A 45 year-old male presents to the emergency department with a “racing heartbeat” that started two hours ago while doing yard work.

He denies syncope, exertional chest pain or dyspnea. This is the first time he has experienced this sensation.

VS 98.8 F / BP 124/82 / HR 158 / RR 14 / SaO2 98%

On exam, the man appears comfortable and in no acute distress. He is awake and oriented x3. Cardiovascular exam reveals a rapid rate with regular rhythm. No murmurs, rubs or gallops are appreciated. Distal pulses +2 with normal capillary refill. Breathing is unlabored without accessory muscle use. Lungs are clear to auscultation bilaterally. No pedal edema.

A 12-lead EKG reveals a narrow complex, regular monomorphic tachycardia with a rate of 158. Bilateral IV access has been obtained.

1. What is the best first step in managing this patient’s*

Sedation and Intubation

Vagal maneuvers

Synchronized cardioversion

Procainamide infusion at 60 mg/min until arrhythmia is suppressed

A standard 15 second, 40 mmHg straining Valsalva maneuver is performed in a semirecumbent position, followed immediately by repositioning to supine and passive leg raise to 45 degrees.

The EKG is unchanged. Clinical status of the patient is otherwise the same.

Supraventricular Tachycardia

2. What is the next best step in management?*

12 mg rapid IV push of Adenosine, followed by NS flush

IV infusion of 6 mg Adenosine over 1 hour

6 mg rapid IV push of Adenosine, followed by NS flush

IV infusion of 12 mg Adenosine over 1 hour

6 mg of Adenosine is administered via rapid IV push.

The patient reports feeling very hot and flushed, clutching his chest due to discomfort. The symptoms resolve spontaneously after just 30 seconds. There is still no change in the rhythm seen on the EKG. Vitals are otherwise stable. The patient is mildly perturbed, but is in no acute distress. Supraventricular Tachycardia

3. The next step is?*

Increase dose to 12 mg rapid IV push of Adenosine

Retry vagal maneuvers

Repeat rapid IV push of 6 mg

Immediate defibrillation

After administering a second dose of Adenosine at 12 mg, the patient experiences severe chest pain and becomes acutely confused.

Blood pressure quickly becomes unobtainable; however, a weak pulse is palpable.

EKG exhibits a major change in rhythm, now displaying a regular, wide (>0.12 s) complex monomorphic ventricular tachycardia at a rate of 220

4. The next step is?*

Immediately perform defibrillation at 200J

Give third dose of 12 mg rapid IV push of Adenosine

Start a beta-blocker

Immediately perform synchronized cardioversion at 100J

Synchronized cardioversion at 100J is performed, with no change to the rhythm on EKG.

The patient rapidly loses consciousness. Pulse is no longer palpable.

Polymorphic Ventricular Tachycardia

5. The next step is?*

Immediately perform defibrillation

Immediately perform synchronized cardioversion at 150J

Pronounce the patient dead

Go to the supply room and retrieve an arterial line kit

Defibrillation is delivered at 200J. CPR is initiated immediately.

6. What rate and compression depth should CPR be ideally performed?*

60-80 per min; 2-2.4 inches

120-140 per min; >3 inches

160-180 per min; 1-1.5 inches

100-120 per min; 2-2.4 inches

After two minutes, there is still no pulse. Rhythm analysis reveals no change.

7. What is the next best step?*

Deliver 2nd unsynchronized shock

Start amiodarone

Give 1 mg IV push of Epinephrine

Find another EKG machine to recheck rhythm

A second unsynchronized biphasic shock is delivered at 200J. CPR is resumed.

8. What medication can be given at this time?*

1 mg IV push of Epinephrine every 3-5 minutes

0.5 mg IV push of Epinephrine every 3-5 minutes

40 U IV push of Vasopressin every 3-5 minutes

Alternating 1 mg IV Epinephrine and 40 U Vasopressin every 3-5 minutes

Epinephrine is given at 1 mg intravenously. After two minutes, reanalysis of the rhythm reveals the patient remains in pulseless VT.

Polymorphic Ventricular Tachycardia

A third unsynchronized shock is delivered and CPR is resumed.

9. What additional medication is appropriate at this time?*

300 mg IV Amiodarone

2 g IV Magnesium sulfate

800 mg IV Dopamine

3 g IV Metoprolol

The subsequent pulse and rhythm analysis reveals a palpable pulse and a return to normal sinus rhythm.

10. What is the most appropriate intervention at this time to reduce the risk of neurologic injury?*

Targeted temperature management

Cardiac catheterization

Transthoracic echocardiography

Carotid doppler followed by endarterectomy if needed

Ventricular Tachycardia

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