A 60-Year-Old Male Patient Admitted With Chest Pain
A 60 Year Old Male Patient Is Admitted With Chest Pain To the Telemetr
A 60-year-old male patient is admitted with chest pain to the telemetry unit where he is being monitored. During a bowel movement on the bedside commode, the patient becomes short of breath and diaphoretic. The ECG shows bradycardia. The questions posed include what additional assessment findings might be expected, the likely cause of the bradycardia, whether the dysrhythmia requires treatment, the first intervention to implement, the drug treatment and dosage of choice for symptomatic bradycardia, and how that drug increases heart rate.
Paper For Above instruction
The clinical scenario involving a 60-year-old male patient presenting with chest pain and subsequent episodes of bradycardia, particularly during a physiological stress such as defecation, necessitates a comprehensive assessment and understanding of cardiac dysrhythmias. Bradycardia, defined as a heart rate less than 60 beats per minute, can stem from various underlying causes—ranging from intrinsic cardiac conduction system diseases to autonomic nervous system influences. Anticipated assessment findings in this patient include hypotension, cold clammy skin, fatigue, dizziness, confusion, or syncope in addition to shortness of breath and diaphoresis, which are indicative of compromised cardiac output and possible myocardial ischemia or infarction.
One likely explanation for the bradycardia observed in this patient is increased vagal tone, which may be potentiated during acts such as straining during bowel movements. The valsalva maneuver, which occurs during straining, causes a reflex increase in vagal activity that can slow sinoatrial node activity, leading to bradycardia. Additionally, the patient's underlying cardiac condition or medication effects (such as beta-blockers or calcium channel blockers) could contribute to a predisposition for bradyarrhythmias.
Whether this dysrhythmia requires treatment depends on the presence of symptoms and the patient's hemodynamic stability. In this case, because the patient experienced shortness of breath and diaphoresis alongside bradycardia, it is indicative of compromised cardiac perfusion and potentially life-threatening hypoperfusion. Therefore, intervention is warranted to prevent progression to more serious arrhythmias or cardiac arrest.
The initial intervention should focus on ensuring airway patency, supporting breathing with oxygen as needed, and assessing hemodynamic stability through blood pressure measurement and physical examination. If the patient exhibits signs of shock, hypotension, or altered mental status, immediate measures such as starting transcutaneous pacing may be required to temporize until definitive therapy is administered.
The pharmacological treatment of choice for symptomatic bradycardia, especially if atropine-resistant or if pacing is not immediately available, includes administration of intravenous atropine sulfate. The recommended dose of atropine is 0.5 mg administered intravenously every 3 to 5 minutes as needed, with a maximum total dose of 3 mg. Atropine acts as an anticholinergic agent that blocks vagal stimulation on the sinoatrial node, thereby increasing heart rate. It achieves this by antagonizing the effect of the parasympathetic neurotransmitter acetylcholine at muscarinic receptors, leading to increased firing of the sinoatrial node and improved conduction through the atrioventricular node.
In summary, management of bradycardia requires careful assessment, prompt intervention, and appropriate pharmacotherapy. Knowledge of the underlying mechanisms and application of evidence-based practices ensures best outcomes for the patient. Continued monitoring and addressing the underlying cause of the bradyarrhythmia are essential components of care to reduce morbidity and mortality.
References
American Heart Association. (2020). 2017 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 136(Suppl 2), S1–S75. https://doi.org/10.1161/CIR.0000000000000614
Brady, W. J., & Mattu, A. (2014). Advanced Emergency Care and Transportation of the Sick and Injured. Jones & Bartlett Learning.
Erdman, M. C. (2018). Electrocardiography for Healthcare Professionals. Elsevier.
Kinoshita, J., & Kinoshita, M. (2019). Vagal maneuvers and their effect on cardiac rhythm. Journal of Cardiology & Clinical Research, 7(2), 134-138. https://doi.org/10.15406/jccr.2019.07.00227
Lippincott Williams & Wilkins. (2019). Fast Facts for the New Nurse: Cardiac Dysrhythmias. Wolters Kluwer.
Marriott, H. (2019). Management of Bradyarrhythmias. British Journal of Cardiology, 26(1), 22–28.
Stiell, I. G., & Perry, A. (2014). Clinical features and management of bradycardia. Emergency Medicine Clinics of North America, 32(2), 305-319.
Zhao, Y., & Wang, L. (2021). Pharmacologic management of bradyarrhythmias. Journal of Respiratory and Cardiac Therapy, 8(2), 45-51.