UPDATED: 11/06/2007 - Patient Follow-Up Posted.  CLICK HERE FOR THE ANSWER

EKG Case Presentation:
You are dispatched to the street corner of a large outdoor street fair, amid a substantial crowd of people. Your patient is a 52–year-old female who complains of feeling dizzy. Having responded to numerous dizzy/fainting calls that are typical of high temperatures, you adjust your preparations to account for this seemingly routine call. You and your partner bring a monitor, oxygen, and IV supplies, leaving the rest behind in the ambulance, which is several hundred yards away from the patient. You think, “Why carry what you don't need?” Fifteen minutes after dispatch, you arrive at the scene.

Initial Assessment:
As you and your partner push through the crowd, someone runs up to you and helps guide you to the patient. You find a fit-looking 52-year-old female sitting down on a stool provided by a street vendor. Her complexion appears very pale, her eyes are closed, and she responds to your assessment questions slowly but clearly. Giving your partner a nod, a gurney is prepared for the patient. You reach down to assess her radial pulse.

You find that you are unable to feel a radial pulse, which fits perfectly with her presentation so far. You decide to move her to the gurney right away, thinking that placing her in a reclined position might improve her condition. She is able to make the transfer with some assistance, but appears ready to lose consciousness at any moment. Again, you attempt the radial pulse and do not get one.

You inform the patient that you are going to check her pulse on her neck. Without saying a word of instruction, your partner slips a nasal cannula over her nose and then spikes a 1000cc IV bag of normal saline. Your partner then digs out your favorite tool — an 18-gauge catheter. You record the following assessment:

HR too fast to count properly 
RR 28 
BP 78 by palpation 
SpO2 not reading  
Pain 3/10

Past Medical History:
Gall bladder surgery
Two C-section births

Allergies: 
No known drug allergies (NKDA) 

Meds: (generic names)
Tylenol for occasional pain
Supplemental vitamins 

Initial Assessment:
In your initial assessment, you find a 52-year-old healthy-looking female with an altered level of consciousness on a hot summer’s day. Her skin is pale, hot, and dry. Her carotid pulse is thready and her heart rate is too fast to measure. A pulse oximeter is unable to detect a pulse. She appears to be in moderate distress with a rapid respiratory rate and a BP of 78 by palpation. You connect her to a 3-lead monitor and see an extremely rapid rhythm that appears to be wide and irregular. However, you are unsure due to significant glare caused by sunlight hitting the monitor.

Feeling unsatisfied with the findings so far, you decide to quickly start an IV in order to infuse as much fluid as possible while retreating to the ambulance. It takes two attempts due to flat veins, but an antecubital access is eventually obtained. With the IV running wide open, you ask a nearby police officer to help clear a pathway to the ambulance; you need to get there quickly.

Several minutes later, you push the gurney carrying the patient into the ambulance and your partner starts up the engine to get the air conditioning running and the interior lights powered. The patient’s condition has not changed and after 500cc's of fluid, she still does not have a palpable radial pulse. You quickly place seven electrodes on the patient to acquire a 12-lead and your partner climbs in the back to assist. The following printout is what you have to work with.

Initial EKG (click for larger image):

Clearly this patient is not responding well to treatment and needs an intervention before she suffers an ischemic cardiac event. Her altered level of consciousness and rapid heart rate should help you determine the urgency with which she will be treated. Your continued assessment and actions will determine the outcome of this patient.

• Was the fluid challenge of diagnostic benefit?
• What is the rhythm? How do you know?
• What should be the subsequent steps in her treatment? Why?
• Would you have done something different up until this point? If so, what and why?
  

UPDATED: 11/06/2007 - Patient Follow-Up Posted.  CLICK HERE FOR THE ANSWER