An elderly patient presents with an episode of syncope. He has had a pacemaker inserted 5 weeks prior. His ECG on arrival is shown below.
The heart rate is very slow here ie., 25 beats per minute, however the patients blood pressure was normal. DON'T BE FOOLED! This patient is still in SHOCK: read below.
If you have completed the pacemaker section of the cardiac self study course, you would be able to pick that there is an issue with capture here.:
At this heart rate, the patient's blood pressure may be normal. BEWARE, this is simply the patient's endogenous sympathetic response producing an increase in systemic vascular resistance and maintaining a blood pressure, however the patient may still have a POOR CARDIAC OUTPUT.
If they are treated with atropine or some other chronotrope and their heart rate responds, although their blood pressure may not change much, they feel much better as their cardiac output increases and they no longer in a 'shock' state.
Our patient responded well to atropine and was later transferred(on an isoprenaline infusion) for a re-implantation of pacing wire.
What's the general approach?