Shock first, ask questions later….

A 39-year-old man presented to the Emergency Department following a sudden onset of palpitations an hour earlier. He was clammy and felt generally unwell. He was normally fit and active with no history of cardiac symptoms including palpitations - he mentioned as a teenager he was told that he had an 'extra bit of wiring in his heart' but nothing further was done. His only regular medication was Sertraline. He drank alcohol to excess. On examination, he was hypotensive but pain free. Bloods including potassium and magnesium were within normal limits - venous lactate was mildly elevated at 2.8.