Complete heart block with a narrow escape rhythm

Second-degree block conducting 2:1

Junctional bradycardia with no atrial activity

Sinus bradycardia with first-degree AV block

Vomiting and clamminess for an hour, with a heavy feeling across the chest

63-year-old man. Vomiting and clamminess for an hour, with a heavy feeling across the chest

Type 2 diabetes on metformin, hypertension on amlodipine. Smokes fifteen a day. Walked into his rural GP surgery, who called an ambulance when the practice nurse could not find a pulse faster than 40.

Stage 1 of 2

Ewan Mackintosh arrives by ambulance, cold and sweating, more troubled by the nausea than by his chest. He is talking and orientated. The nearest primary PCI centre is fifty minutes away and takes direct calls. This tracing was recorded in the ambulance and repeated on arrival unchanged.

Tracing 1 of 2 for the quiz “Vomiting and clamminess for an hour, with a heavy feeling across the chest”. — Twelve-lead on arrival, 25 mm/s, 10 mm/mV. Open this tracing in the studio

What is the rhythm?

ASecond-degree block conducting 2:1 Your answer
BJunctional bradycardia with no atrial activity Your answer
CSinus bradycardia with first-degree AV block Your answer
DComplete heart block with a narrow escape rhythm Correct answer Your answer

What else is on the tracing?

ADownsloping ST depression with a shortened QT Your answer
BWidespread saddle-shaped ST elevation with PR depression Your answer
CST elevation in the inferior leads Correct answer Your answer
DPeaked T waves and a broadened QRS Your answer

What happens in the next ten minutes?

ATemporary pacing wire before any transfer decision Your answer
BSublingual glyceryl trinitrate for the chest discomfort Your answer
CCall the PCI centre and transfer him now Correct answer Your answer
DAtropine 500 micrograms and repeat the tracing in ten minutes Your answer

Stage 2 of 2

The right coronary artery was occluded proximally and was stented ninety minutes after his symptoms began. No pacing wire was needed. He is pain free on the coronary care unit and this tracing was recorded an hour after the procedure.

Tracing 2 of 2 for the quiz “Vomiting and clamminess for an hour, with a heavy feeling across the chest”. — Twelve-lead one hour after the procedure, 25 mm/s, 10 mm/mV. Open this tracing in the studio

Observations

HR: 74
SpO₂ (%): 97
Respiratory rate: 15
Temperature (°C): 36.6
Systolic BP (mmHg): 118
Diastolic BP (mmHg): 72

Why has the conduction returned?

AConduction returned because the ST segments have normalised Your answer
BThe artery supplying the AV node has been reopened Correct answer Your answer
CThe block was vagal in origin and settled once the pain was treated Your answer
DThe block was below the node and the escape focus has recovered Your answer

Vomiting and clamminess for an hour, with a heavy feeling across the chest

The case

On arrival

Observations

Diagnosis

Discussion