This is a 65 y/o WM who has a history of paroxysmal atrial fibrillation and CHF presents via EMS with lethargy, weakness and intermittent syncope. The family found a mostly empty bottle of digoxin in his apartment. Vitals: 24 75/25 6 99% RA. You are handed the following 12 lead ECG by EMS:
The decision is made to begin transcutaneous pacing the patient. The pads are placed and the pacing mode is selected. You are convinced you feel a pulse, and the following ECG strip is obtained:
But the patient remains unconscious. You obtain the following ultrasound. What is the cause of the patient’s continued poor clinical status?