You are called emergent to a 36-year-old female who feels weak. About 30 minutes ago, while trying to sleep, she felt her heart "racing." She now complains of chest pain versus palpitations. She denies other medical history or allergies and only takes birth control. Skin is pink, warm, and dry.
1. Obtain baseline vitals, start an IV, and give a 1 L fluid bolus before applying the monitor 2. Obtain baseline vitals, apply the cardiac monitor, and place her in a position of comfort 3. Obtain baseline vitals, apply high-flow oxygen, and begin transport without a rhythm check 4. Apply defibrillation pads and prepare to deliver a synchronized shock immediately
Answer: A rhythm and a full set of vitals decide everything that follows. Oxygen is given only if hypoxemic, and shock or fluid before knowing the rhythm and perfusion status is premature.
She is stable. Vitals: BP 122/80, HR 160, RR 22, SpO2 99% on room air. The monitor shows a regular, narrow-complex tachycardia without visible P waves.
1. Give 6 mg of adenosine by rapid IV push followed by a 20 mL saline flush 2. Deliver synchronized cardioversion at the lowest available energy because the rate is above 150 3. Apply a non-rebreather at 15 L/min and a 500 mL fluid bolus to slow the heart rate 4. Establish IV access, obtain a 12-lead, and request ALS intercept for rhythm-specific treatment
Answer: She is perfusing well, so there is time for IV access, a 12-lead, and ALS. Adenosine and cardioversion are paramedic-level skills, and oxygen and fluids do not address the rhythm in a normoxic, normotensive patient.
1. Applying an ice pack to the forehead while the patient holds a deep inspiration 2. Modified Valsalva: strain against resistance for about 15 seconds, then lie supine with legs raised 3. Having the patient cough forcefully once every 5 seconds for 2 minutes 4. Bilateral carotid sinus massage held for 10 seconds on both sides at the same time
Answer: The modified Valsalva (strain, then immediate supine position with passive leg raise) has the highest conversion rate and is endorsed by AHA. Carotid massage is not appropriate for bilateral use or in the field without medical direction.
Ten minutes later she becomes lethargic and pale. BP is now 78/48, HR 168, and she reports worsening chest pain.
1. Sit her upright and give sublingual nitroglycerin to treat the worsening chest pain 2. Withhold treatment until the 12-lead is complete and has been fully interpreted by the receiving physician 3. Repeat the vagal maneuver two more times and reassess the blood pressure after each attempt 4. Recognize unstable tachycardia, maintain oxygenation, keep pads on, and expedite ALS intercept or transport
Answer: Hypotension with altered mentation and chest pain makes this unstable tachycardia, which requires immediate synchronized cardioversion by ALS. Delaying for more vagal attempts, nitroglycerin in a hypotensive patient, or waiting on a 12-lead all lose critical time.