A 75-year-old male has been admitted to the emergency
admitting unit. He has ischaemic heart disease with previous myocardial
infarction and has been on treatment for chronic heart failure. He is on
furosemide, ramipril, spironolactone and carvedilol.
He recently developed pain, redness and swelling of his
right metatarsophalangeal joint which came on acutely overnight. His GP
initially treated him with diclofenac but when he did not respond he started
him on colchicine.
Following this he developed diarrhoea, which made him
feel unwell. He stopped eating and drinking and took to his bed. The GP
referred him to the hospital, as he was worried about the deterioration in his
On examination he looked unwell, his mucus membranes were
dry, skin turgor was diminished and he was tachycardic and had low blood
pressure with a significant postural drop. There was a pan systolic murmur at
the apex, which radiated to the axilla but apart from this no other
abnormalities were detected.
Your house officer has arranged blood tests, the results
are not available as yet but he calls you to see the patientís ECG as he
thinks it is abnormal.
The ECG shows bradycardia, flattened p waves and a broad
Your next step would be:
Urgent blood gas analysis
10 % Calcium chloride 10 ml over 5 minutes
50 % dextrose 50 ml with 10 units soluble insulin over 5 minutes
Nebulised salbutamol 20 mg
1.26 % Sodium bicarbonate 500ml over 30-60 mins