History of Present Illness:
A 75-year-old woman is brought to the Emergency Department by EMS. Her family states the patient complained of gradually worsening generalized weakness and decreased responsiveness over the course of the previous week. They also state that she is “not being herself”. EMS noted the patient to be minimally responsive, bradycardic, and hypotensive en route to the hospital.
Allergies: codeine, penicillin
Vitals: T 36.2 C, HR 40, BP 86/43, RR 18, O2 97% on 15 L nonrebreather
Gen: obtunded, oriented x 1, responds to name but not oriented to place or time
HEENT: NC/AT, PERRL, EOMI, no conjunctival pallor, TMs clear b/l, mucous membranes dry, no tonsillar exudates or erythema, + gag reflex
Neck: supple, FROM, no JVD, trachea midline, no cervical LAN
Heart: bradycardic, regular rhythm, no murmurs, rubs, or gallops.
Lungs: clear to auscultation b/l in all fields, no wheezes/rales/rhonchi, normal respiratory effort
Abdomen: soft, nontender, nondistended, bowel sounds normoactive, no rebound/masses/guarding
Vascular: capillary refill 3 seconds, pulses thready but palpable in all four extremities.
Neuro: responds to her name, follows commands. Eyes open spontaneously. Tongue and uvula are midline. Moving all four extremities.
Skin: + mild diaphoresis, no rashes
1. Given this patient’s overall clinical picture, what would be the most appropriate initial course of action?
A. Place patient on a monitor, establish IV access, and administer 0.5 mg doses of atropine while preparing for transcutaneous pacing.
B. Place patient on a monitor, establish IV access, and administer 325 mg of aspirin, 0.4 mg nitroglycerin sublingual, and morphine at 0.1 mg/kg.
C. Place patient on a monitor, establish IV access, and administer CPR while preparing a cardiac defibrillator.
D. Place patient on a monitor, establish IV access, and administer adenosine 6 mg rapid IV push.
E. Place patient on a monitor, establish IV access, and administer a one liter fluid bolus of normal saline
2. Electrical capture by transcutaneous pacing is confirmed by which of the following?
A. A p-wave, QRS complex, and t-wave showing a first-degree heart block pattern
B. A pacing spike followed by a p-wave, QRS complex, and t wave all of normal morphology
C. A return to normal rate with no change in rhythm
D. A return to normal sinus rhythm with normal rate
E. A widened QRS after each pacing spike
3. Which of the following statements regarding cardiac pacing is true?
A. Although alternative approaches are acceptable, the femoral vein is the preferred site of percutaneous access for placement of the transvenous pacer.
B. Hypothermia is a relative contraindication to transvenous pacing.
C. Second degree heart block type I (Wenckebach) is among the indications for transvenous pacing.
D. Transvenous pacing is underutilized in traumatic cardiac arrest and evidence suggests that it may be beneficial in some cases
E. When compared with the blind insertion technique, ECG-guided transvenous pacer insertion has been shown to be faster.
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