Collapsed at the kitchen sink with no warning, out for a few seconds

2026-09-11

The case

77-year-old woman. Collapsed at the kitchen sink with no warning, out for a few seconds

Paroxysmal atrial fibrillation on apixaban. Treated hypertension. Bisoprolol increased from 2.5 mg to 5 mg three weeks ago for palpitations. Two similar collapses in the past month, both unwitnessed.

On arrival

HR: 46
SpO₂ (%): 97
Respiratory rate: 16
Temperature (°C): 36.4
Systolic BP (mmHg): 122
Diastolic BP (mmHg): 70

Stage 1 of 2

She is alert, warm and dry, with no injuries from the fall and no tongue biting or incontinence. Heart sounds are normal and there is no murmur. On the monitor she goes pale mid-sentence, is unresponsive for a few seconds, then comes round on her own with no intervention. This is the strip across that moment.

The tracing for the quiz “Collapsed at the kitchen sink with no warning, out for a few seconds”. — Monitor strip, lead II, 25 mm/s, 10 mm/mV. Open this tracing in the studio

What does this strip show?

AElectrode contact lost and regained across the flat segment Your answer
BAsystolic cardiac arrest with spontaneous return of circulation Your answer
CAtrial fibrillation ending in a long pause before sinus rhythm resumes Correct answer Your answer
DComplete heart block with a slow ventricular escape rhythm Your answer

Stage 2 of 2

She is back to herself and remembers none of it. Potassium 4.2, magnesium 0.85, TSH normal, creatinine 84, troponin not raised. She has been anticoagulated for three years and has never missed a dose. She asks whether she can go home, and whether the tablets are to blame.

Bloods

TSH (m IU/L): 2.1
Magnesium (mmol/L): 0.85
Potassium (mmol/L): 4.2
Creatinine (umol/L): 84

What does the strip commit you to?

ARefer for tilt-table testing to confirm vasovagal syncope Your answer
BReduce the beta blocker and have a informed discussion with the patient about the pros and cons of implanting a pacemaker Correct answer Your answer
CDischarge on a halved bisoprolol dose with an outpatient 24-hour tape Your answer
DHold the apixaban until the pauses have been brought under control Your answer

Diagnosis

Tachy-brady sick sinus syndrome: an asystolic conversion pause on termination of atrial fibrillation

Embed

<script async src="https://www.squiggler.io/embed.js" data-case="collapsed-at-the-kitchen-sink-with-no-warning-out-for-a-few-seconds"></script>

Or, where scripts are stripped:

<iframe src="https://www.squiggler.io/blog/collapsed-at-the-kitchen-sink-with-no-warning-out-for-a-few-seconds/embed" title="Collapsed at the kitchen sink with no warning, out for a few seconds — ECG case from Squiggler" width="100%" height="900" style="border:0" loading="lazy"></iframe>

This tracing was generated, not recorded. It opens in the studio with every dial live.

Open the studio

Discussion

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