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What’s the next step after this syncopal episode?
A 35-year-old cis man with a history of schizophrenia presents to the hospital with acute psychosis. The medical team on call in the ED prescribes haloperidol, an antipsychotic medication often used for acute psychosis, hallucination, delirium events, and agitation. After receiving the haloperidol treatment, the patient is transferred to the general medical ward for clinical monitoring.
After 45 minutes, the team on call notices the patient is responding well to the medication. However, he complains of acute nausea, and the medical intern on call prescribes 4 mg of intravenous ondansetron. The symptoms are resolved.
Later that night, a rapid response team is called to assess the patient after a syncopal episode on the way to the bathroom. An electrocardiogram is performed. The image is recorded with telemetry and reveals electrocardiographic alterations.
What is the mechanism for the arrhythmia seen, and what is the most appropriate next step?
- R on T phenomenon – administer 2 g of IVP magnesium over 1-2 minutes
- Acute coronary syndrome – IV metoprolol stat and immediate transfer to cardiac catheterization
- Artifact – check vitals and offer reassurance
- PAC-induced reentry – administer 6 mg of IVP adenosine
Image credit: @shanxonline.
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