EKG Challenge No. 16: Time to Shock or Block?

EKG Challenge No. 16: Time to Shock or Block?

A 76 year-old male with a history of severe ischemic cardiomyopathy with an ejection fraction of 15%, atrial fibrillation on coumadin, coronary artery disease, and chronic kidney disease is brought in by paramedics from a skilled nursing facility with confusion, somnolence, and vomiting. Per EMS report, the patient has been vomiting for two or three days.

On arrival, the patient’s blood pressure is 128/78 with a heart rate of 130 and oxygen saturation of 99% on room air. On exam, he is oriented to self only. He is slightly agitated but following commands. He has some mild garbled speech and is moving all extremities well. He denies chest pain, dyspnea, or abdominal pain. His extremities are well perfused with intact peripheral pulses and preserved capillary refill. A full set of labs are drawn and pending. A head CT is performed and shows an intracranial hemorrhage and small subarachnoid hemorrhage.

A routine 12-lead EKG is performed:

Based on this EKG and the patient’s medical history, what are your diagnostic considerations? What should you do next to address the findings on the EKG?

Check back next week for the case conclusion and teaching points!