An 82-year-old presents after a witnessed syncopal episode. ECG shows complete heart block with a ventricular escape of 28 bpm. BP 84/52. How will you manage?

Question

Background: hypertension, beta-blocker, no prior cardiac history. Patient is now alert but symptomatic with dizziness.

Accepted Answer

I would manage this as a peri-arrest bradycardia in resus. ABCDE first — oxygen if hypoxic, large-bore access, continuous ECG, defib pads on. I'd identify the adverse features here: syncope and shock, so I need pacing. I'd give atropine 500 mcg IV repeated up to 3 mg while preparing transcutaneous pacing pads. If atropine fails, I'd start an adrenaline infusion 2–10 mcg/min and call cardiology immediately for a transvenous wire. In parallel I'd send urgent troponin, U&Es, magnesium, TFTs, and a portable CXR; review the drug chart for beta-blockers, digoxin, rate-limiting calcium channel blockers. Once paced and stable I'd discuss permanent pacemaker insertion with cardiology and counsel the patient and family about the procedure and driving implications.

Complete heart block with syncope

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