191.A 32-year-old man with no past medical problems presents to the ED
with palpitations. For the past 2 days he has been feeling weak and over the
last 6 hours he has noticed that his heart is racing. He has no chest pain or
shortness of breath. He has never felt this way before. His temperature is
98.9°F, BP is 140/82 mm Hg, HR is 180 beats per minute, and RR is 14 breaths
per minute. His physical examination is normal. You obtain the following
rhythm strip. What is your first-line treatment for this patient?
208 Emergency Medicine
a. Synchronized cardioversion at 100 J
b. Adenosine 6-mg intravenous (IV) push
c. Adenosine 12-mg IV push
d. Valsalva maneuver
e. Verapamil 3-mg IV push
192.You are a passenger aboard an airplane and a 78-year-old woman is
complaining of chest pain and difficulty breathing. You are the only med-
ical professional available and volunteer to help. Fortunately, the aircraft is
well-equipped with basic medical equipment, as well as with advanced car-
diac life support (ACLS) medications and a cardiac monitor. On examina-
tion, the passenger’s BP is 75/40 mm Hg, HR is 180 beats per minute, and
RR is 24 breaths per minute. On examination, the patient is in obvious dis-
tress, but able to answer basic questions. Her heart is tachycardic, regular,
and without murmurs, rubs, or gallops. Physical examination is remark-
able for a bounding carotid pulse. You attach the cardiac monitor and see a
regular rhythm at 180 beats per minute with wide QRS complexes and no
obvious P waves. After asking the pilot to make an emergency landing,
what do you do next?
a. Amiodarone IV
b. Synchronized cardioversion
c. Verapamil IV
d. Lidocaine IV
e. Procainamide IV