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Rate:
- 72 bpm
- Irregular
- No organised atrial activity
- Normal
- QRS - Prolonged (160 ms)
- Minor ST depression leads V5-6
Additional:
- QRS prolongation without typical BBB pattern
- Very low voltage
- Atrial Fibrillation
- QRS Prolongation
- Low voltage
Given the patient's history there are a very broad range of differentials for these ECG findings, including:
- Chronic cardiomyopathy
- Chronic atrial fibrillation
- Pericardial effusion - inflammatory, infective, uraemic
- ACS - chronic / acute
- Electrolyte abnormality - never forget K+ especially in patients with known renal impairment
- Drug toxicity - beta-blocker, calcium channel blocker, digoxin
- Environmental - hypothermia
- Multi-factorial
What happened ?
This patient had a combination of issues:
- Chronic atrial fibrillation
- Chronic dilated cardiomyopathy - EF 34%
- Acute on chronic renal - creatinine 235 from baseline 150 umol/L
- Hyperkalaemia - K 7.6 mmol/L
- Acidaemia - pH 7.15 HCO3 14 mmol/L
- Chronic digoxin toxicity
He required inotropic support, volume replacement, digifab/digibind therapy, correction of hyperkalaemia / acidaemia and renal replacement therapy.
References / Further Reading
Life in the Fast Lane
Textbook
- Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.
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