What will you do for this altered and bradycardic patient?

Written by Pendell MeyersA female in her 60s with COPD, DM, hypothyroidism, CAD, and severe bladder cancer presented from a nursing home with altered mental status, hypotension, hypoxia, and bradycardia.Here is her initial ECG (no prior for comparison):What do you think?Here is another ECG minutes later:There is a regular wide complex bradycardia.There are P-waves at a rate of approximately 100bpm with no clear relationship to the QRS complexes, diagnostic of complete heart block.The QRS morphology is wide (computer QRS duration 179 msec) but it does not fit any clear bundle branch block pattern (it is similar to LBBB but not truly LBBB).The T-waves in the precordial leads are peaked. Overall this is highly concerning, if not diagnostic, for hyperkalemia.Third degree heart block was recognized, but hyperkalemia was not initially. She was given push dose epinephrine and atropine with no change. External pacing was attempted but failed.A transvenous pacemaker was then placed, with capture obtained:Ventricular paced rhythm. Computerized QRS duration 192ms, but it appears to be ~200 msec in several leads. It is unusual for any patient with any conduction pattern to reach 190-200 msec in the absence of hyperkalemia or other sodium channel blockade. The J-point is not easy to find, but there is excessively discordant ST deviation in many leads (this is why we excluded hyperkalemic patients in our ventricular paced rhythm study of acute coronary occlusion using the mo...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs