A patient is in sinus bradycardia with a heart rate of 45/min, complaining of dizziness. His BP is 80/60 mm of Hg. Which of the following should be the priority intervention?

1. A

   Defibrillation

2. B

   Administer digoxin

3. C

   Continue monitor

4. D

   Prepare for transcutaneous Pacing

Appeared in: SCTIMST Staff Nurse - 2015 (Set-B)

Explanation

• The patient's clinical presentation of a very low heart rate (45/min), hypotension (BP 80/60 mmHg), and dizziness signifies symptomatic or unstable bradycardia.
• According to Advanced Cardiovascular Life Support (ACLS) guidelines, when a patient with bradycardia is unstable, immediate intervention is required to increase the heart rate and improve perfusion.
• Transcutaneous pacing (TCP) is a non-invasive, rapid, and effective method to electrically stimulate the heart to beat at a faster rate.
• While atropine is the first-line drug, preparing for TCP is the priority in a severely unstable patient, as it is the definitive next step if atropine is ineffective or not immediately available.

Why Other Options Were Wrong

• Option A: Defibrillation delivers a high-energy, unsynchronized shock to terminate chaotic electrical activity. It is not used for organized rhythms like sinus bradycardia, even if the rate is slow.
• Option B: Digoxin is a negative chronotrope, meaning it slows the heart rate by increasing vagal tone and decreasing conduction through the AV node. Administering it would worsen the bradycardia.
• Option C: Continuing to monitor is a passive measure and is inadequate for a patient who is hemodynamically unstable. This patient requires an active, urgent intervention to correct the life-threatening bradycardia and hypotension.

Related Visual

Clinical Relevance

• Nursing practice connection: Knowing Management of Symptomatic Bradycardia helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
• Nurses must be able to rapidly recognize the signs of unstable bradycardia (hypotension, altered mental status, signs of shock, chest pain) to initiate emergency care.
• The nurse's role includes calling for the crash cart, applying defibrillator/pacing pads in the correct anterior-posterior or anterior-lateral position, and preparing for sedation as TCP can be painful for a conscious patient.
• Prompt intervention is critical as prolonged symptomatic bradycardia can lead to cardiac arrest.

How to Approach the Question

• First, analyze the patient's data provided in the stem: Heart Rate (45/min), Blood Pressure (80/60 mmHg), and Symptoms (dizziness).
• Identify the clinical problem by synthesizing these cues. A low heart rate with signs of instability (low BP, dizziness) equals symptomatic bradycardia.
• Recall the standard treatment algorithm for this emergency condition, which is guided by ACLS protocols.
• Evaluate each option against the algorithm. Ask yourself: 'Is this intervention appropriate for a patient with a pulse who is bradycardic and unstable?'
• Eliminate options that are clearly incorrect or contraindicated. Defibrillation is for pulseless VT/VF. Digoxin worsens bradycardia.
• Choose between the remaining options. 'Continue monitor' is a passive action, whereas 'Prepare for transcutaneous Pacing' is an active, life-saving intervention required for an unstable patient. The priority is always the active, definitive treatment.

Concept Tested & Keywords

• Concept Tested: Management of Symptomatic Bradycardia
• Stem keywords: sinus bradycardia, heart rate of 45/min, dizziness, BP is 80/60 mm of Hg
• Lead-in keywords: priority intervention
• Clinical cues: Heart rate of 45/min indicates bradycardia.
• Clinical cues: Blood pressure of 80/60 mmHg indicates hypotension.

Question ID

QJHYqtmIJ5EJqquocss1O

Copy ID

Reference Book

E6 Medicine Harrison 22e Part 2 pp. 28-30, 29-31

E6 Ghai Essential Pediatrics(pp 26-904 of 913) p. 481-483