COW 2

CC: Dizziness

HPI: A 78 year old male with a history of HTN presents to your ED with the complaint of Dizziness. He describes the sensation as the world darkening in his peripheral vision. States the sensation started approximately 3 days ago but hasn't gotten better, prompting this visit. States that his symptoms are associated with weakness and generalized fatigue. Denies any sensations of the world spinning, CP, SOB, nausea or vomiting. States that he has no focal weakness.

Vital signs

BP 100/50. T: 98 HR: 24 RR: 12 SpO2: 98%

PE: AOx3, Bradycardic, CTA b/l, Abdomen soft and nontender PERRL, Moving all 4 ext.

EKG: (LITFL.org)

Complete Heart Block

Complete heart block aka third degree heart block is a complete loss of AV conduction. This is usually diagnosed on EKG by complete dissociation of P waves and qRS complexes, with differing atrial and ventricular rates. Atrial rates usually hover around 100 bpm, while Ventricular rates hover around 40bpm.

Complete heart block is associated with numerous etiologies. More common causes include degeneration of second degree heart block, medication induced (B-blocker or Calcium Channel Blocker), myocardial infarction, hyperkalemia, and more.

Treatment: Directed at the underlying cause. IF patient is unstable, pacing may be required.

Atropine
- IV 0.5mg q3-5 minutes
- Contraindicated in Acute myocardial infarction as may increase cardiac demand.
Medication induced
- B-Blocker and CCB overdose
  - CCB overdose can be differentiated from B-blocker overdose by hyperglycemia
  - Treatment for both includes:
    - Glucagon 5mg IV over 1 minute
      - If improvement noted: 2 to 5 mg/hr gtt.
    - Calcium Chloride or Calcium Gluconate
      - Depending on IV access site.
    - Consider addition of Epinephrine
Cardiac pacing
- Transcutaneous
- Transvenous

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