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A 20-something presented after a huge verapamil overdose in cardiogenicshock. Today's patient is a young male who presented in cardiogenicshock following a massive verapamil overdose. It's always rewarding and mutually educational to discuss interesting aspects of arrhythmia interpretation. The initial K was 3.0
Some patients have baseline RBBB with LAFB, but in patients with likely ACS, these are associated with severe infarction with cardiac arrest, cardiogenicshock or impending shock. Today's patient did make it to the hospital — but was in cardiogenicshock, and despite valiant attempt at treatment, succumbed soon after.
The axiom of "type 1 (ACS, plaque rupture) STEMIs are not tachycardic unless they are in cardiogenicshock" is not applicable outside of sinus rhythm. In some cases the ischemia can be seen "through" the flutter waves, whereas in other cases the arrhythmia must be terminated before the ischemia can be clearly distinguished.
Because of the tachcardia, I would expect her to be very poor left ventricular function and maybe Cardiogenicshock. As per Dr. Smith — this suggests that despite QRS widening, the rhythm in ECG #3 is AFib with a rapid ventricular response. Old MI with persistent ST Elevation (LV aneurysm morphology) can look like acute MI 2.
Tachycardia is unusual for OMI, unless the patient is in cardiogenicshock (or getting close). Jenkins and Frick — I offer 3 additional examples of artifactual distortion ( excerpted from my ECG Blog ) — that resulted in arrhythmia misdiagnosis. We can see enough to make out that the rhythm is sinus tachycardia.
With the history of Afib, CTA abdomen was ordered to r/o mesenteric ischemia vs ischemic colitis vs small bowel obstruction. An elderly man with sudden cardiogenicshock, diffuse ST depressions, and STE in aVR Literature 1. See this case: what do you think the echocardiogram shows in this case? Left main? 3-vessel disease?
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