EKG case: Geriatric patient with bradycardia is 'feeling fine'

What's your assessment and care for a patient who has a heart rate in 30s and needs a ride to her cardiologist's office?


Article updated August 3, 2017

You are dispatched to the home of a 74-year-old female, who has impaired mobility, to aid in her transfer to your regional hospital.

After arrival, you are greeted at the door by a pleasant elderly female who uses a walker to move around. As you sit down to assess her medical condition, you notice that she carefully moves from place to place and indeed requires assistance to stay mobile. She quickly notes that she has had previous falls over the last few years and now relies on a walker.

Patient presentation: Elderly female with hypertension

The patient calmly explains to you that she visited her cardiologist three days ago for a routine check of her hypertension, which has been successfully treated by the same physician for the last 15 years. Stemming from this visit, the cardiologist ordered a Holter monitor test, although the patient did not recall any recent episodes of palpitations, dizziness or chest pain. She dutifully carried out the doctor's orders and returned the holter machine the next day.

About 45 minutes ago, the cardiologist called her and asked her about the previous 24-hour period and, specifically, the Holter test. Your patient says that she felt the test went fine and that it would prove to be non-diagnostic. The patient says that the cardiologist calmly explained to her that he wanted to carry out some further tests on her as soon as possible.

The patient summoned your help because her only daughter is out-of-town and is unable to return on such a short notice due to distance. She also mentions the fact that she does need physical assistance.

Primary assessment:

You reassess your patient and determine that you still standing in front of a healthy looking 74-year-old female, in no apparent distress, without a particular chief complaint, or any signs or symptoms that warrant your immediate treatment. Nonetheless, you and your partner are more than happy to help such a sweet woman, especially since it has been an uncommonly uneventful day.

Patient's vital signs:

You document your patient care report with the proper information and the following vital signs from the cardiac monitor:

Heart Rate: 31 bpm
Respirations: 18 rpm
Blood Pressure: 146/78 mm Hg 
SpO2: 98 percent 

Past medical history:

Hypertension 
Diabetes Type 2 
Osteoporosis

Allergies: 

Aspirin

Meds:

Metformin 850 mg 
Enalapril 20 mg 
Amlodipine 5 mg

Initial EKG (click for larger image):

You double-check the screen's interpretation with your actual physician measurement and confirm the patient's radial pulse is at 31 bpm. You utter the words, "Ma'am, are you feeling ok?” She denies any signs and/or symptom in any shape or form. Nonetheless, you quickly place the EKG leads and this is your print out:

The computed interpretation is not available. The EKG Club encourages you to print out the EKG and use calipers to completely analyze the 12-lead EKG following a standardized interpretation process.

Patient treatment considerations and questions

Consider these questions about the patient's condition and best course of treatment.

  • Your quick-combo pads are able to monitor, defibrillate, cardiovert and pace each and all patients. Which of these, if any, would you carry out? Why?
  • What is the rhythm being displayed?
  • What treatments should be considered and why would you choose a particular treatment?
  • Does this patient require a red lights and siren rapid transport to the hospital? Why or why not?

Patient follow-up: How to treat 3rd degree AV block

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