Question

A patient has a third degree heart block. He is complaining of chest pain and he is hypotensive and diaphoretic. He also has pulmonary congestion. He has a large-bore intravenous in his left antecubital fossa. He has been given atropine 0.5 mg intravenously x3 with only a transient increase in heart rate and no improvement of symptoms. The next intervention should be:

A) Start a dopamine infusion at 2-10 mcg/kg/minute
B) Start an epinephrine infusion at 2-10 mcg/minute
C) Attempt TCP (transcutaneous pacing)
D) Any of these are acceptable interventions when atropine is ineffective

Answer 1

The next intervention for a patient with a third-degree heart block and poor response to atropine should be to attempt transcutaneous pacing. If pacing is not available, intravenous dopamine or epinephrine can be used as temporary measures.

Step-by-step explanation:

A patient with a third degree heart block who is complaining of chest pain, hypotensive, diaphoretic, and exhibiting pulmonary congestion has been given atropine with minimal effect. Considering the severity of the situation and the ineffectiveness of atropine, immediate advanced interventions are indicated. The correct next step in the management of this patient, given the provided options, should be to attempt transcutaneous pacing (TCP). This is typically the next line of treatment when pharmacologic agents like atropine fail to improve the heart rate and symptoms in the setting of complete heart block. However, in urgent cases where pacing is not immediately available, starting an intravenous inotropic agent such as dopamine infusion at 2-10 mcg/kg/minute or an epinephrine infusion at 2-10 mcg/minute can be considered as a bridge to more definitive treatment like TCP or pacemaker implantation.