Mon25October0757PM 18

A 78-year-old man who is normally fit and well presents to you after 'feeling dizzy' whilst waiting for a bus. He denies a history of chest pain or palpitation. He remembers the episode clearly and there is no history of syncope.

On examination the patient is oriented, his heart rate is 38/min and blood pressure 140/50 mmHg, apyrexial, sats 98% air. Heart sounds are normal with no added sounds. Lungs are clear on auscultation with no crackles.

Blood tests reveal the following:

WCC 9 ×109/L

Hb 130 g/L

Plts 387 ×109/L

Na 135 mmol/L

K 4.3 mmol/L

Urea 14 mmol/L

Creatinine 187 µmol/L

ECG is shown below:

What would be the most appropriate way to manage him in the immediate setting?

(Please select 1 option)

Atropine

Temporary pacing wire This is the correct answer

Observation Incorrect answer selected

Percussion pacing

External pacing

Explanation

Although this man is haemodynamically stable with no symptoms of chest pain, heart failure or syncope, he is developing acute kidney injury indicating circulatory compromise. He requires pacing.

Not all patients with complete heart block require immediate pacing. Signs to look out for include:

Asystole >3 seconds

Bradycardia <40 /min

Reduced conscious level or syncope

BP <100 mmHg systolic

Rising creatinine

Urine output <30ml/hr

Secondary ventricular arrhythmias.

Answer Statistics

1

28%

2

49%

3

16%

4

1%

5

9%

Times answered: 272