The Wire

Nursing home staff became concerned about a patient because he was “floppy.” He was a 59-year-old man with stage 3 chronic kidney disease, right ventricular heart failure, hypertension, cirrhosis, and insulin-dependent type 2 diabetes mellitus. He had been sleeping all day, according to his nurse, but he was not responding when she checked on him in the evening, and she could “drop his arm and it would just hit his face.”   He was hypotensive (90/50 mm Hg) and bradycardic (about 30 beats/min) in the ED. Respirations were slow and shallow. He was protecting his airway, but was hypoxic (SpO2 82%). IV access was established, and initial laboratory tests were sent. He was orotracheally intubated without difficulty and easily ventilated. Atropine was given, but did not increase his heart rate. The symptomatic bradycardia meant starting transcutaneous pacing. Fingerstick glucose was 174 mg/dL. Given his history of kidney disease and diabetes mellitus, there was a high suspicion for hyperkalemia so he was empirically treated with calcium gluconate and shifted with insulin/glucose. It was difficult to get good electrical capture with the transcutaneous pacing. Multiple different pad locations were attempted, and eventually we were able to achieve intermittent capture using pads in the right-parasternal and apex position.   A 12-lead ECG was obtained that demonstrated sinus bradycardia with a narrow QRS complex and no T-wave abnormalities. (Figure1.) There was no ST-segment ...
Source: Spontaneous Circulation - Category: Emergency Medicine Tags: Blog Posts Source Type: blogs