20-something with huge verapamil overdose and cardiogenic shock

A 20-something presented after a huge verapamil overdose in cardiogenic shock.  He had been seen at an outside institution and been given 6 g calcium gluconate, KCl, and a norepinephrine drip.The initial K was 3.0 mEq/L and ionized calcium was 5.5 mg/dL (sorry, Europeans, for the weird units)Here was the initial ED ECG:There is a junctional rhythm with retrograde P-waves (see the dip in the T-wave in lead II across the bottom; you can follow that up to all the other leads and see the retrograde P wave).  There is also Left Bundle Branch Block (LBBB). There is huge proportionally excessively discordant ST Elevation.  There is what appears to be a hyperacute T-wave in V4. This meets the Smith Modified Sgarbossa criteria,but the situation is wrong for diagnosing OMI!!By the way, thePM Cardio Bot Queen of Hearts says this is Not OMI with High Confidence.  And she does not know that this is an overdose; she thinks it is a patient with chest pain!!Case Continued:He was stabilized on more calcium, pressors, and high dose insulin.  3 hours later, this was recorded at a K of 2.8 mEq/L and total calcium of 14.7 mg/dL:The massive ST Elevation persists.He was admitted to the ICU and was unstable, in shock, overnight.  He had this ECG recorded at 8 hours:Now the ST Elevation is nearly goneAnother was recorded at 19 hours:The ST Elevation is back!!  What is going on here?Case continuedThe patient has vasoplegia and was treated wit...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs