Conversing with Life

ECG case

A 49-year-old man presents to the emergency department with fatigue and palpitations over the last 24 hours.

His family states that he has also been drowsy and fatigued for the past 2-3 days. They state that, when he is awake, he appears to be somewhat confused. The patient denies having a fever or chills, shortness of breath, chest pain, or abdominal pain. He does not have a headache and has not vomited or had diarrhea.

His medical history includes chronic hepatitis C, cirrhosis, chronic renal failure, and hypertension. His current medications are lamivudine, nadolol, lactulose, and spironolactone.

On physical examination, the patient is awake but somnolent. His temperature is 98.2°F, his heart rate is 96 bpm, and his blood pressure is 114/72 mm Hg. His oxygen saturation is 94% on room air. Findings on pulmonary and cardiac examination are unremarkable, but his abdomen is slightly distended. Trace peripheral edema is observed. Findings on neurologic examination are nonfocal. The patient does not know the date, though he can state his name and knows that he is in an emergency department.

The patient is attached to a cardiac monitor and given oxygen. A full set of laboratory investigations and 12-lead ECG are ordered (see Image 1). Soon after the initial ECG is obtained, the nurse calls you into the room to examine the patient, who has become diaphoretic. His heart rate is now about 40 bpm. He appears ashen and uncomfortable. Repeat ECG is performed (see Image 2).

What finding on the repeat ECG indicates the need for immediate therapy?

Tag me for the answer.

Wei Qiang converses @ 20:13