Syncope and Chest Pressure, then an Unusual Bradycardia with Shock

This case is from one of our fantastic 3rd year residents, Aaron Robinson.A woman in her 60s with SyncopeA woman in her 60s presented to a facility with syncope. She had a history of CHF, pulmonary hypertension,CAD s/pCABG, and ESRD on hemodialysis. She had a dialysis run the day prior. Prehospital VS were: BP 115/70, HR 65, RR 12. The patient did not have a 12 lead completed pre-hospital.She arrived at the ED awake, alert, and complaining only ofmild chest discomfort. A 12 lead ECG was immediately completed:Aaron showed this to me and this is what I said:Suggestive of inferior posterior MI, but not diagnostic. There is sinus rhythm (with one aberrant beat, #2, which might be artifact)There is T-wave inversion in aVL, which is a soft sign of inferior MI.There is a bit of downsloping STD in V2 suggestive of a posterior MI.But nothing diagnostic.Clinical CourseBedside echo demonstrated no pericardial effusion, no b-lines, but a dilated RV with septal bowing, so PE was on the differential.  However, review of records showed that she had a history of pulmonary hypertension and a large RV on previous echos. --Lactate 9.0.  K was normal.--Initial high sensitivity troponin (assay unknown) returned elevated at 174 ng/L (roughly equivalent to 0.174 ng/mL in contemporary assay). Suddenly, the patient developed severe shortness of breath and chest pain. There was bradycardia with a narrow QRS on the monitor. She was given 1 mg of at...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs