Welcome to the Emergency Medicine Cases podcast. I'm your host, Dr. Anton Hellman, bringing you Canada's brightest minds in emergency medicine from EMC studios in Toronto.

EM cases is part of Shremi, the Schwartz-Riseman Emergency Medicine Institute. That's the nonprofit organization dedicated to improving EM care through high

quality research and education. The opinions expressed on this podcast are intended for general information and educational purposes only and should not be used to diagnose treat or prevent any medical condition, nor should they be used as a substitute for medical advice from a qualified practicing physician. Unless stated otherwise, the opinions expressed by the hosts or guests are made in their individual capacity, not on behalf of the Institute nor medicine cases. In the first part of this podcast, we mainly talked about our general approach to

bradycardia, sorting out the differential, and sorting out the ECG.

Now it's time to move on to the nitty gritty of treatment of the various brady dysrhythmias.

And I'd like to start off with a case.

EMS rolls in with a 60-year-old gentleman who they say has a history of diabetes and hypertension,

who had a crescendo onset of crushing central chest pain radiating into the right shoulder

associated with shortness of breath and diaphoresis one hour prior.

They hand you an ECG, which shows a classic inferior stem-y pattern.

They told you that his vitals were stable when they arrived at his house, and they gave him one

spray of sublingual nitro and ASA to chew. He's hooked up to your monitors in your recess

bay. His heart rate is 37 in a junctional bradicardia.

BP is 90 on 60.

He's alert, and he tells you pretty much the same story that EMS told you, but now he feels

very dizzy.

And he asks you, am I going to die? So, Dr. Dorian, how would this case be

handled in the ideal situation? So here's what I would be thinking. Obviously, why is the patient

this bradacardic? There's two possible reasons, which may be coexisting. Three, actually. One is that the most

likely thing is the patient has an inferior or posterior while myocardial infarction, often with right ventricular

involvement. So the bradacardiardia by itself is a consequence sometimes of the mycardial infarction itself,

which can involve the avidotal artery. Typically, this is inferior or posterior MI. And this can cause

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