Which of the following is the most appropriate next step in management for this patient’s condition?
This patient presents to the Emergency Department after a cardiac arrest with an unknown medical history. Important components of Basic Life Support (BLS) include early initiation of high-quality CPR at a rate of 100-120 compressions/minute, compressing the chest to a depth of 5 cm (5 inches), providing 2 rescue breaths after every 30 compressions (30:2 ratio), avoiding interruptions to CPR, and allowing for adequate chest recoil after each compression. In the Advanced Cardiovascular Life Support (ACLS) algorithm, intravenous epinephrine is administered every 3-5 minutes and a “pulse check” is performed after every 2 minutes of CPR. The patient’s cardiac rhythm, along with the clinical history, helps decide if the patient should receive additional medications or receive unsynchronized cardioversion (defibrillation, or “electrical shock. The ACLS algorithm divides management in patients with pulseless ventricular tachycardia (pVT) or ventricular fibrillation (VF) and patients with pulseless electric activity (PEA) or asystole.
The cardiac rhythm seen during the pulse check for this patient is ventricular fibrillation. The ACLS algorithm advises unsynchronized cardioversion at 150-200 Joules for patients with pVT or VF. Continuing chest compressions (Choice A) with minimal interruptions is a crucial component of BLS, however, this patient’s cardiac rhythm is shockable. Defibrillation (Choice B) takes precedence over CPR in this scenario. Amiodarone (Choice C) is an antiarrhythmic agent that is recommended in patients with pVT, in addition to unsynchronized cardioversion. This patient has VF, not pVT. Sodium bicarbonate (Choice D) is an alkaline medication that is helpful in cardiac arrests caused by severe acidosis or certain toxins (i.e. salicylates or tricyclic antidepressants). The next best step in this patient scenario would be defibrillation for the patient’s VF (Choice B).
For medical students! – Question of The Day – A 68-year-old man presents to the Emergency department after a witnessed collapse. ❓Which of the following is the most appropriate next step in management for this patient’s condition ❓ pic.twitter.com/N5HIjINtpx— iem-student (@iem_student) November 27, 2020
- Ionmhain, U.N. (2020). Basic Life Support. Life in the Fast Lane. Retrieved from https://litfl.com/basic-life-support-bls/
- Nickson, C. (2020). Ventricular Fibrillation. Life in the Fast Lane. Retrieved from https://litfl.com/ventricular-fibrillation/
- Ong, M.H., Leong, B.H., & Ng, Y (2020). Defibrillation and electrical cardioversion. Tintinalli, J.E., Ma, O., Yealy, D.M., Meckler, G.D., Stapczynski J, Cline, D.M., & Thomas, S.H. (Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353§ionid=204498618