off the pace…

the case.

An 80 year old male is bought to your ED via ambulance following a syncopal episode. He reports sitting on a church pew, when he apparently collapsed without prior warning. According to bystanders he was unresponsive on the ground looking pale then ‘blue’. He was making some respiratory effort and eventually recovered without intervention.

By the time you examine him, he is alert and oriented (though, amnestic to the actual event). His pulse is 60, he is warm and perfused (with a BP of 138/66). There is no evidence of cardiac failure and his neurological exam is unremarkable. You do note a pacemaker box in his upper left chest and his CXR shows that this is a ‘dual-lead’ variety….

This is his ECG.

Syncope in Church

What’s going on here ?
How do you explain his syncope ??
What needs to happen now ??? Continue reading


The Case.

A 38 year old male presents to your ED with left sided chest heaviness which radiates to his left shoulder & down the arm. He has associated dyspnoea, nausea & vomiting. He looks unwell.

He underwent a CT-Coronary Angiogram 4 months earlier showing a Calcium-Score of 450 !! (‘Extensive plaque burden’. 8x increase in Framingham predicted risk). However, a Sestamibi study performed at the same time showed no evidence of inducible ischaemia.

This is his ECG…

38yo ECG01

What’s your interpretation ?
Is it significant ??
Where do you go from here ???

Continue reading

another ECG case…

The Case.

I was superficially involved in this case of a 32 year old suicidal patient who ingested two full packets of Solian (amisulpride) (~ 24 grams) approximately 90 minutes prior to arrival to ED.

On initial assessment he was GCS 12/15 & had a systolic BP of 115 mmHg.

This is his ECG….

Continue reading

generally unwell (part 2)…

For those joining the story for the first time, you can catch up here….

My interpretation of the ECG;

Sinus rhythm with 1st degree HB, an ‘odd’ axis. Wide complex QRS (~140-160ms) with symmetrical tall T-waves.
? Hyperkalaemia. Needs urgent bloods….

The nurse returns…

No one can place an IV or take bloods from her. So off you go, USS in tow to the bedside.

IV placed; bloods taken; urgent VBG to the iStat…..

Continue reading

more than man-flu (part2)…

Here is the follow-up to the story of our 19 year old febrile patient…..

The case continues…

His CXR demonstrates the following ….

  • Clear lung fields
    • No pneumonia
    • No CCF
  • is that a ‘globular heart’  ??
  • This is his ECG…

    Sinus tachycardia. Non-specific T-wave changes, but no ST-segment changes.

    My thoughts at this stage were;

    • 19 year olds should be able to stand on their own
    • Constitutional symptoms… ?viral illness
    • I cannot exclude concomitant sepsis –> so treated with empiric ABx / fluids
    • Globular heart silhouette

     ** Is this myocarditis ?? **

    Continue reading

    broad, fast & regular…

    There are some things in medicine that I feel require a standardized approach for rapid diagnosis & management, especially in the face of an unstable patient & you have a little sweat on your brow. The following are two somewhat straight forward cases that got me thinking …

    Case 1

    66 year old self presents to ED following 4 hours of palpitations. She has had no chest pain, dyspnoea or pre-syncope. She has had this before.

    HR 170. BP 128 systolic. Speaking full sentences with a clear chest. Sats 98%.

    This is her ECG…


    Case 2: 

    84 year old transferred to ED from the dialysis suite with 30mins of palpitations that commenced towards the end of his haemodialysis. He has no chest pain, dyspnoea or pre-syncope. He has had this before.

    HR 160. BP 118 systolic. Speaking in phrases but clear chest. He looks grey & slightly clammy.

    This is his ECG…


    … both are broad, fast & regular leading me to investigate “Ventricular Tachycardia vs SVT with Aberrancy”

    Continue reading