doc_clotaire
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A 45-year-old male suddenly loses consciousness and falls to the ground. He has been previously healthy and has been on no medications. There is no obvious evidence of trauma. An electrocardiogram reveals wide complex tachycardia at a rate of 300 beats per minute. Which of the following is the most appropriate intervention?
A. Obtain vital signs
B. Administer a bolus of intravenous lidocaine
C. Administer a thrombolytic agent
D. Perform asynchronous cardioversion
E. Perform synchronous cardioversion
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| Aashi
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VT---------->Shock him----------->D
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| robin082006
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E------> Perform synchronous cardioversion
SYncope is considered as hemodynamic compromise---->electrical shock
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| 92306
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E. Perform synchronous cardioversion
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| Aashi
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Do we go for synchronous CV when the pt is already lost his consiousness,which signifies an unstable VT(pulseless VT)
I thought We give synchronised for ppl whho are hemodynamically stable
No wasting time chking the vitals here..I think we consider this as an unstable VT----->we shld go for D----->unsynchr CV
anyways will wait for doc clotaires ans
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| NE
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Syncronized CARDIOVERSION:
• reentrant tachycardia with narrow or wide QRS complex (ventricular rate >150) who is unstable (eg, chest pain, pulmonary edema, lightheadedness, hypotension)
• stable VT that does not respond to a trial of intravenous medications.
• atrial fibrillation, atrial flutter, or other supraventricular tachycardia- hemodinamically stable patients
Asyncronized CARDIOVERSION:
• Unstable Ventricular tachycardia
• Ventricular fibrillation
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| hypochondriac
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E
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| Diego Casali
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I think E is the correct answer.
"Unstable VT is characterized by symptoms of insufficient oxygen delivery such as chest pain, dyspnea, hypotension, or altered level of consciousness, indicating that rate and stroke volume are not providing adequate cardiac output.
Unstable VT is treated as ventricular fibrillation, with immediate synchronized cardioversion, followed by expeditious airway management (if needed), supplemental oxygenation, vascular access, and antiarrhythmic therapy. Most patients respond to low levels of energy (eg, 1-50 watt-seconds of electrical energy). Failure to synchronize the shock with the patient's QRS may precipitate ventricular fibrillation."
from eMedicine
Please, check also the American Heart Association guidelines.
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| NE
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guys, something isn't right because I had 2 sources for those indications- FA and emedicine.com!
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| Aashi
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Ok..looks like I am fighting an impossible battle
Dr clotaire pls paste in the answer..just for the records..
GL
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| Diego Casali
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I checked the "American Heart Association 2005 Guidelines for CPR and ECC" (2005), where I found some informations useful to answer this vague question:
"Synchronized cardioversion is also recommended to treat unstable monomorphic (regular) VT. (...)
If the patient with monomorphic VT (regular form and rate) is unstable but has a pulse, treat with synchronized cardioversion. (...)
If a patient has polymorphic VT and is unstable, treat the rhythm as VF and deliver high-energy unsynchronized shocks (ie, defibrillation doses). (...)
If there is any doubt whether monomorphic or polymorphic VT is present in the unstable patient, do not delay shock delivery to perform detailed rhythm analysis - provide high-energy unsynchronized shocks (ie, defibrillation doses)."
Therefore, according to the ACLS guidelines, the correct answer would be D.
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| doc_clotaire
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The correct answer is : D
The patient is in ventricular tachycardia and is hemodynamically unstable as apparent from the loss of consciousness. He should be emergently cardioverted asynchronously with 200 joules of energy initially.
He is hemodynamically unstable, as apparent from his loss of consciousness. Precious time will be lost by obtaining vital signs (choice A) if cardioversion can be done now.
A lidocaine bolus should be given once a pulse and sinus rhythm is obtained to keep him out of ventricular tachycardia. This is especially beneficial if the event is ischemic in origin (choice B).
He may be having an infarct, and this may be the cause of his ventricular tachycardia. Emergently, the physician needs to restore sinus rhythm and then the man will be treated for myocardial infarction, if indicated (choice C).
If the patient were stable, synchronous cardioversion could be attempted (choice E).
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| Aashi
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| doc_clotaire
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Good call Aashi !
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