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.
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.
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