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A 75-year-old male with HTN, DM2, ESRD, PVD, and CAD with a CABG in the past is admitted with an acute ST elevation myocardial infarction status post–cardiac stent placement. He has a BP of 90/50, and a heart rate of 110 bpm early in the morning. You are at the nurses' station and the telemetry monitor goes off showing the rhythm in Figure 14-1.

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Figure 14-1.
Graphic Jump Location

Ventricular fibrillation with disorganized rhythm.

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1. What do you do next?

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Answer

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  1. Call a code blue, followed by cardioversion and IV amiodarone.

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Ventricular Fibrillation

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Diagnosis

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VF is the most frequent mechanism of sudden cardiac death (SCD). It is a rapid, disorganized ventricular arrhythmia resulting in no uniform ventricular contraction, no cardiac output, and no recordable blood pressure. The electrocardiogram in VF shows rapid (300–400 bpm), irregular, shapeless QRST complexes with variable amplitude, morphology, and intervals. Over time, these waveforms decrease in amplitude. Ultimately, asystole occurs.

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Treatment

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Immediate unsynchronized cardioversion is the treatment of choice, followed by intravenous antiarrythmics such as amiodarone.

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  • Quick recognition of arrhythmias is important and comes with practice and experience.
  • Anticoagulation with warfarin has significant risks, so should be reserved for patients with high CHADS2 scores.
  • Mortality outcomes are similar for patients with atrial fibrillation who are treated with rhythm control compared with those treated with rate control.

Ahya SN, Flood K, Paranjothi S. Cardiac Arrhythmias. The Washington Manual of Medical Therapeutics. 30th ed. Philadelphia: Lippincott Williams & Wilkins; 2001:153–167.
Cheng A, Kumar K. Overview of atrial fibrillation. In: Zimetbaum P, Saperia G, eds. UpToDate. 2012.
Phang R. Overview of the evaluation and management of atrial flutter. In: Zimetbaum P, Saperia G, eds. UpToDate. 2012.

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