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Emergency Medicine News:
doi: 10.1097/01.EEM.0000437841.15012.9e
Spontaneous Circulation

Spontaneous Circulation: A Sweet Wide Complex Tachycardia

Bruen, Charles MD

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Dr. Bruen is a fellow in critical care medicine and emergency cardiology at Hennepin County Medical Center in Minneapolis. He has special interest in stabilization, resuscitation, hemodynamic evaluation, and emergency cardiovascular care.

A 29-year-old man with history of type 1 diabetes mellitus presents after two weeks of feeling ill, which grew worse over the past two days. This included a productive cough, subjective fevers, and frequent vomiting. He reports no headache, chest pain, or abdominal pain. He has had financial problems after losing his job about a month earlier, and is currently living in a local motel. His brother brought him to the emergency department for evaluation after finding him in bed confused, with vomit on the floor.

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He appeared ill, and was oriented only to self. Vital signs were blood pressure 78/43 mm Hg, pulse 146 bpm, respiratory rate 26 bpm, temperature 37.2°C, and SpO2 96%. A fingerstick glucose measurement read “high.” Intravenous access was established, initial laboratory tests were sent, and fluid resuscitation was initiated with 2000 mL 0.9% saline. A 12-lead ECG was obtained.

The ECG shows a regular wide complex tachycardia at a rate of about 170 bpm with QRS width of 160 ms. The patient was hemodynamically unstable, and was therefore electrically cardioverted (biphasic synchronized at 150 J). A repeat ECG after cardioversion showed sinus tachycardia with peaked T-waves. The patient was found to be in profound diabetic ketoacidosis (glucose 1120 mg/dl, bicarbonate 10 mEq/L) and hyperkalemic (6.6 mEq/L).

He was treated successfully for DKA, with return to normal sinus rhythm. Hyperkalemia is a cause of aberrant conduction that can manifest as wide complex tachycardia.

Find a complete case discussion and more information on wide complex tachycardia by reading Spontaneous Circulation in EMN's iPad App on Nov. 6 or in the Spontaneous Circulation blog at http://bit.ly/EMNblogPageonNov. 13, where additional EKGs are also available.

Click and Connect! Access the links in EMN by reading this issue on our website or in our iPad app, both available on www.EM-News.com.

© 2013 by Lippincott Williams & Wilkins

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