Severe shock, obtunded, and a diagnostic prehospital ECG. Also: How did this happen?

A middle-aged woman was found down in her apartment unconscious. She was in shock with thready pulses.A prehospital ECG was recorded:Limb leads:Precordial LeadsWhat is the therapy?This is pathognomonic of hyperkalemia (I suppose it could be due to a massive overdose of a sodium channel blocking drug, maybe).Is it ventricular tachycardia (VT) due to hyperK or is it a supraventricular rhythm with hyperK? ---I don ' t think that it is possible to say for certain, and it does not matter.  The rate is not fast enough to be causing shock, so if it is VT, the priority is still to treat hyperK and secondarily to cardiovert.The patient should receiveimmediate IV calcium (and also treatment to shift the potassium into the cells).The medics did not recognize hyperkalemia. They thought it was VT, but did not shock.  They later told me that even if they had diagnosed hyperK, the only calcium they have is Calcium chloride, not gluconate.  ....However, it is perfectly fine to give Calcium chloride!!  Just have a reliable IV so that it will not extravasate.  The morbidity of extravasated CaCl is minimal compared to the mortality of life threatening hyperkalemia.  Important: It takes 3 grams of calcium gluconate to equal the amount of calcium in 1 gram of Ca Cl. They transported to the ED.  On arrival, the patient was in shock, was intubated, and had an immediate cardiac ultrasound.What does a heart look like on ultrasound when the EKG lo...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs