Stuck in slow motion

Does your heart skip a beat when you're called about a bradycardic patient? Take 10 minutes to work through this module and leverage your AMBOSS resources!

You're sitting in the workroom, wrapping up the paperwork for your last admission to the cardiology service. Your pulse quickens when you realize you're only 10 minutes away from shift change. You admitted this patient in just 30 minutes, start to finish. How's that for efficiency! It's been an unusually quiet day, and you may even get out on time for once...

Suddenly, your pager goes off. Click the pager icon to reveal the message.

Oh, just another rapid. You're about to ignore the page—you're not on the rapid response team today. But then you take a second glance at the room number, and you realize it's the patient you just admitted.

Question: What do you do next?

Make your choice, then click on the explanation bubble to reveal the answer.

• Go to the night float room to sign out your list and let the rapid response team take care of it.
• Call the patient's nurse for an update so you can let night float know.
• Go to the rapid response.

The patient's room is at the far end of the long hallway. As you pass the many open doors on the way—offering glimpses of mounted TVs and dinner trays in various degrees of consumption—you review the information you gathered while admitting the patient earlier.

Question: What information is most crucial to know?

Pay particular attention to the following information, which you can have at the ready to share with the rapid response team:

• Age
• Code status
• Admission diagnosis
• PMH, procedures, and interventions
• Medications
• Allergies
• Recent laboratory results

As you pass the nurses' station, you notice the patient's nurse anxiously watching the telemetry monitor while awaiting the rapid response team. You quickly stop and ask the nurse for more information. She tells you that she called the rapid response because the patient's heart rate was consistently below 45 beats/minute; however, the patient has not reported any symptoms.

Question: What do you do next?

Make your choice, then click on the explanation bubble to reveal the answer.

• Call off the rapid response team—it sounds like the patient is stable.
• Get a detailed account from the nurse regarding the patient's condition since admission.
• Assess the patient at the bedside.

You and the nurse arrive at the patient's room. The rapid response team is not there yet—they were called only a minute or two ago. It's up to you to assess the patient first, so you take a moment to mentally rehearse the clinical features of unstable bradycardia that you'll be looking for.

Question: Which of the following are clinical features of unstable bradycardia?

Make your choices, then click on the explanation bubbles for more information.

• Acutely altered mental status
• Ischemic chest pain
• Acute heart failure
• Hypotension
• Signs of shock despite adequate airway and breathing

That's right—all of the above! And you can assess many of these clinical features quickly, often within seconds of entering the patient's room.

Un-break my heart...

Question: Which clinical scenario would you like to explore?

Choose an option to continue the module:

• Option 1: Unstable bradycardia
• Option 2: Stable bradycardia

Your heart may have skipped a beat, but your management was right up to speed! And now your patient's heart will go on and on…

• You did a great job:
  • Differentiating between stable and unstable bradycardia
  • Acutely managing unstable bradycardia (Option 1)
  • Identifying and appropriately treating reversible causes of bradycardia (Option 1)
  • Initiating a workup for stable bradycardia (Option 2)
  • Interpreting bradycardic rhythms on ECG (Option 2)
• For a quick review of the initial management of bradycardia, check out this flowchart.

Congratulations on completing this module. Hopefully you now feel more comfortable assessing a patient with bradycardia!

Personal story from an AMBOSS clinician

It was toward the end of the day, and I was the resident covering the heart failure service. About an hour before signout, I was notified of a new admission for decompensated heart failure. She would be bypassing the emergency department and coming directly to the floor. Since I had already received the patient’s name and some background information, I decided to get ahead by writing the admission H&P and placing initial orders before the patient arrived.

The hospital served a population with fairly low health literacy, and I was used to calling pharmacies to complete accurate medication reconciliations. In most cases, patients had little idea what medications they were actually taking, and a quick call to the pharmacy could fill in the gaps. I felt efficient—almost proud—as I finished the H&P and entered the medication orders. When the patient finally arrived, I spoke with her briefly to gather an HPI, then returned to my work area to finalize documentation, confident I’d finish up in time for a smooth handoff at shift change.

Five minutes later, I got a page: rapid response in my patient’s room. I did a double-take. I had just seen her—she had seemed stable, engaged, fine. When I got to the room, the rapid response team was managing a code. The patient was in profound bradycardia, unresponsive to multiple doses of atropine. Her heart rate remained dangerously low, and she was ultimately transferred to the cardiac care unit for intensive management of refractory bradycardia.

I learned afterward that the nurse had given her a high dose of metoprolol—per my preemptive orders—not long before the event. The patient reportedly looked confused when it was handed to her and said she didn’t usually take that medication at home, but she took it anyway because it had been prescribed. It was, in hindsight, a large dose for someone naive to beta blockers. The bradycardia was ultimately attributed to beta blocker toxicity.

This could have been avoided. I had not yet seen the patient when the medication was given, and I had not yet confirmed the medication reconciliation with her directly. I assumed that calling the pharmacy was enough. I assumed she wouldn’t know. I assumed that getting ahead would help.

The lessons I learned: Always consider reversible causes of bradycardia. And always, always speak to the patient about their medications—what they actually take, how they take them, whether they tolerate them. Even if something is on a pharmacy list, it doesn’t mean the patient is taking it. Give them the chance to tell you. Never put speed ahead of safety.

And another lesson: Use beta blockers judiciously in acute heart failure.