When the colour drains from your face!

Author: Cherie Hegarty / Editor: Nick Tilbury / Reviewed: Cherie Hegarty / Codes: CC1, CC3, CP4, SLO3 / Published: 03/09/2021 / Reviewed: 14/11/2024

An 87-year-old female is brought to the Emergency Department (ED) by ambulance with possible new onset seizure activity. Collaborative history from her son describes transient loss of consciousness (TLOC) associated with abnormal eye movements and myoclonic jerking. A further 6 episodes were witnessed by paramedics. Prior to this, the patient had not seen a medical practitioner for over 5 years. Her only medication is alendronic acid.

While in the emergency department she has several more episodes of TLOC, during which she becomes diffusely pale and has some jerking of her arms and legs. Between episodes, the patient’s level of consciousness returns to normal, and her skin becomes globally hyperaemic. A 12-lead ECG shows sinus rhythm with a right bundle branch block. Venous blood gas analysis is unremarkable. Continuous 3-lead ECG monitoring during these episodes reveals the following rhythm:

In the ED, the patient is given a pharmacological therapy and is attached to a pacing defibrillator for consideration of transcutaneous pacing should pharmacological therapy be ineffective.

Following the commencement of the medication, there are no further episodes of p-wave asystole. She is admitted under the care of the cardiology team for emergent insertion of temporary pacing wires prior to planned permanent pacemaker insertion.

Subsequent investigations reveal the patient has suffered from an inferior myocardial infarction and she is treated accordingly.