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ECG of the week #15: 90 year old with weakness, vomiting, and paced rhythm – what treatment is needed?

Test yourself with this week’s ECG case. Then scroll down for a structured step-by-step interpretation and clinical pearl.

Clinical Scenario

90 year old with a history of a pacemaker presented with weakness, vomiting, and bradycardia.

ECG

Question

What treatment is needed?

ECG Analysis

H: AV pacing at slow rate, with capture
E: very wide QRS around 300
A: left (paced)
R: late (paced)
T: normal
S: secondary ST, mild peaked T

Answer

= weakness/vomiting with slow pacing and very wide QRS. Given empiric calcium. Potassium returned at 8.8

Clinical Pearl

Severe hyperkalemia may cause pacemaker complications (eg failure to capture, increased latency, oversensing), or may be visible in paced rhythms (eg very wide QRS). High pre-test presentation of hyperkalemia + ECG changes of hyperkalemia = empiric calcium

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