You are the medical senior house officer on call in a busy tertiary hospital. It is 2am and you get called to see a 75-year-old gentleman on the coronary care unit (CCU). The nursing staff tell you that 2 days ago he underwent percutaneous coronary intervention with 2 drug eluting stents to his right coronary artery. He was admitted to CCU for monitoring following the procedure as he had had an earlier episode of ventricular tachycardia. You review his admission ECG which shows ST segment elevation in leads II, III and aVF.
Currently he is alert with no chest pain and is comfortable at rest. However, his cardiac monitor shows that his observations are: heart rate 28/min, blood pressure 83/65mmHg, respiratory rate of 18/min with oxygen saturations 94% on 1L via nasal cannulae.
Both his ECG, which was done shortly before you arrived, and the tracing on the cardiac monitor show no association between the P and QRS waves. His QRS breadth on ECG is 120ms.
Which of the following is the most appropriate management plan?
1 A trial of atropine and isoprenaline with a view to permanent pacing if sinus rhythm has not been restored by day 5
2 Immediate pacing with a temporary wire until permanent pacing can be put in place
3 A trial of atropine and isoprenaline
Continue monitoring only as he is asymptomatic
4 Immediate pacing with a temporary pacing wire that can then be removed/discontinues if the patient stabilises
5 Immediate pacing with a temporary pacing wire that can then be removed/discontinues if the patient stabilises