Thanks go to an anonymous reader for this excellent case, as always we hope you find it as interesting as we did! As always, details have been changed where appropriate to protect patients and providers.
You're on an ALS fly-car dispatched for an unresponsive female, a BLS ambulance and engine company are already en-route.
You arrive to a small townhome in a quiet retirement community, finding the engine and BLS unit on scene already; a firefighter is in the doorway waving you inside. He grabs your monitor and directs you to a back bedroom.
The crew has already moved the patient to the floor, placed an OPA, and is assisting ventilations. A panicked young man is pacing on the other side of the bed. One of the firefighters places your patient on the monitor. You introduce yourself to the young man–her boyfriend–and get a quick history.
"She's not been herself today, depressed and crying. This is her grandmother's house, she died two days ago."
When asked about medication usage, medical problems, or other pertinent history he says he's not sure, but that she's tried to commit suicide in the past.
One of the BLS providers gives you the initial vitals:
- GCS: E1V1M4, "no problems with the OPA"
- Pulse: 75 bpm, no radials, weak carotids; "but the monitor says 140 bpm"
- BP: 62/38
- RR: 6, now assisted at 12
- SaO2: 70% prior to ventilations, 77% @ 15 L/min
- BGL: 192 mg/dL (10.6 mmol/L)
The initial rhythm strip is torn off and handed to you as they package the patient for transport.
A quick physical exam reveals no trauma, clear and equal lung sounds, 5mm equal and reactive pupils. A quick scan of the room finds no medicine bottles, but the boyfriend remembers her grandmother taking medication for depression.
In the back of the unit the BLS crew obtains a 12-Lead at your request while you start an IV.
The interpretive statement reads Atrial Fibrillation with Rapid Ventricular Response and Left Bundle Branch Block. It is a 20 minute ride to the nearest hospital.
What does the rhythm strip show?
What does the 12-Lead ECG show?
What is your working diagnosis and treatment plan for this patient?