Unstable Bradycardia

This case was written by Dr. Martin Kuuskne from McGill University. Dr. Kuuskne is a PGY5 Emergency Medicine resident and one of the editors-in-chief at EMSimCases.

Why it Matters

High-degree AV blocks (second degree Mobitz type II and third degree AV block) rarely respond to atropine and necessitate the utilization of electromechanical pacing, IV chronotropic agents or both. This case highlights the following points:

  1. Anticipating for the deterioration of patient with an unstable bradycardia by early pacer pad placement and initiating transcutaneous pacing
  2. The use of IV chronotropic agents in the treatment of severe bradycardia
  3. Recognizing PEA in the deteriorating bradycardic patient

Clinical Vignette 

A 78-year-old male from a long-term care facility is being transferred to the emergency department for decreased mental status.

Case Summary

A 78-year-old male presents to the emergency department with an unstable bradycardia. The patient deteriorates from a second degree, Mobitz Type II-AV block into a third degree AV block requiring ACLS protocol medications, transcutaneous pacing, and ultimately transvenous pacing until definitive management with a permanent pacemaker can be arranged.

Download the case here: Bradycardia

First EKG for the case:


Second EKG for the case:

3rd AVB


CXR for the case here:



Bedside Ultrasounds for the case:

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