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Feeling Weak

by on July 10, 2012

84 year old female at home sitting in chair.  She stated she is feeling a little weak.  She denies any pain but does have some mild shortness of breath.  Skin is warm and dry and color normal for her.  She tells EMS crew that S/S were sudden onset while she was watching tv.  Fire fighter first responders on scene had already placed her on 15 lpm NRB.  Pt was carried to stretcher and moved to unit where a 12 lead was obtained.


Her blood pressure is 90/40

RR 16

Pulse radial 20 and faint

She has a pacemaker and history of HTN.  No other medical history could be obtained.

IV attempted en route but initial attempt was unsuccessful.

From → Case File

  1. Looks like her AV sequential pacemaker is not capturing. My first guess would be an accidental medication OD, perhaps a B-blocker or Ca-channel blocker. Second guess would be an electrolyte problem (flat T-waves, prolonged QT, prolonged ST).

    My guess is pacing won’t work without a correcting of the underlying abnormality, so I’d be hunting for an IV so I could get at least some calcium on board. You probably have to start pacing her, although she seems to be maintaining an adequate blood pressure in spite of her near death experience.

    If she comes close to peri-arrest she’s getting IO access, push-dose epi (she’s probably euvolemic), calcium, and if I know its B-blocker/Ca-channel blocker at least start some glucagon (high dose insulin drips come to mind in the ED).

    Good case!

  2. Wow. Pretty much agree with Christopher.

    I’m left wondering if the 600ms QTi is due to the slow rate, escape rhythm, or precipitating cause of the non-capture.

  3. I’m going mostly on my gut instinct here as it has historically served me well. When I initially glanced at the “cropped” image of the 12-lead ECG above, the very first thought that popped into my head was that I seemed to be seeing Osborn waves in inferior leads III and aVF. And maybe just a hint of an Osborn wave at the base of the QRS in lead II as well. I would have loved to have viewed her conducted beats in V4 through V6 but her rate is so slow that they didn’t have a chance to manifest in any of those 3 precordial leads.

    Much of her clinical presentation, S/S, and vital signs are consistent with a hypothermic patient. Admittedly, I’m not comfortable with her skin feeling “warm” but I guess it would depend on just how cold the surrounding air temperature was in relation to her skin temp. It would also depend on what part of her anatomy you felt for the skin temperature on. Was it on an extremity like the back of her hand versus on her forehead? Classic hypothermia has a tendency to prolong all of the intervals (P-R, QRS, ST, QT) and cause bradycardia. I’ve heard of cases where people can become hypothermic during heat waves if they are in close proximity to an industrial-strength air conditioner and are frail enough. An air conditioner could have directly blown concentrated air flow on one particular exposed part of her body while other parts were covered and not in the direct line of fire, so to speak.

    I know I’m clutching at theoretical straws here but that’s my story and I’m sticking with it.

  4. To my previous comment, I wanted to add the following. Hypothermia is also on the short list for causes of pacemaker failure to capture.

  5. Anonymous permalink

    In conclusion the answer is? av pacer not capturing?

    • Deb permalink

      Nope, not capturing. You see both AV spikes with no corresponding complex.

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