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Syncope & Bradycardia

History:  A man in his late 50’s presents with generalized weakness and loss of appetite that has been gradually worsening for a few weeks.  Today he fainted.  He denies any injury or any palpitations, chest pain, SOB, fever, cough or other complaints.

Exam: Vital signs are normal except a pulse in the 40’s

An EKG is done

Computer Read: junctional rhythm rate 44, borderline voltage, NSTWA

 

What is the most likely cause of the EKG findings?

    • A) Hyperkalemia
    • B) Dehydration
    • C) Acute coronary syndrome
    • D) Hypothyroidism

“BRADY” DOWN FOR THE EKG ANALYSIS & 1-MINUTE CONSULT

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QUIZ ANSWER, EKG ANALYSIS, CASE OUTCOME, 1-MINUTE CONSULT & CASE LESSONS: 

1) Quiz Answer:

  • A) Hyperkalemia: CORRECT.  Always consider hypokalemia as a cause of bradycardia, especially junctional bradycardia
  • B) Dehydration: clinically could make sense but not usually associated with bradycardia unless there is another cause
  • C) Acute coronary syndrome: can cause weakness, syncope or bradycardia but doesn’t typically come on over a period of weeks
  • D) Hypothyroidism: can certainly cause bradycardia but doesn’t typically cause junctional bradycardia

2) EKG/Echo analysis (check out more great EKG’s from Dr. Stephen W. Smith of Dr. Smith’s ECG Blog):

3) Case Conclusion:  Troponin-i was <0.03 (99% URL <0.030: troponin-i immunoassay, Abbott laboratories), potassium was 7.4

4) 1-Minute Consult from the Emergency Medicine 1-Minute Consult Pocketbook & Smartphone app on the topic for this case: See highlighted areas of sample page below.

5) Case Lessons: 

  1. Always
  2. Never

6) OMI Manifesto: If you haven’t yet read the OMI manifesto, you should.  It’s long but everyone should know at least the basics of why current STEMI criteria miss about 1/3 of occlusion MI’s that would benefit from emergent reperfusion and how you can pick up those patients and get them the care they need. for more information CLICK HERE

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