What is the appropriate management of nausea and vomiting in a patient with third-degree atrioventricular block?

Management of Nausea and Vomiting in Third-Degree (Complete) Heart Block

The priority in managing nausea and vomiting in a patient with third-degree AV block is to address the underlying life-threatening bradyarrhythmia with immediate pacing, not to treat the nausea symptomatically, as these symptoms likely reflect hemodynamic compromise from the complete heart block itself. 1

Critical First Step: Recognize This as a Cardiovascular Emergency

Third-degree AV block is a cardiovascular emergency requiring immediate assessment of hemodynamic stability and preparation for pacing. 1, 2 The nausea and vomiting are likely manifestations of poor cardiac output and cerebral hypoperfusion from the bradycardia, not a primary gastrointestinal problem. 1

Immediate Actions Required:

• Rapidly assess for signs of hemodynamic instability including altered mental status, hypotension, chest pain, dyspnea, or syncope. 1
• Obtain a 12-lead ECG immediately to assess QRS width, as this determines the location of block and prognosis—wide QRS (>120 ms) indicates infranodal block with high mortality risk that will not respond to atropine. 1
• Initiate transcutaneous pacing (TCP) immediately if the patient is symptomatic or hemodynamically unstable, as this is the preferred initial intervention. 1

Why Atropine Should Be Avoided

Atropine is contraindicated or should be used with extreme caution in third-degree AV block, particularly with wide QRS complexes. 3, 1 The 1990 ACC/AHA guidelines explicitly classify atropine as Class III (contraindicated) for AV block at the His-Purkinje level (type II AV block and third-degree AV block with new wide QRS complex). 3

Key Problems with Atropine in Complete Heart Block:

• Atropine is ineffective for infranodal blocks and may paradoxically worsen the block by increasing the sinus rate while the ventricles cannot keep up. 3, 1
• Atropine should not delay definitive pacing in hemodynamically unstable patients. 1
• If attempted while preparing for pacing, use only 0.5 mg IV every 3-5 minutes (maximum 3 mg total), but recognize this is temporizing at best. 1

The Exception: Morphine-Related Nausea in Acute MI Context

The only scenario where atropine is appropriate for nausea/vomiting in the context of AV block is Class I indication: nausea and vomiting associated with morphine administration in acute myocardial infarction. 3 This is specifically for morphine's vagotonic side effects, not for treating nausea from the heart block itself.

Definitive Management Algorithm

Step 1: Stabilize the Bradyarrhythmia

• Initiate transcutaneous pacing immediately for symptomatic patients. 1
• Arrange for transvenous pacemaker placement as a bridge to permanent pacing. 2

Step 2: Permanent Pacemaker Implantation

• Permanent pacemaker implantation is a Class I indication for third-degree AV block not attributable to reversible causes. 1, 4
• Rule out reversible causes before permanent pacing: electrolyte abnormalities, drug toxicity (beta-blockers, calcium channel blockers, digoxin), Lyme disease, acute MI with expected resolution. 4, 5

Step 3: Address Nausea Only After Hemodynamic Stability

Once pacing is established and hemodynamics improve, if nausea persists, consider:

• 5-HT3 receptor antagonists (ondansetron 4-8 mg or granisetron 1 mg) are safe antiemetics that do not affect cardiac conduction. 3
• Avoid phenothiazines (prochlorperazine) and metoclopramide until cardiac stability is confirmed, as these can have cardiovascular effects. 3

Critical Pitfalls to Avoid

• Do not treat nausea symptomatically without addressing the underlying complete heart block—this delays life-saving treatment. 1
• Do not rely on atropine as primary therapy, especially with wide QRS, as this is ineffective and delays definitive treatment. 1
• Do not assume nausea is gastrointestinal in origin—in the context of complete heart block, it likely represents hemodynamic compromise requiring urgent pacing. 1
• Do not delay transcutaneous pacing for pharmacologic trials in hemodynamically unstable patients. 1

Special Consideration: Vomiting-Induced Heart Block

While rare, vomiting itself can trigger paroxysmal AV block through a vagovagal reflex from upper esophageal distension. 6 However, in a patient presenting with established third-degree AV block and nausea/vomiting, the block is the primary problem requiring immediate pacing, not the vomiting.

Prognosis and Disposition

• All patients with third-degree AV block require admission to intensive care with continuous cardiac monitoring and cardiology consultation. 2
• Without treatment, ventricular escape rhythms can fail, leading to asystole and cardiac arrest. 2
• Permanent pacemaker implantation provides definitive treatment and excellent long-term prognosis. 4