Wed3November0903PM 6

A 75-year-old woman is admitted with a pre-syncopal episode.

She had felt as though she were going to 'black out' whilst out shopping and an ambulance was called. She denies chest pain and shortness of breath. She has a past history of hypertension for which she has been taking a diuretic.

On examination she is conscious and has a BP of 85/40 mmHg. Her ECG is shown below:

What is the immediate management?

(Please select 1 option)

DC cardioversion Correct

IV lidocaine

Sotalol

IV amiodarone

IV flecainide

Explanation

The electrocardiogram (ECG) shows a wide complex tachycardia with a rate of about 200 with marked left axis deviation.

On careful examination of the rhythm strip there is evidence of independent atrial activity - P waves can be seen 'marching through' the QRS complexes. Even without demonstrating independent P waves the QRS width, axis deviation and rate all suggest a ventricular origin rather than a supraventricular origin.

This is not torsades, as there is no characteristic twisting about the isoelectric line, and it is not ventricular fibrillation (VF) since there is a regular pattern to the QRS complexes.

Another possibility (not listed here) is ventricular flutter but this would normally have an even higher rate.

Since this lady is elderly and compromised with a low blood pressure, even though she is asymptomatic, the treatment of choice is DC cardioversion.

An anaesthetist needs to be called to assist with direct current cardioversion (DCCV) which should be 'synchronised' to limit the risk of conversion to VF.

Should she deteriorate in the meantime and become pulseless, then a praecordial thump should be given, followed immediately by DCCV if not successful.

Answer Statistics

1

93%

2

1%

3

1%

4

6%

5

2%

Times answered: 276