An elderly woman found down with bradycardia and hypotension

Submitted by Alex Bracey, with edits by Pendell Meyers and Steve SmithA female in her 70s with PMH of hypertension, coronary artery disease, and a remote history of an aortic valve replacement was brought into the ED after being found down by her son. On arrival she was confused. Her initial ECG isshownbelow.What do you think? - Sinus bradycardia with HR of ~50 BPM (plus artifact that mimics PVCs) - Peaked T waves particularly visible in leadsV1-V3, I, and aVL - RBBB with QRS duration 152 ms (comparison to prior shows similar RBBB morphology but with QRS duration of 116 ms)In addition to being bradycardic as seen on this ECG, she was also hypotensive, with systolic blood pressures maintaining around 60 mmHg.At this point let ’s review the most common causes of bradycardia and hypotension:Drugs: AV nodal blockers, Calcium channel blockersIschemia: usually RCA occlusion leading to bradycardia via sinusbradycardia or AV blocksElectrolytes:HyperkalemiaWith this patient ’s history of CAD and HTN it may be inferred that the patient is likely on an AV nodal blocking agent (i.e., calcium channel blockers (CCB) or beta-blockers (BB)). A review of this patient’s chart indeed confirmed that this patient had been prescribed metoprolol succinate (extended release).Based on the ECG it is likely that you have already surmised the other underlying pathology: hyperkalemia (as demonstrated by bradycardia, peaked T waves and widened QRS).The astute ED physician and resident correctly iden...

Source: Dr. Smith's ECG Blog - June 6, 2018 Category: Cardiology Authors: Pendell Source Type: blogs