Abstract
Background
Bradycardia is a common vital sign encountered in the emergency department. These
patients are often hemodynamically stable and require no emergent intervention. On
occasion, bradycardia can cause hemodynamic instability, and there are established
treatment pathways involving atropine, ionotropic and vasopressive infusions, and
eventual mechanical pacing, if necessary. However, these pathways fail to account
for the many and varied causes of bradycardia and their treatment.
Case Report
A 24-year-old man presented to our emergency department with syncope caused by symptomatic
bradycardia. This was caused by a largely unrecognized synergistic bradycardia resulting
from renal failure, AV nodal blocker use, and hyperkalemia. Our patient's worsening
renal failure caused accumulation of both potassium and beta blocker, which resulted
in bradycardia and hypotension, in turn worsening renal failure secondary to poor
renal perfusion and potentiating his hyperkalemia and beta blocker toxicity.
Why Should an Emergency Physician Be Aware of This?
There is a growing number of cases that suggest this is an underrecognized synergistic
and potentially lethal mechanism of hemodynamically unstable bradycardia and the treatment
falls outside of typical algorithms for handling bradycardia. Understanding the multiple
causes of these patients’ hemodynamically unstable bradycardia allows for maximal
medical management and can prevent unnecessary invasive management for these patients.
Key words
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Article info
Publication history
Published online: May 30, 2019
Accepted:
March 27,
2019
Received in revised form:
March 20,
2019
Received:
July 20,
2018
Footnotes
Reprints are not available from the authors.
Identification
Copyright
© 2019 Elsevier Inc. All rights reserved.
