You are working in a small surgery center when a patient’s husband approaches the desk and says, “my wife is not feeling well.” As you approach the patient you note that she appears pale and is sweating profusely. She is anxious and unable to answer questions as she seems confused. You attempt to take her pulse at her radial artery (in her wrist), and you cannot feel a pulse there. You check the other arm, and it is not present on that side either. What conclusion can you reach with this information?
Your patient is most probably hypotensive (Systolic BP less than 80mmHg). It takes a blood pressure of 80mmHg or higher to produce a radial pulse in most patients. There is another possibility, although not likely. That is peripheral vascular disease. If this were the case, you would not expect it to be occlusive bilaterally. In addition, she would not be experiencing the other symptoms of hypotension.
You feel her pulse at her carotid artery and find it to be very slow. You estimate it to be around 30 beats per minute. You place her on the cardiac monitor, and it reveals the following.
What is the name of this rhythm?
This is a third-degree heart block. You notice that there are no two PR intervals that are the same. The ventricular rhythm (QRS) and the P waves are not related to each other. This is a very serious rhythm and can quickly deteriorate to full cardiac arrest.
If you are unable to obtain IV access, what other options do you have to treat this patient?
A transcutaneous pacemaker is a great option in this setting. After placing the monitor leads and the pacing pads, set the pacemaker to 80 per minute with an output of 80. You should see capture on the monitor and the patient’s pulse and blood pressure should increase. Always be sure to check the patient and not just rely on the monitor. Transcutaneous pacing can be very painful. This patient should receive something for pain and possibly sedation if her blood pressure will tolerate it.
Should this patient be transported to the hospital?
Absolutely! This patient is very seriously ill. They will require the implantation of a permanent pacemaker prior to their discharge from the hospital.