Implantable Cardiac Devices Case 1

You are asked to see a 22-year-old male student in the ED. He has had an ICD implanted at his home town cardiology centre 3 years ago. He reports a previous diagnosis of Brugada Syndrome, and that his father and one of his brothers also have ICDs in situ. Both he and his father have had syncopal attacks prior to device implantation. He is otherwise entirely well, extremely fit and active as a University rower. He does not think his device has ever activated.

On this occasion, he has been drinking through the evening and smoking a small amount of cannabis. He reports being suddenly thrown to the ground whilst in a nightclub and initially thought that he had been assaulted. Whilst on the floor he was aware of 6 or 7 violent internal shocks in quick succession. He remained conscious throughout and noticed no particular cardiac symptoms. He was brought to the hospital by friends and received three more shocks whilst in the car.

On examination, he is haemodynamically stable and comfortable but anxious. He has clearly been drinking alcohol, but is otherwise alert and orientated. The bedside cardiac monitor shows the following:

On the basis of this initial information, what is the most likely diagnosis?

What is likely to be the most helpful next investigation?

Whilst you are evaluating him, he suffers a further episode. This is captured on the bedside monitor printout. What does it demonstrate?

What does the chest x-ray show? Click the image to see a larger verxion. 

What is the best immediate treatment?

What is the best further management strategy?