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.