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Management of a 75-Year-Old Man Presenting with Syncope: ECG Interpretation and Initial Treatment

A 75-year-old man with a history of hypertension presents by ambulance after an episode of syncope. Initial observations reveal hypotension (BP 80/60), tachypnea (RR 24), and mild hypoxia (SpO2 92%). The ECG shows characteristics indicative of complete heart block (CHB) with broad QRS complexes and T-wave inversions. This scenario requires a detailed description and interpretation of the ECG, alongside a structured outline of the initial treatment options, including the use of atropine and transcutaneous pacing.

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Management of a 75-Year-Old Man Presenting with Syncope: ECG Interpretation and Initial Treatment

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  1. VAQ 4Monash Trial Exam Sept 2014

  2. 75 yr old man from home presents by ambulance after an episode of syncope. History of HT but otherwise well and independent. Obs: BP 80/60 RR 24 SpO2 92% T 36.8 A: Describe and interpret his ECG B: Outline your initial treatment

  3. ECG

  4. Exam common sense 2 part question • A+ B • Each part worth 50% of the marks • Tailor the time spent & volume written accordingly Glossary of Terms • Describe and interpret • State the characteristics including relevant negatives • State a conclusion which includes DDx but excludes management • Outline your initial treatment • Measures undertaken to cure or stabilise the patient’s condition

  5. Exam savvy • Tailor the answer to the stem • Well man from home, sudden syncope • Not about trauma • Not about hypothermia • Obs provided: • Each obs tells a story: • Hypotension = shock • Mildly hypoxic and tachypneic ?why

  6. Pass criteria: Part A • Rate • Ventricular 27/min (accept 25-30) • Atrial 60/min (accept 55-65) • Rhythm CHB • AxisRAD (+130) • Broad QRS 0.16s, RBBB pattern • T inv II, III, aVF, V1-3, flat/inv V4-6 Interpretation • Haemodynamically significant CHB • DDx: Ischaemia2/4 to pass Degenerative Hyperkalaemia Toxicity (bblocker, ca blocker, digoxin)

  7. Pass criteria: Part B • Atropine • Adrenaline • Pacing - transcutaneous transvenous

  8. Features of good answers • Systematic description of ECG • No omissions • Extra detail eg • QRS measurement not just qualitative statement • Axis measurement, not just “RAD” • Doses including dose limits • eg atropine 600mcg  3mg • Realistic DDxeg degenerative, drug toxicity, ischaemia

  9. Features of good answers (cont) • Related stem to ECG • shocked patient • noted tachypnoea….. • considered LVF • appropriate caution with fluids • Realistic O2 • Evidence based approach eg ARC

  10. Features that detracted • Poor adherence to glossary of terms = wasted time • Eg attempting to cover “management” instead of treatment • Including assessment eg investigations • Spending too much time on Part A at the expense of Part B

  11. Omissions in ECG description • Failure to take interpretation any further than what has been covered in the ECG description • Formulaic approach to Part B • No value in wasting time with • “Resus cubicle, team approach, put pads on chest, large bore IV cannulae, take bloods” • 100% O2 ?why (SpO2 92% RA)

  12. Unrealistic DDxeg trauma, hypothermia, SAH • Read the stem! This is not a trick • Lack of knowledge of guidelines eg ARC • Omission of adrenaline • Isoprenaline only drug mentioned

  13. Marks • Range 2 - 7

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