Complete heart block

[anbuitachi]

For patients w lbbb that convert to complete heart block intra op. I read first thing to do is atropine, followed by epi/dopa infusions, or transcutaneous pacing. My question is in complete heart block, atropine shouldn't work since it targets SA node and SA node doesn't pass. But epi or isoproterenol should since it is direct acting. Is this correct?

Also what would you guys do if patient with a LBBB went into complete heart block in the middle of a case?

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[gasdoc77]

For patients w lbbb that convert to complete heart block intra op. I read first thing to do is atropine, followed by epi/dopa infusions, or transcutaneous pacing. My question is in complete heart block, atropine shouldn't work since it targets SA node and SA node doesn't pass. But epi or isoproterenol should since it is direct acting. Is this correct?

Also what would you guys do if patient with a LBBB went into complete heart block in the middle of a case?

Tap scope vs pacing swan

 

[deleted59964]

atropine shouldn't work since it targets SA node and SA node doesn't pass.
But epi or isoproterenol should since it is direct acting. Is this correct?

Also what would you guys do if patient with a LBBB went into complete heart block in the middle of a case?

that would be my expectation too.
I would try to pharmacologically increase the heart rate ... i'd start an adrenaline infusion, and I'd then try pacing (transcutaneously if necessary while arranging transvenous).

 

[deleted9493]

For patients w lbbb that convert to complete heart block intra op. I read first thing to do is atropine, followed by epi/dopa infusions, or transcutaneous pacing. My question is in complete heart block, atropine shouldn't work since it targets SA node and SA node doesn't pass. But epi or isoproterenol should since it is direct acting. Is this correct?

Also what would you guys do if patient with a LBBB went into complete heart block in the middle of a case?

Correct—anticholinergics affect SA node only and have no effect on ventricular rate of 3rd degree block.

Whether this is stable or unstable, I am consulting cardiology for direction...temporizing with epinephrine if unstable.

 

[pgg]

ACLS has been dumbed down so that followers of the protocol don’t have to distinguish between high and low grade blocks. The algorithm directs the administration of atropine for all causes of bradycardia as a first step. I guess too many EMTs and nurses thought the old ACLS was too hard.

That doesn’t mean that those of us who know better should waste time with anticholinergics in patients who are obviously in complete heart block. Direct acting drugs (epi) and pacing are the right answers.

 

[deleted162650]

Direct acting drugs (epi) and pacing are the right answers.

This. I had a lil' old lady go into complete hear block on me in PACU recently. It was hard to distinguish the exact rhythm on our crappy PACU monitor (aside from the obvious brady).

Pushed glyco when she got into the 30's and called for 12 lead - no response.
Pushed atroine when she hit 30 with marked hypotension and AMS, no response and still no 12 -lead
At this point I'm convinced it's complete block - called for an epi stick
Pushed 10mcg epi when she hit 27 which fixed her, had to repeat with one more 10mcg bump before the SA node woke back up
12 lead finally shows up but is unimpressive at this point
Cardiology comes by - takes a look at the strip and agrees complete block after studying it for a while - they don't wanna do anything about it since it's gone now unless it happens again - OK

 

[nimbus]

Epi titrated in the right dose is almost always the right answer.

 

[deleted162650]

Epi titrated in the right dose is almost always the right answer.

Any time someone is trying to die on you, almost regardless of etiology - Epi.

 

[Psai]

Any time someone is trying to die on you, almost regardless of etiology - Epi.

What if they have an irritable myocardium that's itching to go into vfib

 

[Noyac]

What if they have an irritable myocardium that's itching to go into vfib

Then you shock them when they go into it.

 

[deleted162650]

What if they have an irritable myocardium that's itching to go into vfib

A) I said almost regardless

B) What drug are you gonna push when they do go into Vfib? 😉

 

[deleted697535]

Any time someone is trying to die on you, almost regardless of etiology - Epi.

10mcg boluses fixed everything on the planet I used to think. Except for my last case last night...

 

[sethco]

A) I said almost regardless

B) What drug are you gonna push when they do go into Vfib? 😉

I can think of at least two situations where Epi is definitely not the answer and is more likely detrimental. Residents/Fellows, oral boards practice time, what are some examples of such?

 

[dchz]

I can think of at least two situations where Epi is definitely not the answer and is more likely detrimental. Residents/Fellows, oral boards practice time, what are some examples of such?

1)HOCM, IHSS, AS, and other stenotic lesions.

2)coronary ischemic events

3)type 1 hypersensitivity to epinephrine 🙂

 

[gasdoc77]

1)HOCM, IHSS, AS, and other stenotic lesions.

2)coronary ischemic events

3)type 1 hypersensitivity to epinephrine 🙂

 

[pgg]

What if they have an irritable myocardium that's itching to go into vfib

Turn off the halothane, give epi. 🙂

 

[pgg]

10mcg boluses fixed everything on the planet I used to think. Except for my last case last night...

Details?

 

[deleted162650]

Details?

He pushed roc - things went downhill from there. 😀

 

[Crabbygas]

I would add Tsako Tsubo cardiomyopathy to the list of things that might not do well with epi.

 

[Noyac]

Turn off the halothane, give epi. 🙂

Ooh halothane.
I used to love to use that in pedi hearts to slow them down.

 

[deleted697535]

He pushed roc - things went downhill from there. 😀

You're gonna laugh but.... Lol

It went really badly anyway. Still.trying to figure out why.

 

[Aether2000]

During a trans-septal ablation of atrial and PV tracts in the EP lab today, the patient's ECG suddenly disappeared and the A-line went to zero for about 20 sec. The patient had atrial but not ventricular pacing leads in. The cardiologist asked for atropine, but slowly sinus bradycardia developed with maintenance of BP. Best drug for this situation?

 

[btbam]

During a trans-septal ablation of atrial and PV tracts in the EP lab today, the patient's ECG suddenly disappeared and the A-line went to zero for about 20 sec. The patient had atrial but not ventricular pacing leads in. The cardiologist asked for atropine, but slowly sinus bradycardia developed with maintenance of BP. Best drug for this situation?

I’m pretty sure no ECG or pulse for 20 seconds is called a code.

 

[dchz]

During a trans-septal ablation of atrial and PV tracts in the EP lab today, the patient's ECG suddenly disappeared and the A-line went to zero for about 20 sec. The patient had atrial but not ventricular pacing leads in. The cardiologist asked for atropine, but slowly sinus bradycardia developed with maintenance of BP. Best drug for this situation?

EPI?

 

[facted]

EPI?

Most definitely. Atropine is no longer part of asystole algorithm in ACLS. If your in the OR and can give all sorts of stuff at once, don't think it would hurt, but would definitely go for epi first.

 

[jwk]

Is anyone still using isoproterenol? I haven't used it in years but one of our vascular surgeons asked for it recently.

 

[Arch Guillotti]

Is anyone still using isoproterenol? I haven't used it in years but one of our vascular surgeons asked for it recently.

What was the indication?

 

[alternatecharacter]

Is anyone still using isoproterenol? I haven't used it in years but one of our vascular surgeons asked for it recently.

The price is insane now. Some company did that thing where you buy up all the factories of everyone making the generic and raise the price. An EP doc wanted to try an experiment on a patient in the ICU (don't ask) and anyway ICU pharmacy was like this costs $8000 per vial and we have one in the hospital how valuable is whatever it is you are planning on doing. So no experiment.

 

[Psai]

The price is insane now. Some company did that thing where you buy up all the factories of everyone making the generic and raise the price. An EP doc wanted to try an experiment on a patient in the ICU (don't ask) and anyway ICU pharmacy was like this costs $8000 per vial and we have one in the hospital how valuable is whatever it is you are planning on doing. So no experiment.

Should sell that vial

 

[Ronin786]

The price is insane now. Some company did that thing where you buy up all the factories of everyone making the generic and raise the price. An EP doc wanted to try an experiment on a patient in the ICU (don't ask) and anyway ICU pharmacy was like this costs $8000 per vial and we have one in the hospital how valuable is whatever it is you are planning on doing. So no experiment.

I don't know how expensive it is but our EP docs use it for all their ablations to try and induce arrhythmia.

 

[btbam]

I don't know how expensive it is but our EP docs use it for all their ablations to try and induce arrhythmia.

Same. .01-.02 mcg/kg/min

 

[dhb]

The price is insane now. Some company did that thing where you buy up all the factories of everyone making the generic and raise the price. An EP doc wanted to try an experiment on a patient in the ICU (don't ask) and anyway ICU pharmacy was like this costs $8000 per vial and we have one in the hospital how valuable is whatever it is you are planning on doing. So no experiment.

I'm planning my next vacation, how many do you want?

 

[drmwvr]

The price is insane now. Some company did that thing where you buy up all the factories of everyone making the generic and raise the price. An EP doc wanted to try an experiment on a patient in the ICU (don't ask) and anyway ICU pharmacy was like this costs $8000 per vial and we have one in the hospital how valuable is whatever it is you are planning on doing. So no experiment.

The capture charge and what the patient sees are two different things. What the third party pays, even more so. EP lab cost, anesthesia, PACU...isuprel is a drop in the bucket.

 

[deleted9493]

Is anyone still using isoproterenol? I haven't used it in years but one of our vascular surgeons asked for it recently.

I've been seeing epinephrine used more commonly in our peds EP lab the past several months in lieu of isoproteronol for arrhythmia induction...guess cost is probably why.

 

[AdmiralChz]

https://www.eplabdigest.com/articles/Rising-Costs-Isoproterenol

The capture charge and what the patient sees are two different things. What the third party pays, even more so. EP lab cost, anesthesia, PACU...isuprel is a drop in the bucket.

Disagree, the article above shows how much the price has gone up (and alternative drugs used along with their limitations). A mid-to-large center may be spending over $1-2 million on Isuprel where they used to spend $10K or the like.

In residency we used to use it as a chronotropic agent post-Heart transplant, but it doesn’t work very well. Eventually the hospital convinced (forced) the surgeons to stop using it due to cost.

 

[anbuitachi]

Same our proceduralists use it all the time in EP

 

[drmwvr]

https://www.eplabdigest.com/articles/Rising-Costs-Isoproterenol




Disagree, the article above shows how much the price has gone up (and alternative drugs used along with their limitations). A mid-to-large center may be spending over $1-2 million on Isuprel where they used to spend $10K or the like.
.

I'm kind of aghast reading that article. Hard to say what the regional differences are, but I can tell you that our 915 dollar, 1 mg amp can be made into 5 doses. Probably more if we wanted to, given the amount of time we have it infusing. 183 dollars a dose? Very probably among the least expensive elements of the entire procedure.

 

[BLADEMDA]

Marathon Pharmaceuticals sold isoproterenol to Valeant Pharmaceuticals International Inc. in February 2015. Upon acquisition, Valeant Pharmaceuticals increased the price from $218.3/dose to $1,200/dose.” The United States Congress was trying to pass legislation to prohibit this type of behavior by the pharmaceutical industry, but to no avail. The cost of Isuprel continues to escalate, with its price now at $1,356 per vial.


Valeant Pharmaceuticals Intl Inc (VRX) Stock Will Be Just Fine

 

[GA8314]

Is anyone still using isoproterenol? I haven't used it in years but one of our vascular surgeons asked for it recently.

Our EP uses it for SVT ablations to attempt to induce the SVT after ablating.... I've run it for A-fib EP ablation cases for same reason. Really gets the heart racing without much change in BP.

 

[dhb]

Marathon Pharmaceuticals sold isoproterenol to Valeant Pharmaceuticals International Inc. in February 2015. Upon acquisition, Valeant Pharmaceuticals increased the price from $218.3/dose to $1,200/dose.” The United States Congress was trying to pass legislation to prohibit this type of behavior by the pharmaceutical industry, but to no avail. The cost of Isuprel continues to escalate, with its price now at $1,356 per vial.


Valeant Pharmaceuticals Intl Inc (VRX) Stock Will Be Just Fine

Isuprel sol. perf. à diluer i.v. [amp.] 5 x 0,2 mg / 1 ml
€ 9,82
So 2€/vial

 

[nimbus]

Isuprel sol. perf. à diluer i.v. [amp.] 5 x 0,2 mg / 1 ml
€ 9,82
So 2€/vial

Wow! Too bad you can’t arbitrage the stuff. Ship over a few cases full.

 

[Psai]

Isuprel sol. perf. à diluer i.v. [amp.] 5 x 0,2 mg / 1 ml
€ 9,82
So 2€/vial

Let's go into business, I think we can make a lot of easy money together.

 

[dhb]

I'll put up shop on the darknet

 

[Swtfrk]

How commonly do you guys see LBBB convert to complete heart block? I had it happen to me for the first time in our outpatient GI center during an EGD. 76M with history of chronic LBBB following a AVR/CABG in the past, but cardiac function stable since then, was asymptomatic pre-op. Towards the end I think he vagaled, and his HR never recovered after that and just sat in the 30s. Unresponsive to atropine/glyco but BP and other vitals were fine, and mental status was normal once the propofol wore off. Threw on the transcutaneous pads and had epi ready to go and sent him off to the ED. EKG confirmed complete heart block. He ended up doing OK but it sure threw a wrench into our busy schedule.

Looking back maybe I would have done this patient in a non-ambulatory setting, but my partners had scoped him in the past as an outpatient without any issue. Maybe I just got unlucky.

 

[GaseousClay]

For patients w lbbb that convert to complete heart block intra op. I read first thing to do is atropine, followed by epi/dopa infusions, or transcutaneous pacing. My question is in complete heart block, atropine shouldn't work since it targets SA node and SA node doesn't pass. But epi or isoproterenol should since it is direct acting. Is this correct?

Also what would you guys do if patient with a LBBB went into complete heart block in the middle of a case?

Doesn't the heart have muscarinic receptors on the AV node as well

 

[anbuitachi]

How commonly do you guys see LBBB convert to complete heart block? I had it happen to me for the first time in our outpatient GI center during an EGD. 76M with history of chronic LBBB following a AVR/CABG in the past, but cardiac function stable since then, was asymptomatic pre-op. Towards the end I think he vagaled, and his HR never recovered after that and just sat in the 30s. Unresponsive to atropine/glyco but BP and other vitals were fine, and mental status was normal once the propofol wore off. Threw on the transcutaneous pads and had epi ready to go and sent him off to the ED. EKG confirmed complete heart block. He ended up doing OK but it sure threw a wrench into our busy schedule.

Looking back maybe I would have done this patient in a non-ambulatory setting, but my partners had scoped him in the past as an outpatient without any issue. Maybe I just got unlucky.

How did he get to the ED. You called an ambulance?

Doesn't the heart have muscarinic receptors on the AV node as well

It has minimal compared to SA node , right?

 

[deleted171991]

It has minimal compared to SA node , right?

Nope.

"Boron's Medical Physiology":
"The vagus nerve, which is parasympathetic (see p. 339), releases acetylcholine (ACh) onto the SA and AV nodes and slows the intrinsic pacemaker activity by all three mechanisms discussed in the preceding paragraph.[see figure]

The effects of ACh on currents in the AV node are similar to its effects on those in the SA node. However, because the pacemaker normally does not reside in the AV node, the physiological effect of ACh on the AV node is to slow conduction velocity. The mechanism is an inhibition of ICa that also makes the threshold more positive for AV nodal cells. Because it is more difficult for one cell to depolarize its neighbors to threshold, conduction velocity falls."

 

[chocomorsel]

Let's go into business, I think we can make a lot of easy money together.

Seriously though. This can’t be illegal. What’s preventing hospitals from buying from Europe or Canada? Is there a law behind this?

This would help ease the cost for hospitals. Which I am SURE they would pass on to patients. Lol.

But seriously, what’s to prevent them?

 

[NotYou20]

ACLS has been dumbed down so that followers of the protocol don’t have to distinguish between high and low grade blocks. The algorithm directs the administration of atropine for all causes of bradycardia as a first step. I guess too many EMTs and nurses thought the old ACLS was too hard.

That doesn’t mean that those of us who know better should waste time with anticholinergics in patients who are obviously in complete heart block. Direct acting drugs (epi) and pacing are the right answers.

Im a ms2 and got my ACLS cert recently. We were taught that atropine is useless in third degree and that second degree type 2 we should consider skipping atropine and starting with epi.

 

[anbuitachi]

Nope.

"Boron's Medical Physiology":
"The vagus nerve, which is parasympathetic (see p. 339), releases acetylcholine (ACh) onto the SA and AV nodes and slows the intrinsic pacemaker activity by all three mechanisms discussed in the preceding paragraph.[see figure]

View attachment 230723

The effects of ACh on currents in the AV node are similar to its effects on those in the SA node. However, because the pacemaker normally does not reside in the AV node, the physiological effect of ACh on the AV node is to slow conduction velocity. The mechanism is an inhibition of ICa that also makes the threshold more positive for AV nodal cells. Because it is more difficult for one cell to depolarize its neighbors to threshold, conduction velocity falls."

so why are we skipping atropine in complete heart block, if patient has a pressure that can sustain life