The Patient:  This ECG is from a 59-year-old woman who was found by the EMS crew to be unresponsive, with agonal respirations at about 6 breaths per minute. Her pulse was thready at the carotid, and absent peripherally. Her skin was pale, cool, and mottled.  Her BP via the monitor is 81/40, peripheral pulses not being palpable.  An initial rhythm strip showed sinus rhythm at 75 bpm with right bundle branch block and ST elevation.

The patient’s husband gave a history of “difficulty breathing” since sometime this morning, alcohol dependence, hypertension, tobacco use, and insomnia. He said she had been drinking heavily for several weeks.

She was immediately ventilated and intubated, and an intraosseous infusion line established.  A12-lead ECG was done, and it showed a dramatic change in the rhythm and ST segments over the initial strip. She was transported to a nearby hospital with CPR support. She achieved return of spontaneous circulation (ROSC) at the Emergency Department, after having three doses of epinephrine.  Follow up with the ED physician revealed that the patient had suffered a massive gastrointestinal bleed.  This patient, due to loss of a critical amount of blood, had low blood pressure and very poor perfusion, which resulted in damage to her heart (and possibly other organs as well). I do not have further follow up, but will update this if I receive more information.