Option 2: Stable bradycardia

The patient does not have any signs of unstable bradycardia. She is awake, alert, and oriented to person, place, and time. She reports having no symptoms. The nurse takes a fresh set of vital signs: heart rate 40 beats/minute, blood pressure 125/82 mm Hg, and SpO2 98% on room air. Physical examination is unremarkable.

You begin the initial management of bradycardia and ensure the patient has adequate IV access and pacer pads attached. You keep the crash cart nearby just in case.

Question: What is your next step?

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

• Obtain a TTE to evaluate for structural heart disease.
• Consult cardiology.
• Obtain a 12-lead ECG for rhythm identification.

You examine the patient's ECG to assess the rhythm and determine whether the QRS complex is narrow or wide.

Question: Can you name some common bradyarrhythmias?

Think of two possible bradyarrhythmias for each of the following, then click on the explanation bubbles to see some examples.

• Regular narrow QRS complex
• Irregular narrow QRS complex
• Regular wide QRS complex
• Irregular wide QRS complex

For a refresher on ECG findings and management, take a look at “Overview of atrioventricular blocks.”

The patient's ECG shows a Mobitz type II AV block. The rapid response team arrives, but the patient's other vitals remain stable, so the team leaves further management to you. As you initiate your next steps, the patient remains asymptomatic, still on cardiac monitoring with pacer pads attached.

Question: What additional studies should you order for this patient tonight?

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

• Troponin
• Serial ECGs
• Electrolytes
• Lyme serology
• TSH
• TTE
• Cardiac MRI

You'll also want to screen the patient's medication list for medications that might be causing her bradycardia.

All patients with Mobitz type II, high-grade, or third-degree AV block with an irreversible cause require the placement of a permanent pacemaker. Consult cardiology for further management.

Further management

You get your orders in and check on the patient one more time. She remains stable and asymptomatic. You speak with cardiology and ensure they are planning to see her in the morning. You ask night float to keep a close eye on the patient and make several checks overnight to assess for any clinical features of unstable bradycardia.

For more information on management of Mobitz type II AV block, see “Management of high-risk AV block.” See also “Stable bradycardia.”

The management of bradycardia depends on the underlying rhythm and the etiology. Fortunately, in a patient with stable bradycardia, you have time to assess their ECG and determine the type of bradyarrhythmia.

ECG interpretation

Practice interpreting the ECGs below to see if you can identify the cardiac rhythm.

If you haven't explored the other scenario yet, jump over to “Option 1: Unstable bradycardia.” You can also return to the main module; see “Stuck in slow motion wrap-up.”