A 72-year-old man taking Carvedilol 25 mg bd for congestive cardiac failure was admitted to the emergency department with symptomatic brady-cardia. On arrival he was comatose (Glasgowcoma scale score 8/15); his blood pressure was 80/40 mmHg and this failed to improve despite four doses of 600 mug of intravenous atropine. Haemo-dynamic and symptomatic improvement occurred only following a brief period of anterior posterior external cardiac pacing (Output 30 mA, Rate 60). He went on to have an uncomplicated single lead ventricular pacemaker implanted. Prior to discharge a 3 mm deep ulcer was found underneath the site of the anterior pacing pad; a swab showed no growth.
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