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Flecainide : This is a potentially dangerous Na channel blocker which can cause ventricular dysrhythmias including ventricular fibrillation. It simply does not make physiologic sense to suddenly see an all-negative QRS complex in this most lateral chest lead. She is already anti-coagulated, so that is not an issue.
Likewise, in some cases of ischemia concealed by flutter waves, the ischemia can be seen despite the flutter waves, whereas in other cases the dysrhythmia must be terminated before the ischemia can be clearly distinguished. Even when flutter waves conceal true ST segment deviations, the cause and effect relationship may be unclear.
Then there is loss of pulses with continued narrow complex on the monitor ("PEA arrest") Learning Points: Sudden witnessed Cardiac Arrest due to ACS is almost always due to dysrhythmia. The ECG accurately reflects the physiologic state of the underlying myocardium, but there is always more than one possible etiology of that physiologic state.
Smith comment: In a large randomized trial of dopamine vs. norepinephrine (11) for shock which was published after the above-mentioned recommendations, dopamine had more adverse events (especially severe dysrhythmias, and especially atrial fibrillation). Any alteration in physiology can change "compensated" AS to "decompensated" AS.
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