A 55-year-old man is brought to the emergency department due to sudden onset of palpitations and chest tightness. His other medical problems include hypertension, gout, and type 2 diabetes mellitus. Cardiac monitoring shows atrial fibrillation at a rate of 120-140/min. His initial blood pressure is 112/70 mm Hg and oxygen saturation is 92% on room air. As the nurse is attempting to establish intravenous access, the patient becomes unresponsive. There is no palpable pulse over the carotids or femoral arteries, and he has agonal breathing. The cardiac monitor still shows atrial fibrillation at the same rate. Which of the following is the best next step in management of this patient?

Question

A 55-year-old man is brought to the emergency department due to sudden onset of palpitations and chest tightness.  His other medical problems include hypertension, gout, and type 2 diabetes mellitus.  Cardiac monitoring shows atrial fibrillation at a rate of 120-140/min.  His initial blood pressure is 112/70 mm Hg and oxygen saturation is 92% on room air.  As the nurse is attempting to establish intravenous access, the patient becomes unresponsive.  There is no palpable pulse over the carotids or femoral arteries, and he has agonal breathing.  The cardiac monitor still shows atrial fibrillation at the same rate.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d17c_8c02_bc81_056c339d28dc_MD0003_00 Pulseless electrical activity (PEA) is the presence of an organized rhythm (eg, atrial fibrillation in this patient) on cardiac monitoring without a palpable pulse (or measurable blood pressure) in a cardiac arrest patient. The advanced cardiac life support (ACLS) guidelines recommend managing PEA with cardiopulmonary resuscitation (CPR) and vasopressor therapy (eg, epinephrine) to achieve adequate cerebral and coronary perfusion. CPR should be continued while attempts are made to identify and treat the reversible causes of PEA (5 Hs and Ts). (5 Hs and Ts) PEA, a nonperfusing rhythm treated similarly to asystole, is NOT a shockable rhythm. Therefore, there is no role for defibrillation or synchronized cardioversion in patients with PEA or asystole. Defibrillation delivers energy randomly during the cardiac cycle without synchronization to the QRS complex. In cases of cardiac arrest, defibrillation is used in patients with ventricular fibrillation. It is also used in patients with pulseless ventricular tachycardia (VT), which, despite also being a nonperfusing rhythm, does require defibrillation (by contrast to PEA/asystole, which does not) (Choice C). Synchronized cardioversion delivers energy synchronized to the QRS complex. It is used in symptomatic or sustained monomorphic VT (unresponsive to antiarrhythmics) and hemodynamically unstable atrial fibrillation with rapid ventricular response. However, if the patient develops PEA (as in this case) or asystole, ACLS guidelines should be followed (Choice E). (Choice A) An arterial blood gas analysis should be performed while CPR is being administered to assess for and correct hypoxia as a potential reversible cause of PEA. CPR had not been initiated in this patient. (Choice D) Intravenous lidocaine is a second-line antiarrhythmic agent used for hemodynamically stable monomorphic VT. Intravenous epinephrine (1 mg every 3-5 minutes) is recommended in the American Heart Association guidelines for the treatment of cardiac arrest with PEA. These guidelines do not recommend the routine use of atropine in patients with PEA due to lack of therapeutic benefit. Educational objective: Pulseless electrical activity (PEA) or asystole should be managed with uninterrupted cardiopulmonary resuscitation along with vasopressor therapy to maintain adequate cerebral and coronary perfusion. Potentially reversible causes of PEA should also be investigated. Defibrillation or synchronized cardioversion has no role in the management of these patients. References: Continuous mechanical chest compression during in-hospital cardiopulmonary resuscitation of patients with pulseless electrical activity. (http://www.ncbi.nlm.nih.gov/pubmed/21126816)

A 55-Year-Old Man Is Brought to the Emergency Department Due