205.A 48-year-old man is brought to the ED by paramedics for general-
ized weakness. His medical history is significant for a CABG last month. He
has been unable to get out of bed for the past day because of dizziness
when changing position. He denies chest pain, shortness of breath, or syn-
cope. His temperature is 98.9°F, BP is 86/60 mm Hg, HR is 44 beats per
minute, RR is 18 breaths per minute, and oxygen saturation is 98% on
room air. There is a well-healing midline sternotomy incision. Cardiac
examination reveals a III/VI systolic ejection murmur. There are minimal
rales at his lung bases. He is immediately attached to the cardiac monitor.
His rhythm strip is shown below. What is your initial treatment?
214 Emergency Medicine
a. Observe on monitor
b. Transcutaneous pacing
c. Transvenous pacing
d. Atropine 0.5-mg IV
e. Epinephrine IV drip at 2 μg/min