Drive My Car

Presenting Complaint
This 77 year old woman got into her car after shopping. She put the car into reverse and then was seen to slump over the steering wheel. The car reversed atlow speed into a shop front. There was no damage to the shop, and only a small dent in the back of the car. The patient rapidly recovered consciousness. She was not confused and there was no headache nor chest pain nor abdominal pain on recovering consciousness.       

Past History
There is a past history of obesity,  non-insulin dependent diabetes,  severe obstructive sleep apnoea, hypertension, heart failure and atrial fibrillation.  
Five months ago she had gastro-intestinal bleeding due to gastric and peptic ulcers.  At that time she was taking aspirin and rivaroxaban, but these have been ceased. The bleeding was complicated by acute pulmonary oedema and non ST elevation myocardial infarction.

On arrival her Glasgow Coma Score was 15.
There were no signs of trauma to the head, torso or limbs. There was no tenderness in the neck and spine.
Her pulse was irregular with a rate of 50 per minute. The blood pressure was 150∕90 mm Hg (with no postural drop), her respiratory rate was 20 per minute and her oxygen saturation on pulse oximetry was 92 percent on room air.  
Her jugular venous pulse was 2cm, there was an ejection systolic murmur maximal over the aortic area and crepitations at both lung bases. There was no leg oedema.     
Neurological examination was normal.  
Rectal examination was normal

Initial Investigations
Blood glucose concentration was 10 mmol/L
The patient’s chest Xray is shown in Figure 1


Figure 1. Chest Xray of Case ECG_0014

Which of the following is/are true about this chestXray?

  1. The mediastinum is widened
  2. The heart is enlarged
  3. The main cardiac changes are those of left ventricular failure
  4. The aortic shadow is widened
  5. The shape of the cardiac outline  suggests a pericardial effusion


The initial ECG is shown in Figure 2.




Figure 2.  ECG_0014

Describe the main findings in the ECG

Comment on the computer’s calculation of the QRS axis.
Using the Cabrera format of the frontal leads shown in Figure 3 determine the quadrant in which the following vectors are located:

  1. The vector of the initial 0.04 seconds of ventricular depolarization
  2. The vector of the S wave component of ventricular depolarization
  3. The T wave vector


Figure 3.  Frontal leads of ECG_0014   in the Cabrera format

What are the most likely causes of the syncope in this case?