Bradycardia in a Patient With Myocardial Infarction

Vital Signs

• Temperature: 98.2 °F, axillary

• Blood Pressure: 100/52 mmHg

• Heart Rate: 51 bpm - regular rhythm ( Fig. 10.1 )

  

• Respiratory Rate: 22 breaths per min

• Pulse Oximetry: 94% oxygen saturation on room air

Focused Physical Examination

The patient was an elderly male in moderate distress, altered, pale, and diaphoretic grabbing the center of his chest. Appropriate personal protective equipment was established, and the patient was examined. A cardiac exam showed normal heart sounds with no murmurs. He had an elevated jugular vein distention. His lung exam showed minimal bibasilar crackles. His abdomen was soft, non-tender, and non-distended. His extremities were warm to the touch, and no peripheral edema was noted. Capillary refill was <2 s.

Interventions

A cardiac monitor and pacing pads were attached immediately to the patient. Then, a 1000 mL of normal saline fluid bolus was started. One dose of 2 mg IV morphine was administered because of severe pain. A stat electrocardiogram (EKG) was obtained, which showed sinus bradycardia with elevated ST segments in leads II, III, and aVF concerning for an inferior wall myocardial infarction. A stat page was sent to interventional cardiology for review of the EKG. Troponin levels, complete blood count, comprehensive metabolic panel, and lactate level were obtained. The patient’s hemodynamics deteriorated during the rapid response event, and his heart rate dropped to the mid-30s, with blood pressure dropping to 82/50 mmHg. Atropine 0.5 mg was administered per advanced cardiac life support (ACLS) protocol, and transcutaneous pacing was initiated, which improved the BP to 102/59 mmHg. Cardiology was consulted, and the patient was immediately sent to the cardiac catheterization lab for possible percutaneous coronary intervention and from there to the intensive care unit for further care.

Final Diagnosis

Second-degree atrioventricular (AV) block in the setting of inferior myocardial infarction.