off the pace…

the case.

An 80 year old male is bought to your ED via ambulance following a syncopal episode. He reports sitting on a church pew, when he apparently collapsed without prior warning. According to bystanders he was unresponsive on the ground looking pale then ‘blue’. He was making some respiratory effort and eventually recovered without intervention.

By the time you examine him, he is alert and oriented (though, amnestic to the actual event). His pulse is 60, he is warm and perfused (with a BP of 138/66). There is no evidence of cardiac failure and his neurological exam is unremarkable. You do note a pacemaker box in his upper left chest and his CXR shows that this is a ‘dual-lead’ variety….

This is his ECG.

Syncope in Church

What’s going on here ?
How do you explain his syncope ??
What needs to happen now ??? Continue reading


The Case.

A 38 year old male presents to your ED with left sided chest heaviness which radiates to his left shoulder & down the arm. He has associated dyspnoea, nausea & vomiting. He looks unwell.

He underwent a CT-Coronary Angiogram 4 months earlier showing a Calcium-Score of 450 !! (‘Extensive plaque burden’. 8x increase in Framingham predicted risk). However, a Sestamibi study performed at the same time showed no evidence of inducible ischaemia.

This is his ECG…

38yo ECG01

What’s your interpretation ?
Is it significant ??
Where do you go from here ???

Continue reading

a troublesome tachycardia

The Case.

An 11 year old boy is bought to ED by his mother on a busy weekday evening. Mum reports that he has been ‘a little bit off’ over the past 24 hours, in particular he’s not keeping down his food or fluids. She is also worried about his colour, stating ‘he looks a little pale and sweaty’.

You find him a little wheezy on auscultation, with room air saturations of 93%. Of concern is his pulse rate of greater than 150 per minute.

This is his ECG…

What’s your interpretation ?
What would you do next ??

Continue reading

another ECG case…

The Case.

I was superficially involved in this case of a 32 year old suicidal patient who ingested two full packets of Solian (amisulpride) (~ 24 grams) approximately 90 minutes prior to arrival to ED.

On initial assessment he was GCS 12/15 & had a systolic BP of 115 mmHg.

This is his ECG….

Continue reading

slowly, slowly…


76 year old female, presents with lightheadedness and lethargy. She is complaining of mid-scapular pain & is syncopal at triage.

She has cold hands & clammy skin. Systolic BP 70 mmHg. Crackles to mid-zones of her chest. Distended JVP.

PMHx: AF (on metoprolol) & rheumatic heart disease (?mitral stenosis)

This is her ECG.

Continue reading

generally unwell (part 2)…

For those joining the story for the first time, you can catch up here….

My interpretation of the ECG;

Sinus rhythm with 1st degree HB, an ‘odd’ axis. Wide complex QRS (~140-160ms) with symmetrical tall T-waves.
? Hyperkalaemia. Needs urgent bloods….

The nurse returns…

No one can place an IV or take bloods from her. So off you go, USS in tow to the bedside.

IV placed; bloods taken; urgent VBG to the iStat…..

Continue reading

generally unwell…

The setting:

Busy Saturday morning shift. Lots on the go as usual…

You sit for a moment to catch up on your notes and review patient results…

A nurse hands you this ECG to sign-off saying, “this lady is generally unwell and has been drowsy & vomiting for 3 days. She doesn’t look well but doesn’t speak any English”…..

What’s your interpretation ?

There will be a 4-5 hour wait for her to be seen…

Where do we go from here ?? What do you do next ??

…. the conclusion can be found here –> generally unwell (part 2) …

more than man-flu (part2)…

Here is the follow-up to the story of our 19 year old febrile patient…..

The case continues…

His CXR demonstrates the following ….

  • Clear lung fields
    • No pneumonia
    • No CCF
  • is that a ‘globular heart’  ??
  • This is his ECG…

    Sinus tachycardia. Non-specific T-wave changes, but no ST-segment changes.

    My thoughts at this stage were;

    • 19 year olds should be able to stand on their own
    • Constitutional symptoms… ?viral illness
    • I cannot exclude concomitant sepsis –> so treated with empiric ABx / fluids
    • Globular heart silhouette

     ** Is this myocarditis ?? **

    Continue reading

    supply & demand…


    74 year old female is placed in the acute-area of our ED with a complaint of retrosternal chest tightness at approximately 9am. Her symptoms sound very typical for ACS. She looks clammy and pale.

    My colleague has placed her on telemetry, high flow oxygen and has prescribed 300mg aspirin &  600mcg sublingual anginine.

    I am handed her ECG, which shows a sinus tachycardia and evidence of left ventricular hypertrophy with a repolarisation pattern. Of concern is the associated anterior ST depression, so I make my way to the bedside….

    …as I approach her bed I witness her telemetry deteriorate from a sinus tachycardia to ventricular fibrillation !!

    There is a defibrillator 15 metres away, across the department. The following takes place…

    • Precordial thump (by me. did nothing except hurt my hand).
    • Immediate CPR until defib pads placed.
    • 200J shock
    • 2 further minutes of CPR with 1mg IV adrenaline.
    • 3 minutes post arrest she has return of spontaneous circulation.

    Cardiology are notified of this and want her in their Cath-lab immediately….

    Continue reading

    broad, fast & regular…

    There are some things in medicine that I feel require a standardized approach for rapid diagnosis & management, especially in the face of an unstable patient & you have a little sweat on your brow. The following are two somewhat straight forward cases that got me thinking …

    Case 1

    66 year old self presents to ED following 4 hours of palpitations. She has had no chest pain, dyspnoea or pre-syncope. She has had this before.

    HR 170. BP 128 systolic. Speaking full sentences with a clear chest. Sats 98%.

    This is her ECG…


    Case 2: 

    84 year old transferred to ED from the dialysis suite with 30mins of palpitations that commenced towards the end of his haemodialysis. He has no chest pain, dyspnoea or pre-syncope. He has had this before.

    HR 160. BP 118 systolic. Speaking in phrases but clear chest. He looks grey & slightly clammy.

    This is his ECG…


    … both are broad, fast & regular leading me to investigate “Ventricular Tachycardia vs SVT with Aberrancy”

    Continue reading