diabetes type II, and elevated cholesterol.   He reported to EMS that on Friday, 3 days ago, he went to the doctor's office and was started on a new blood pressure medication (labatelol) that he was supposed to take twice a day.  He went to work this morning and began to feel weak and nauseated.  He sat down thinking that he could rest for a while but passed out.  A review of his home medications revealed that he had been taking both metoprolol and labetalol.  He did not understand that he was supposed to stop the metoprolol.  

Initial rhythm by EMS














Initial rhythm by EMS















1215:  Vital signs:   97.8-39-20.  BP 84/50.   O2 sats 94% on 2L/min
Alert and mild confusion.  Restless.  MAEs, c/o dizziness, generalized weakness.
Lungs:  clear, no cough, dyspnea with exertion
Abdomen:  soft, nontender
Skin:  cool, clammy with capillary refill > 3 sec.

Initial rhythm on monitor














1220:  MD orders:   Basic metabolic panel, CBC,  Troponin,  CK,  CKF,  EKG,  CXR.  IV access and  500cc fluid bolus of NS.  Glucagon 5mg IV bolus
1225:  IV started with # 20 in the right AC.  Fluid bolus started.  Labs specimens obtained.  Glucagon given.

Rhythm after giving glucagon












1230:  CXR done, 12 lead EKG done.   Vital signs:  HR 38  Resp 24  BP 83/54.  Fluid bolus in progress. 
1240:   Fluid bolus completed.  HR 37, BP 82/50.  Glucagon 10mg IV bolus repeated.   No change in rhythm.   Dopamine started 5mcg/kg/min.
1250:  Dopamine titrated up to 10mcg/kg/min for BP 84/46. HR 41
1300:  BP 87/51.  HR 42.   Skin remains cool and clammy with delayed capillary refill.  Dopamine increased to 15mcg/kg/min.
1305:  Standby external pacing initiated.   Cardiologist consult initiated.  TNI results: 0.33. 


Initial rhythm

Pacemaker engaged


Transcutaneous pacing at 40 mA

Transcutaneous pacing at 50 mA

Transcutaneous pacing at 60mA

Transcutaneous pacing at 70 mA








1315.  Unable to obtain mechanical capture.  No improvement in BP.   External pacing stopped.  Cardiologist in to assess patient and insert transvenous pacemaker.  

Comments

  1. I'd love to feature one or two of these strips in a piece on the unrealistic nature of training strips / rhythm generator strips for transcutaneous pacing. Could you reach out to me via email? christopher dot watford at gmail dot com. Thanks!

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    Replies
    1. Thank you Christopher. Feel free to use the strips. They are for teaching purposes. If your piece is going to be published please reference the strips as courtesy of Float Nurse. This will avoid any conflict if your material is copyrighted. Thanks for your inquiry.

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