82 year old male found on the floor at home. He was last seen by his neighbour 18 hours earlier.
(a) Describe and interpret the ECG
(b) Outline the Investigations you would perform
The first thing to comment on, is that this elderly person may have been on the floor for a period of time and so the issues of rhabdomyolyis, hyperkalaemia and renal failure need to be considered. Think of this scenario in terms of what caused him to be on the floor and the sequelae of it.
P waves: No regular P waves seen, although an occasional retrograde P wave is present. This indicates that this is atrioventricular node abnormality
QRS: widened with deep Q waves anteriorly
ST-T: Peaked T waves
This is a Broad Complex bradycardia, with Q waves and peaked T waves
The differential diagnosis must include ischaemia, hyperkalemia,overdose.
When investigating this patient we need to think of what caused him to be on the floor as well as the result of him being on the floor.
Investigations must include:
BSL(high or low, to potentially explain collapse)
K(hyperkalaemia as a result of rhabdomyolysis)
CK- to look for rhabdomyolysis
Urea and Creatinine(looking for renal impairment in rhabdomyolysis)
FBC (looking for septic clues in wcc)
Also consider given the presentation and following examination, for the need for CXR(infective causes), CT brain( to explain collapse, or if there has been a head injury, to rule out bleeds etc), MSU, thyroid function tests, lumbar puncture and other X-rays as indicated to exclude other injuries.