At the conclusion of this case study, the learner will be able to: Identify two common treatment modalities for Second degree heart block Identify a list of uses of, doses and contraindications for giving Beta Blockers. Recognise a Mobitz II heart block rhythm.
Over the path of the paper, a definition of Mobitz II heart block will be given a long with what can happen to the rhythm if beta blocker medications are taken at the same time and its treatment. The intensive care unit involved is 12 beds in a private hospital that predominately does heart surgery including coronary artery bypass grafts, valve replacements and repairs, craniotomies and some high dependency beds. All research articles on both Mobitz II heart block and Metoprolol advise that people shouldn’t be given beta blockers if they are have any block further than first degree heart block.
S.G. Webb (personal communication, September 17, 2009) notes that there is not many studies and journal articles done with regards to giving Metoprolol to patients in Mobitz II heart block as it should not be happening. Mr Webb is an Intensivist in two leading Perth hospitals and stated that he can recall three incidences where a beta blocker was given to a heart block patient causing complete heart block.
Introduction to topic
Mr Cecil Jones, a 74-year-old male, was admitted to the intensive care unit for the purpose of a coronary angiogram, echocardiogram and possible cardiac bypass. Five days previously, Cecil had presented to an emergency department with complaints of shortness of breath on exertion, pneunoperiteum (PNO) and orthopnea. After being treated at the previous hospital for acute pulmonary odema (APO), secondary to a Non-Stemi with a Troponin level of 0.88l/min and was treated accordingly with Frusemide and continuous positive airway pressure (CPAP). He has no previous history of cardiac arrhythmias but he does have a history of hypertension, hypercholesterolemia and non-insulin dependant diabetes. Current medications are:
Irbersatin 150mg mane’
Glicazide 80mg mane’
Asprin 100mg mane’
Atorvastatin 20mg nocte’
Atenolol 25mg mane’
Amlodipine 10mg mane’
Upon admission, post angiogram, Mr Jones was had ST-T depress changes in leads II, III and AVF. His lungs are clear to auscultation and denies any pain or discomfort. The 12-lead ECG shows sinus rhythm, rate 86 without ectopy.
Cecil was treated for three days at a large hospital and then transferred to a smaller private hospital for a coronary angiogram and echocardiogram. The angiogram showed:
Left Main Coronary Artery (LMA): 25% distally occluded.
Left Anterior Descending Artery (LAD): Occluded at proximal end. Diagonal branch (DI): 60% occluded at distal end.
Right Coronary Artery (RCA): 75% occluded.
Left Ventricle (LV): Moderate impaired systolic function.
It was also revealed that Cecil had an ejection fraction (EF) of 45% on the echocardiogram.
After speaking with the cardiologist’s Cecil was booked in to have Coronary Artery bypass grafts (CABG) x 2. On return to the unit after the operation, Cecil had CABG to the LAD and RCA using the right and left saphenous veins. As with all CABG patients at my hospital, Cecil was ventilated on SIMV mode with Peep 5 and Pressure Support 10, had two chest drains, a swan ganz catheter, central venous catheter, arterial line, atrial and ventricular pacing wires and an indwelling catheter. After eight hours, the endotracheal tube was removed and Cecil’s decreased need for oxygen therapy had him requiring only 2L/min of oxygen. All patients’ medications are usually ceased for the first 24hrs and replaced with transfusions of any of the following; Glyceryl Trinitrate
All infusions are gradually weaned with the patient has adequate fluid volume and is peripherally and cardiovascularly stable. Mr Jones...
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