A 67 year old man has collapsed and is on the floor. He is pale, clammy, and moaning, with vomit around his mouth. Vital signs are BP 70/30, P110 and weak R 28 and shallow. Oropharynx is clear and lungs are clear bilaterally. His ECG is shown below. What should you do?

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Multiple Choice

A 67 year old man has collapsed and is on the floor. He is pale, clammy, and moaning, with vomit around his mouth. Vital signs are BP 70/30, P110 and weak R 28 and shallow. Oropharynx is clear and lungs are clear bilaterally. His ECG is shown below. What should you do?

When a patient is unstable due to a tachyarrhythmia but still has a pulse, the immediate treatment is synchronized cardioversion. The signs here—hypotension, pallor, clammy skin, altered mental status, and poor perfusion—show he is hemodynamically unstable from a rapid rhythm. Delivering a synchronized shock to the heart resets the rhythm while avoiding delivery on the vulnerable part of the cycle (the T wave), which reduces the risk of converting to a worse rhythm. Start with a moderate energy, about 100 joules, and escalate if needed. Adenosine is reserved for stable, narrow-complex tachycardias and can worsen instability or hypotension in this setting, so it isn’t appropriate here. Epinephrine would be used in pulseless arrests or persistent instability after other measures, not as the first-line treatment when a shockable rhythm with a pulse is present. Defibrillation is used when there is no pulse (pulseless VT or VF), not when a pulse exists.

When a patient is unstable due to a tachyarrhythmia but still has a pulse, the immediate treatment is synchronized cardioversion. The signs here—hypotension, pallor, clammy skin, altered mental status, and poor perfusion—show he is hemodynamically unstable from a rapid rhythm. Delivering a synchronized shock to the heart resets the rhythm while avoiding delivery on the vulnerable part of the cycle (the T wave), which reduces the risk of converting to a worse rhythm. Start with a moderate energy, about 100 joules, and escalate if needed.

Adenosine is reserved for stable, narrow-complex tachycardias and can worsen instability or hypotension in this setting, so it isn’t appropriate here. Epinephrine would be used in pulseless arrests or persistent instability after other measures, not as the first-line treatment when a shockable rhythm with a pulse is present. Defibrillation is used when there is no pulse (pulseless VT or VF), not when a pulse exists.

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