In the ED, their vitals/exam are as above. Patient is ***tensive. With*** altered mental status. With*** chest pain. With*** s/s of acute decompensated heart failure. With*** evidence of 2nd/3rd degree heart block on EKG. With*** current GI illness. With*** clear vagal event. With*** s/s of beta blocker overdose, calcium channel blocker overdose, clonidine overdose, opioid overdose, alcohol intoxication, digoxin use, other acute ingestions, or bug bites. Electrolyte, ischemic, native conductive (SSS) etiologies are high on differential, hence will proceed as below.
– Labs/Tests: Lactate, CBC, CMP, TSH w/ reflex free T4, Troponin x2, BNP, Serum Tox, UA w/ reflex UCx, UTox. Review medication list. Consider stress test as inpatient vs. Outpatient.
– Imaging: CXR, BSUS
– Treatments: Anterior/posterior pads, Escalating respiratory support as indicated (NC -> NRB -> HFNC -> BiPAP -> Intubation), PRN Atropine (0.5-1mg bolus, repeat q3-5mins for max 3g), PRN epinephrine push/gtt (2-10mcg/min) +/- isoproterenol gtt (2-10mcg/min), PRN transcutaneous (A: Set rate 60-70, Increase mA until you get electrical capture; B: Confirm mechanical capture with pulse/cardiac ultrasound, C: Hold down 4:1 button as needed to check underlying rhythm)/transvenous pacing (6F cordis, 5F catheter)
– Consults: Cardiology +/- Electrophysiology
– Dispo: Pending further testing