Post-return of spontaneous circulation (ROSC) Accelerated Idioventricular Rhythm in the Setting of Severe Pancreatitis and Hyperkalemia

Abstract

A 73-year-old female with a history of coronary artery disease, hypertension, and diabetes presented to the emergency department in cardiac arrest. After cardiopulmonary resuscitation (CPR) and return of spontaneous circulation (ROSC), a post-ROSC electrocardiogram demonstrated Accelerated Idioventricular Rhythm (AIVR). The patient was found to have hyperkalemia due to anuric acute renal failure and antecedent severe pancreatitis. After medical management and dialysis, the patient recovered with good neurological recovery. AIVR traditionally has been seen or documented as occurring after ischemia and subsequent coronary artery reperfusion. However, etiologies that promote ventricular automaticity must be considered as well. Electrolyte disturbances, drug toxicities such as digoxin, volatile anesthetics, cardiomyopathies, and ischemia can lead to AIVR. Treatment involves considering and correcting any underlying etiology with avoidance of antiarrhythmics, which may precipitate hemodynamic instability and asystole.

Keywords: accelerated idioventricular rhythm; aivr; hyperkalemia; post-rosc ecg; ventricular rhythm.

Figure 1. Initial pulseless electrical activity rhythm, demonstrating a wide complex, irregular rhythm

Figure 2. Post-return of spontaneous circulation electrocardiogram showing a regular wide-complex rhythm with no discernible P waves. The rate is 77 beats/min. The axis is normal. There is left bundle branch block morphology with narrow-based, tall T waves.

Figure 3. Post-dialysis electrocardiogram showing normal sinus rhythm and resolution of peaked T waves. Findings of normal sinus rhythm and a rate of 78 beats/min. Poor R-wave progression. Left axis deviation with T-wave inversions in lateral leads I, aVL. Similar to her ECG one year prior.