eMedicine Specialties > Emergency Medicine > Cardiovascular

Heart Block, Third Degree: Follow-up

Author: Michael D Levine, MD, Physician, Department of Medical Toxicology, Banner Good Samaritan Medical Center
Coauthor(s): David FM Brown, MD, Assistant Professor, Department of Medicine, Division of Emergency Medicine, Harvard Medical School; Associate-Chief, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital
Contributor Information and Disclosures

Updated: Apr 13, 2009

Follow-up

Further Inpatient Care

  • The admitting cardiologist will determine the need for and timing of permanent pacemaker implantation.
  • All patients with third-degree heart block need to be admitted to either a telemetry floor (if hemodynamically stable and transcutaneous pacing achieves capture) or an intensive care unit. The decision on telemetry versus intensive care should be made in conjunction with the cardiologist.
  • Any patient who is hemodynamically unstable, has persistent complete heart block, has electrolyte abnormalities, or who is in complete heart block as a result of an overdose or myocardial infarction should be admitted to the intensive care unit.

Transfer

  • Patients may be transferred to a higher level of care if the hospital does not have intensive care capabilities or if appropriate consultation services (eg, cardiology) are not available.

Deterrence/Prevention

  • Patients with renal insufficiency or failure, dehydration, and certain electrolyte disturbances are predisposed to develop digoxin toxicity. Careful monitoring of electrolytes, drug levels, and renal function is essential in patients on chronic digoxin therapy.
  • Patients on multiple nodal agents (eg, beta-blockers and calcium channel blockers) are at an increased risk to develop complete heart block; the more nodal blockade that occurs, the higher the chance of developing complete heart block.

Complications

  • Complications from complete heart block include cardiovascular collapse and death.
  • Ventricular arrhythmias from atropine or catecholamines may occur.
  • Common complications include those related to line and/or transvenous pacemaker placement. These complications include arterial injury, hemothorax, pneumothorax, or cardiac tamponade.

Patient Education

  • Patients should be educated about possible drug interactions when starting any new medication.
  • Patients who are on digoxin should be educated about possible early symptoms of digoxin toxicity.

Miscellaneous

Medicolegal Pitfalls

  • Failure to initiate temporary transcutaneous or transvenous pacing in a timely fashion
  • Failure to interpret cardiac dysrhythmia correctly. This includes recognizing that "regularized" atrial fibrillation is complete heart block until proven otherwise.
  • Failure to diagnose and treat underlying etiology of the third-degree block
  • Failure to ensure the patient is admitted to an appropriate level of care
  • Failure to seek, identify, or treat reversible causes of third-degree AV block, such as hyperkalemia or digoxin toxicity
 


More on Heart Block, Third Degree

Overview: Heart Block, Third Degree
Differential Diagnoses & Workup: Heart Block, Third Degree
Treatment & Medication: Heart Block, Third Degree
Follow-up: Heart Block, Third Degree
Multimedia: Heart Block, Third Degree
References
Further Reading
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References

  1. Narula OS, Scherlag BJ, Javier RP, Hildner FJ, Samet P. Analysis of the A-V conduction defect in complete heart block utilizing His bundle electrograms. Circulation. Mar 1970;41(3):437-48. [Medline].

  2. Rosen KM, Dhingra RC, Loeb HS, Rahimtoola SH. Chronic heart block in adults. Clinical and electrophysiological observations. Arch Intern Med. May 1973;131(5):663-72. [Medline].

  3. Costedoat-Chalumeau N, Georgin-Lavialle S, Amoura Z, Piette JC. Anti-SSA/Ro and anti-SSB/La antibody-mediated congenital heart block. Lupus. 2005;14(9):660-4. [Medline].

  4. Bestetti RB, Cury PM, Theodoropoulos TA, Villafanha D. Trypanosoma cruzi myocardial infection reactivation presenting as complete atrioventricular block in a Chagas' heart transplant recipient. Cardiovasc Pathol. Nov-Dec 2004;13(6):323-6. [Medline].

  5. Epstein AE, DiMarco JP, Ellenbogen KA, Estes NA 3rd, Freedman RA, Gettes LS, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol. May 27 2008;51(21):e1-62. [Medline].

  6. American Heart Association. Guidelines for cardiopulmonary resuscitation and emergency cardiac care. Emergency Cardiac Care Committee and Subcommittees, American Heart Association. Part III. Adult advanced cardiac life support. JAMA. Oct 28 1992;268(16):2199-241. [Medline].

  7. International Laison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 4: Advanced life support. Resuscitation. Nov-Dec 2005;67(2-3):213-47. [Medline].

  8. Syverud S. Cardiac pacing. Emerg Med Clin North Am. May 1988;6(2):197-215. [Medline].

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Further Reading

Clinical guidelines

Adult basic life support: 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations.Adult basic life support. In: 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation 2005 Nov 29;112(22 Suppl):III5-16.

Advanced life support: 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Advanced life support. In: 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation 2005 Nov 29;112(22 Suppl):III25-54.

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Keywords

heart block, third-degree heart block, atrioventricular block, AV block, third-degree atrioventricular block, third-degree AV block, complete heart block, AV node, cardiac conduction system, AV dissociation, atrioventricular dissociation, His bundle

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Contributor Information and Disclosures

Author

Michael D Levine, MD, Physician, Department of Medical Toxicology, Banner Good Samaritan Medical Center
Michael D Levine, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, Emergency Medicine Residents Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

David FM Brown, MD, Assistant Professor, Department of Medicine, Division of Emergency Medicine, Harvard Medical School; Associate-Chief, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Schering  Honoraria Speaking and teaching

Medical Editor

Theodore J Gaeta, DO, MPH, FACEP, Clinical Associate Professor, Department of Emergency Medicine, Joan and Sanford Weill Medical College at Cornell University; Vice Chairman and Program Director of Emergency Medicine Residency Program, Department of Emergency Medicine, New York Methodist Hospital; Academic Chair, Adjunct Professor, Department of Emergency Medicine, St George's University School of Medicine
Theodore J Gaeta, DO, MPH, FACEP is a member of the following medical societies: Alliance for Clinical Education, American College of Emergency Physicians, Clerkship Directors in Emergency Medicine, Council of Emergency Medicine Residency Directors, New York Academy of Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eddy Lang, MDCM, CCFP (EM), CSPQ, Assistant Professor, Department of Family Medicine, McGill University; Consulting Staff, Department of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Eddy Lang, MDCM, CCFP (EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD, Assistant Professor, Department of Medicine, Division of Emergency Medicine, Harvard Medical School; Associate-Chief, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Schering  Honoraria Speaking and teaching

 
 
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