STEMI with Bradycardia

This case is written by Dr. Rob Woods. He works in both the adult and pediatric emergency departments in Saskatoon and has been working in New Zealand for the past year. He is the founder and director of the FRCP EM residency program in Saskatchewan.

Why it Matters

This case requires learners to coordinate multiple components of care at once. A patient presenting with a STEMI requires urgent PCI, however they must also be stable enough to safely travel to the cardiac catheterization lab. This case emphasizes important adjuncts to STEMI management in an unstable patient, including:

  • The utility of transcutaneous pacing and epinephrine infusion in the context of symptomatic bradycardia
  • The importance of recognizing complete heart block as a complication of a STEMI
  • The need for intubation in order to facilitate medication administration and safe transport in a PCI-requiring patient who presents with severe CHF or altered LOC

Clinical Vignette

To be stated by the bedside nurse: “This 65-year-old woman came in with 1 hour of chest pressure and SOB. Her O2 sats were 84% on RA at triage, and they are now 90% with a non-rebreather mask. She’s also bradycardic at 30 and hypotensive at 77/40.”

Case Summary

A 65-year-old female is brought to the ED with chest tightness and SOB. On arrival, she will be found to have an inferior STEMI with resultant 3rd degree heart block and hypotension. The team will be expected to initiate vasopressor support and transcutaneous pacing. However, prior to doing so, the patient will develop a VT arrest requiring ACLS care. After ROSC, the team will need to initiate transcutaneous pacing and activate the cath lab for definitive management.

Download the case here: STEMI with Bradycardia

ECG for the case found here:

Inferior STEMI with CHB

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CXR for the case found here:


(CXR source:

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: