Oh yes that is a very good question indeed James Yates or sorry the people that contributed to that. You didn't come up with the question you didn't come up with the question. And also I think that last comment from Glenn brings us on brilliantly to our very next question.

So what about atropine in third degree AV blocks and I think this came from Tom and Kristin it? Yeah certainly did and I think before I answer that question it's just worth clarifying again something that Simon said earlier on because I didn't do it well enough. Well you know it's always worth going over just in case. So third degree heart blocks can be associated with narrow QRS complexes and that means that the rhythm is arising from that junctional area albeit probably really low down and in the bundle of hits but it's still junctional. So I guess what we're thinking about here is those third degree blocks with broad QRS complexes where the pacemaker origin is within the ventricles. So I would love to sprout loads of knowledgeable stuff about this but I think probably worth passing over to Glenn again and he says that complete heart block in the context of an MI is usually structural and the AV node just needs the blood supply starting up again to restart conduction. Now atropine will increase the sinus rate but it's going to have very little impact on the ventricular escape rate that we're seeing with that broad QRS complex. So in this context Glenn says that he would probably choose in hospital and isoprenaline infusion and in the pre-hospital setting probably our best approach would be with small doses of post-rosk style adrenaline but actually realistically sedation and external pacing is most likely to be required and the sort of the definitive approach to the shocked post-infarct complete heart block patient. So that doesn't really help ambulance crews I guess who might be limited in their scope to step outside of trust guidance and use that adrenaline. So I just wonder if there's anything else we could offer to these patients who are refractory to atropine. And on that there was one final question that I posed to Glenn from Luke Barker and he was asking about fluid use in bradycardia and I guess that makes a lot of sense. What he's thinking here I assume is that rather than increasing the heart rate to improve the cardiac output we could increase the stroke volume instead. I mean that seems like a pretty sensible suggestion so I did some reading around on this but I couldn't find anything to support this practice. So thankfully Glenn again was on hand to give very insightful commentary and actually his feeling was that it probably wouldn't confer any benefit either. So it seems like fluid in bradycardia isn't

something

that we should be reaching for. Excellent well that slowly brings us to the end of our bradycardic episode. So as a recap we've been through the electrical conduction pathways yet again and then we've had a think about the different causes that actually exist with patients that were going to see bradycardia into those cardiac and extra cardiac causes and we really need to bear those in mind. We've had to think about those presentations and it is really key to do a good clinical assessment of our patients to really gain an understanding of whether or not they are compromised. We've then had to think about the different drugs that we might use, had a big think about atropine, the other alternatives that exist out there, thought about our stepwise approach to the compromised patient and thought about those features that might put patients at risk of degrading into OCCI and that we really even when we've got them out of compromise need to be considering them and a big thanks to Glenn for his help on some of those tricky questions too. So that's it for this episode. A big thanks once again to SGA trim for supporting the podcast and making us all free and open access and available to you. If you like this sort of thing go and check out our sedation and cardiac arrest master class that are both available on the website and we will be soon to bring you a new master class that's going to be looking at RSI and RSI assist. So that's it from us. Take care of yourselves and

we will speak to you soon.