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- 36 bpm
- Nil consistent atrial activity
- Possible atrial activity in ST segment of 2nd complex and after T wave of 3rd complex
- QRS - Normal (100ms)
- QT - 480ms (QTc Bazette 375 ms)
- T waves leads V3-5 appear prominent and peaked
- Slow atrial fibrillation
- Broad differentials including:
- Drug toxicity
- Sinus node dysfunction
- Electrolyte abnormalities
In this case the major concerns were hyperkalaemia and drug toxicity from beta-blocker.
What happened ?
The patient had taken an extra metoprolol dose earlier in the day ! Venous blood gas revealed a potassium of 7.0 mmol/L.
Further beta-blocker medication was withheld and hyperkalaemia was treated with calcium gluconate and insulin / dextrose therapy prior to planned dialysis later in the day.
Following ED treatment of hyper-k the patients heart rate improved to ~50 bpm and he made an uneventful recovery.
References / Further Reading
Life in the Fast Lane
- Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.