Paramedic Education at Monroe Community College, Rochester, New York

C is the best answer

An important rule in EMS is "if it ain't broke, don't fix it". This patient was comfortable lying flat and had no symptoms to demand urgent treatment. Don't treat the monitor! This case illustrates that in some patients, the vasoconstrictive and autoregulatory systems can maintain BP and CO despite an incredibly slow heart rate. Precise measurements of the ECG strips show a heart rate of 14.8 beats per minute. In this case, the patient was transported to the local hospital without complication. Two hours after arriving at the ED, and with no prior medications, the patient received a permanent transvenous pacemaker. Lab tests and EKG ruled out myocardial infarction.

Salient Learning Points:

Regular Rhythms in an Atrial Fibrillation should cause you to suspect complete heart block.

The T wave is farther from the QRS due to the slow rate and could be confused as a VPC by the neophyte

QRS measurements from the beginning of the r wave to the J point is 0.08 seconds. WNL

To attain accurate blood pressure readings, the deflation of the cuff would have to be very slow ie 2 mm per beat. Too rapid a deflation would lead to a falsely low BP.

The patients cardiologist suspects that the patient was a victim of Lev's disease. Lev's disease is a degeneration of the fibrous skeleton of the heart, with fibrosis and calcification involving the conduction system. This is not a rare disease. Had the transport time been longer or if the patient began to show signs of hypoperfusion, then atropine or external pacing would be in order.

Consultation with your Medical Control Physician is of utmost importance in these cases.

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Updated: October 13, 1997
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