UOTW #15

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?


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