85 yo M with PMHx of CHF, paroxysmal atrial fibrillation and dual chamber PPM placed for sick sinus syndrome, who presents with lightheadedness, confusion and progressive lethargy x 1 day. At arrival to the ED patient hypotensive 70/30, bradycardic 46 x min, febrile 102 F.
EKG is obtained
Initial labs are remarkable for pH 7,10 HCO3 10 and Lactate of 5, with normal electrolytes
Patient’s pacemaker is set at a rate of 60 and recent interrogation showed no abnormalities.
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