What is the immediate management for an elderly female patient who collapses after a sudden bout of weakness, exhibits left-sided weakness that resolves in 1-2 minutes, is diaphoretic, vomiting, and has bradycardia?

Immediate Management of Elderly Female with Transient Left-Sided Weakness, Collapse, and Symptomatic Bradycardia

This patient requires immediate ABCDE assessment with priority focus on airway protection (given vomiting), cardiac monitoring, and urgent atropine administration for symptomatic bradycardia, while simultaneously evaluating for stroke versus cardiac causes of her presentation. 1, 2, 3

Initial Assessment and Stabilization

Airway and Breathing

• Immediately assess and secure the airway given active vomiting and risk of aspiration, positioning the patient to protect airway patency 1, 3, 4
• Check for adequate breathing and oxygenation; provide supplemental oxygen and prepare for advanced airway management if consciousness deteriorates 1, 3
• The vomiting combined with diaphoresis suggests significant autonomic instability requiring close monitoring 2

Circulation - Bradycardia Management

• Administer atropine 0.5-1 mg IV immediately for symptomatic bradycardia (HR 45) with hemodynamic compromise (collapse, diaphoresis, vomiting) 2, 5
• Repeat atropine every 3-5 minutes as needed, up to maximum total dose of 3 mg 2, 5
• Establish IV access and initiate continuous cardiac monitoring with 12-lead ECG 1, 2, 3
• If bradycardia persists despite atropine, prepare for transcutaneous pacing and consider IV infusion of rate-accelerating agents (dopamine or epinephrine) 2

Critical Differential Diagnosis Considerations

This presentation suggests two possible life-threatening scenarios:

Posterior Circulation Stroke with Cardiac Involvement

• The transient left-sided weakness (1-2 minutes) represents either a TIA or resolving stroke 4
• Bradycardia, vomiting, and diaphoresis may indicate brainstem involvement affecting cardiovascular centers 2
• Posterior circulation strokes can cause autonomic dysfunction with bradycardia 4

Primary Cardiac Event with Cerebral Hypoperfusion

• Symptomatic bradycardia causing collapse and transient focal neurological symptoms from hypoperfusion 2
• The "weakness" may represent hypoperfusion rather than true stroke 1
• Consider complete heart block, sick sinus syndrome, or medication-induced bradycardia 2, 5

Immediate Diagnostic Workup

• Obtain 12-lead ECG immediately to evaluate for heart block, ischemia, or other cardiac abnormalities causing bradycardia 2
• Check blood glucose, electrolytes (particularly potassium), and cardiac biomarkers 6
• Urgent CT head to rule out intracranial hemorrhage or acute stroke once hemodynamically stable 4
• Review medications for QT-prolonging drugs, beta-blockers, calcium channel blockers, or other bradycardia-inducing agents 1, 5

Ongoing Management

If Patient Deteriorates to Cardiac Arrest

• Begin high-quality CPR immediately with chest compressions at 100-120/minute, depth 5-6 cm 1, 3
• Check rhythm every 2 minutes 1, 3
• For asystole or PEA: administer epinephrine 1 mg IV every 3-5 minutes while searching for reversible causes 1, 6, 3
• For VF/VT: deliver immediate defibrillation and resume CPR 1, 3

Search for Reversible Causes ("5 H's and 4 T's")

Particularly relevant in this elderly patient: 1, 6

• Hypokalemia (can cause both bradycardia and neurological symptoms) 1
• Hydrogen ion (acidosis) from prolonged hypoperfusion 1
• Toxins/medications (beta-blockers, calcium channel blockers, digoxin) 1, 5
• Thrombosis (coronary or pulmonary) 1, 6
• Hypothermia in elderly patients 1

Special Considerations in Elderly Patients

• Atropine elimination half-life is more than doubled in elderly patients (>65 years), requiring careful monitoring for both therapeutic effect and potential toxicity 5
• Elderly patients are at higher risk for QT prolongation with multiple medications, which can precipitate cardiac arrest 1
• The combination of cardiovascular disease, age, and female sex increases risk for both cardiac and cerebrovascular events 1

Critical Pitfalls to Avoid

• Do not delay atropine administration while obtaining diagnostic studies in symptomatic bradycardia with hemodynamic compromise 2, 5
• Do not assume the neurological symptoms are purely cardiac - this patient needs stroke evaluation once stabilized 4
• Do not overlook medication review - polypharmacy in elderly patients frequently causes bradycardia and other complications 1, 5
• If CPR becomes necessary, ensure complete chest recoil between compressions and minimize interruptions, as incomplete recoil prevents cardiac refilling 3