#002 Curveball Case Study - Unrelenting bradycardia

FY2 twilight shift in A&E Majors

36F BIBA following long lie

Family called ambulance to patient's home as they were concerned she was not answering the phone or the door. Paramedics arrived at scene to find patient in underwear on the floor by the stairs. Patient reports she fell 3 days ago and hadn't been able to get up to call for help.

Bariatric patient with mobility issues, learning difficulties and anxiety. History of self-neglect following loss of parents. Currently living alone.

Sertraline

NKDA

A – Patent

B – Sats 97% on 10L, B/L expansion and air entry. Shallow breathing.

C – HR 41, BP 97/52, HS I+II+0, JVP down, CRT 3s, cold to touch centrally

D – GCS 8 E3, V2, M5. PEARL

E – Temp 29.7C. Abdo SNT. Bruising to chest and superficial abrasions consistent with mechanism of fall

Bloods – WCC 11, Hb 115, Urea 19.5, Creatinine 220, Creatine kinase 2450

ECG – sinus bradycardia with Osborn wave (J wave)

credit: LITFL ECG Library

Patient was treated for hypothermia with a Bair Hugger but despite body temperature steadily rising, she remained bradycardic. Continuous body temperature monitoring showed 34.7C. Atropine 1mg IV was given and heart rate was responsive, increasing from 41bpm to 56bpm but eventually returning to ~44bpm within 30 minutes. Half life of atropine is 2-5 hours so you would expect the effects to be sustained for longer.

Patient reassessed. Adequate exposure showed body temperature probe on her chest was producing spurious results as it was sandwiched between the patient's skin surface and the Bair Hugger. Warm air from the Bair Hugger was making it appear that the hypothermia was resolving when patient was still not warmed up. The bradycardia was refractory to continued state of hypothermia and physiologically would not be fixed by atropine.

Learning point – beware of validity of readings when using equipment. If things aren't headed in the direction you'd expect, always reassess and make sure to be thorough.

This is one of many stories with pesky temperature probes. Here's a bonus one for you.

Over summer a few years ago, one hospital at a seaside town threw out all of their tympanic/ear probe thermometers and replaced them with infrared thermometers which scan a patients’ forehead. The FY1 on call over the sunny weekend kept getting bleeped about newly pyrexic patients. It turned out that these patients tended to be sat next to a window with the sun on their face. When scanned on a different part of their forehead, their temperature mysteriously returned to normal.