Case Study: QRS 3rd Degree AV block

A 78 year old male has been transported to your facility via EMS. You observe his skin is cyanotic, blue and diaphoretic. His level on consciousness is severely reduced. He is only responding to uncomfortable stimulation. The paramedics report his blood pressure is 42/0 with a weak radial pulse of 28. When placed on the ECG monitor, you see a wide-QRS 3rd degree AV block.

Oxygen is administered and transcutaneous cardiac pacing patches are attached to the patient’s chest. Pacing is initiated at 20mA without capture. The amperage is increased incrementally until capture is observed at 110 mA. Within a minute, the patient’s level of consciousness improves and he is showing signs of discomfort each time of TCP discharges. Morphine sulfate is given in 2.0 mg increments until the patient becomes comfortable.

The patient is prepared for insertion of an emergency venous cardiac pacer.

One of the staff posed several questions based on their participation in an ACLS course:

Bonus Practice Questions

Atropine is always the first-line drug of choice when treating any bradycardia.

1. True
2. False

Which of the following might be improved by using atropine?

1. Sinus bradycardia
2. 1st degree AV block
3. 2nd degree AV block type I
4. All of the above

The recommended dose of I.V. atropine used to treat symptomatic bradycardia is:

1. 0.4 mg IV bolus repeated every 10-15 minutes as needed
2. 0.5 mg IV bolus every 3-5 minutes as needed
3. 2 mg IV bolus, may repeat as necessary
4. Any of the above are acceptable

​When treating symptomatic bradycardia in adult patients, epinephrine should only be used by careful titration of an infusion, never by bolus.

1. True
2. False

Both epinephrine and dopamine titrated infusions are recommended as follows: 2 – 10 mcg/kg/min.

1. True
2. False