ACLS Review Questions

3.  A 26 year old male who was an unrestrained driver in a motor vehicle accident was admitted to ICU with a diagnosis of cardiac contusion.  On admission is alert and oriented but complains of some chest discomfort.   His initial vital signs are 98.4-90-24.  His oxygen saturations are 95% on 2L/min via nasal cannula.  The cardiac troponin done in the ER is 0.31 and his chest film showed a normal cardiac silhouette.  Three hours after admission, he becomes more anxious and restless.  His skin is noted to be more cool and clammy.  His heart rate is now up and his blood pressure is 88/60.  He is also noted to have some jugular venous distension.  As you prepare to call the cardiologist, the patient becomes unresponsive, pulseless, and apneic but continues to display this rhythm on the monitor:

What is the appropriate treatment for this patient?

A.      Immediate cardioversion at 50 J then reassess the rhythm

B.      Initiate vagal maneuvers

C.      Administer adenosine 6mg rapid IV push

D.      Begin CPR and prepare for a pericardiocentesis

Answer D   Begin CPR and prepare for a pericardiocentesis

The patient has developed PEA secondary to cardiac tamponade.  Pulseless electrical activity displays an electrical rhythm on the monitor but the patient is pulseless and without perfusion.   Initial treatment is aimed at improving hemodynamics by administering vasoconstrictors such as epinephrine and vasopressin.   The most important aim is identify and treat the underlying cause of the PEA rhythm.   This patient has a cardiac contusion which has lead to a cardiac tamponade.  With cardiac tamponade the blood in the pericardial sac squeezes the cardiac chambers and reduces the volume of blood that is ejected during cardiac contraction.  This patient exhibited signs of right side failure by the presenting signs of JVD and reduced pulse pressure.  Answer A is appropriate for a patient with unstable SVT but not for a patient with a fast PEA rhythm.  Answer B may be tried on a symptomatic patient with SVT.  The patient in this scenario is unresponsive and apneic.   Answer C.  Adenosine may be given to a patient with symptomatic SVT because it helps to stop the reentry cycle of the supraventricular rhythm.  It has no value in treating the tachycardia associated with obstructive shock. 

Reviewed 3/1/16