Ventricular arrhythmias Quiz: Ace Your Exams

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A 3-year-old male presents to the emergency department due to persistent nausea, vomiting, and diarrhea for one day. The patient has been unable to tolerate oral intake. Past medical history is otherwise unremarkable. The patient’s parents report he has been meeting all developmental milestones, but sometimes does not respond when his name is called. Temperature is 38.0°C (100.4°F), pulse is 121/min, respirations are 20/min, and blood pressure is 100/62 mmHg. On physical exam, the patient is actively vomiting and has dry oral mucous membranes. The patient is given intravenous fluids and ondansetron. Several minutes later, the following is observed on telemetry:  

 
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Which of the following features most likely precipitated this electrocardiographic finding?  

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