I’m not that great with mnemonics.
I can never remember all the terms involved, often I screw up the mnemonic itself, and I’m always scared that I’m going to substitute something that isn’t actually part of the differential. It’s as though one day I’m going to debate with myself whether hyperthyroidism falls under “H-for-hyper” or “T-for-thyroid” while reviewing the H’s-and-T’s during a cardiac arrest and miss the patient’s tamponade.
Still, there’s one mnemonic that I live and die by, and that is the DIE acronym for bradycardia.
[D]rugs
[I]schemia
[E]lectrolytes
I stole this differential from the great Mel Herbert and a talk he gives on dysrhythmias. Here’s the bradycardia section of his lecture, posted on the EMRAP-TV website. I initially created this acronym for his differential assuming that it had been documented before, but after a cursory Google search I don’t see anyone else using it, so maybe I’m the first to give it a chance for widespread dissemination. Go-figure.
Now this is far from a comprehensive list of the causes of bradycardia. On the ValueMD site they have an 16-item acronym for the differential of sinus bradycardia alone, which just so happens to spell-out SINUS BRADYCARDIA. Instead, DIE just covers the major reversible players that I am most likely to miss if I don’t force myself to ask, “Could this bradycardia be from drug-effects, ischemia, or an abnormal electrolyte level?”
ECG of a patient with a sotalol overdose, courtesy of Life in the Fast Lane. Click image for source.
I’ve lost count of the number of ECG’s where this simple acronym has saved me from missing the major treatment-changing cause. Usually it’s because I failed to consider effects B-blockers, Ca-channel Blockers, or digoxin. Whether it’s due to an acute overdose, slightly supra-therapeutic levels, or other drug interaction that results in a symptomatic or worrisome bradycardia, all of those causes fall under the heading of “drug-effect.” Still, there’s also a fair share of hyperkalemic and ischemic cases I attempted to overlook as well, so I still walk through all three steps for every patient I see with a slow pulse.
This patient’s K+ was 6.9 mmol/L. Click to enlarge.
In terms of its saves-to-size ratio, this acronym offers the most bang-for-your-buck of any mnemonic I’ve come across. Plus it’s incredibly easy to remember and piece-together.
Enjoy, and let me know how it works for you. I’ve often considered adding hypothermia and changing it to HIDE, but then it loses a lot of the impact factor you get from the word DIE.
edit: Also check out Dr. Ken Grauer’s excellent commentary below. A few minor changes were made to the post as a result, but there’s far more to his insight than the simple rewording I implemented.
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