Case 16: Hypotension

A 68 year-old female with a history of diabetes, renal disease and pacemaker placement for heart block presents with 36 hours of weakness, near syncope and occasional vomiting. On exam she is afebrile with a pulse of 126 and a blood pressure of 81/53. She appears adequately hydrated and has clear lungs and a non-focal exam. Her labs are unremarkable except for a positive UA. Her EKG is shown below. How would you initiate treatment?

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ANSWER:

ANSWER: Antibiotic treatment was initiated for presumed urosepsis despite neither fever nor leukocytosis. Though there was no clear evidence of dehydration, IV fluids were administered for the hypotension, history of vomiting and possible sepsis. When blood pressure remained unchanged, pacemaker interrogation was expedited for possible pacemaker mediated tachycardia, which turned out to be the correct diagnosis. The pacer rep. reprogrammed the unit and all vital signs immediately normalized. Here is her repeat EKG.

QUICK ESSENTIALS of: Pacemaker Mediated Tachycardia
Sx: Pre-syncope, palpitations, chest pain
Signs: Low BP. Tachycardia: Rate ususally only 110-125
Dx: Pacer interrogation. Resolution with magnet use
note: A paced rate >110 is PMT until proven otherwise
Rx: Apply magnet, reprogram pacer(call pacer rep to ED)
meds: AV nodal blockers (metoprolol, diltiazem)
Dispo: Consider admission for prolonged hypotension or chest pain

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