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Management Any clear cause of bradycardia or complication of the collapse should be treated on its merits. However, if the diagnosis is simply ‘heart block’ with no obvious precipitant that can be removed, then management should depend on the state of the patient: If the patient is well Some patients can tolerate complete heart block at a pulse rate of 30 bpm if their left ventricular function is good. They may be fully conscious MMC Core Curriculum 29 AM_C01 12/15/10 10:16 Page 30 ACUTE MEDICINE: PACES STATIONS AND ACUTE SCENARIOS with a normal BP and warm peripheries.

Does she look dead or nearly dead? Get help quickly. • Does she appear agitated or exhausted? Get help quickly. • Can she speak in full sentences, only in words or is she unable to speak? If only in words or unable to speak, get help quickly. • Is she cyanosed? If she is, she is nearly dead. Respiratory rate must be interpreted in the context of the whole patient: a normal respiratory rate is consistent with imminent death in the asthmatic who is becoming exhausted. Widespread wheezing indicates airways obstruction, but beware the asthmatic who has a silent chest on auscultation: the tidal volume may be reduced so much that insufficient flow is being generated to create a wheeze.

Was she fully clothed when found, and what was the ambient temperature of her surroundings? If she spent the night on the floor, then it means that following the collapse she was not able to mobilise sufficiently to call for help or return to bed, which may What medication is she on and have any drugs been started recently? Enquire specifically about antihypertensives (especially betablockers), but also hypoglycaemic agents, analgesics, sedatives and antiparkinsonian medications, all of which can cause confusion and/or disturbance of consciousness.

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