The first ECG reveals a regular wide-complex tachycardia of unclear origin (Figure 1). The differential diagnosis for this finding includes supraventricular tachycardia with aberrancy or bundle-branch block, pacemaker-mediated tachycardia, sodium channel blocker toxicity, hyperkalemia, preexcitation, and ventricular tachycardia. Which of the following diagnoses is best supported by the ECGs and clinical findings? Fifteen minutes later, a second ECG is obtained (B). After arterial blood gas measurement reveals significant metabolic acidosis (pH, 7.08 PO2, 217 mm Hg PCO2, 22 mm Hg), sodium bicarbonate is administered. Initial treatment includes oxygen, intravenous fluids, and lidocaine the patient’s condition does not change. Neurologic examination demonstrates mild diffuse symmetric weakness.Īn ECG is obtained (A). A 2/6 systolic murmur is audible. Abdomen is soft and nontender. Heart rate is 152 beats per minute and regular respiration rate, 24 breaths per minute blood pressure, 142/68 mm Hg. Pulse oximetry shows that oxygen saturation is 95% on room air. He has no history of cardiac disorders, and he denies chest pain, palpitations, and abdominal pain. A 34-year-old man presents to the emergency department with progressive, generalized weakness and shortness of breath that began 2 weeks earlier.
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