Scenario: This 12-lead electrocardiogram (ECG) was obtained by paramedics on an 81-year-old man with chief complaints of dizziness, weakness, nausea, and vomiting for 2 days. The patient reported that he had experienced 2 similar near-syncopal episodes the preceding week. The patient denied chest pain or shortness of breath. He had a complex medical history that included coronary artery disease, arrhythmias, and renal failure. During the prehospital evaluation, the patient was lethargic, had a weak pulse at 28 beats per minute, and his blood pressure was undetectable.Atrial flutter with complete heart block and 4 ventricular escape beats of multifocal origin. Although the fourth beat looks narrow, it is unlikely to be of supraventricular origin given the lack of distinctive waveform morphology in leads V4 through V6.The 4 QRS complexes (ie, heartbeats) seen in this rhythm (arrows) are mostly of ventricular origin, as indicated by the characteristic bizarrely shaped QRS complexes that are wide, not related to a P wave, and have a discordant T wave (opposite direction to the QRS deflection). All of the escape beats have different QRS morphologies, suggesting that they are multifocal in origin; that explains the lack of a detectable heart rate, which is why the term beats is used rather than escape rhythm. An escape rhythm typically sustains some cardiac output and therefore is usually lifesaving and is common when atrial activity is not propagated through the normal conduction pathway. Complete heart block can be caused by acute myocardial infarction, structural heart disease, electrolyte imbalance, or atrioventricularnodal blocking medications (eg, calcium channel blockers). The absence of a sustainable escape rhythm despite supraventricular activation is usually referred to as ventricular standstill and should be treated as an asystole equivalent. The rapid atrial flutter combined with the infrequent random escape beats explains the patient’s slow, weak pulse. In addition, these escape beats were not sufficient to maintain a detectable blood pressure, which explains the patient’s syncopal symptoms.Remarkably, he was able to survive this extreme bradycardia event. Because this rhythm was an asystole equivalent, the patient was given a bolus of intravenous epinephrine and multifunction pads were applied to the torso in case transcutaneous pacing was needed. On arrival at the emergency department, the patient was oriented, with a heart rate of ~50/min. Initial cardiac workup was negative for acute myocardial infarction, and serum electrolyte levels were normal. However, a repeat 12-lead ECG showed atrial flutter with left bundle branch block, a potentially life-threatening combination usually seen in patients with progressive conduction system disease due to structural cardiac remodeling (eg, necrosis due to atherosclerotic disease as in this scenario). The patient was admitted to the intensive care unit for intravenous dopamine infusion, later received a permanent biventricular implantable cardiac defibrillator, and was eventually discharged home.
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