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

supply & demand…

Case:

74 year old female is placed in the acute-area of our ED with a complaint of retrosternal chest tightness at approximately 9am. Her symptoms sound very typical for ACS. She looks clammy and pale.

My colleague has placed her on telemetry, high flow oxygen and has prescribed 300mg aspirin &  600mcg sublingual anginine.

I am handed her ECG, which shows a sinus tachycardia and evidence of left ventricular hypertrophy with a repolarisation pattern. Of concern is the associated anterior ST depression, so I make my way to the bedside….

…as I approach her bed I witness her telemetry deteriorate from a sinus tachycardia to ventricular fibrillation !!

There is a defibrillator 15 metres away, across the department. The following takes place…

  • Precordial thump (by me. did nothing except hurt my hand).
  • Immediate CPR until defib pads placed.
  • 200J shock
  • 2 further minutes of CPR with 1mg IV adrenaline.
  • 3 minutes post arrest she has return of spontaneous circulation.

Cardiology are notified of this and want her in their Cath-lab immediately….

Continue reading