Here's a case from a faithful reader who wishes to remain anonymous. As usual, some information has been changed to protect patient confidentiality.
You are called to transfer a 63 year old female from a community hospital to a large medical center.
Upon arrival at the local hospital, you are confronted with chaotic scene. You see your patient, now resting, and are told she presented with chest pressure and palpitations a couple of hours ago, was also becoming obtunded, and her family had stated she had not had any any similar episodes in the past. Her vitals are as follows:
- Pulse: 200 and irregular
- BP: 132/76
- RR: 22 regular
- Eyes: Pearl
- Skin is cool and dry
They hand you an ECG and tell you she presented in the following rhythm:
And with the following history:
- She had sudden onset of chest pressure and palpitations, which began while she was doing some work around the house.
- Nothing changed the discomfort
- felt like "pressure" and "palpitations"
- No radiation
- she rated the pressure as a 7/10
- began one hour prior to presentation
- No allergies to medications
- She takes a "pill for blood pressure", name unknown
- Past medical history significant only for hypertension
- had a normal breakfast and lunch
- She can not recall any specific trigger for the episode
In the ED prior to your arrival, she had received the following treatments: Lopressor, Amiodarone, Magnesium Sulfate, Heparin, Lidocaine, Morphine and Versed.
None of these treatments changed the patient's rhythm:
The patient's mentation continued to decline, and her BP started to crash. After three attempts, she was successfully cardioverted. Here is the post-conversion 12 Lead:
You transport your patient, now stable, to the medical center without incident.
So, now the key questions:
- What was the presenting rhythm and why?
- What is the post-conversion rhythm and why?
- What are the best treatment options for this rhythm?