A 15-year-old adolescent boy is brought to the emergency department via ambulance after co… — USMLE Step 2 CK

A 15-year-old adolescent boy is brought to the emergency department via ambulance after collapsing during a high school basketball game. His friends report that he complained of a "racing heart" and severe shortness of breath right before feeling dizzy and sitting down on the court. He has a past medical history of a congenital heart defect that was surgically repaired during infancy, though he has not followed up with a cardiologist in several years. On arrival, he is agitated and diaphoretic. His temperature is $37.1^\circ\text{C}$ ( $98.8^\circ\text{F}$ ), blood pressure is $72/40 \text{ mm Hg}$ , pulse is $215/\text{min}$ , and respiratory rate is $28/\text{min}$ . Pulse oximetry shows $93\%$ on room air. Physical examination reveals a right ventricular heave and a well-healed midline sternotomy scar. An electrocardiogram demonstrates a wide QRS complex tachycardia with a uniform morphology. Which of the following is the most appropriate next step in the management of this patient?

Perform synchronized direct current cardioversionCevap
B
Obtain a computed tomography pulmonary angiogram
C
Administer intravenous vancomycin and ceftriaxone
D
Administer nebulized albuterol and intravenous methylprednisolone
E
Obtain an arterial blood gas to calculate expected respiratory compensation

Cevap

Perform synchronized direct current cardioversion

The correct answer is to perform synchronized direct current cardioversion. This patient has a history of surgically repaired congenital heart disease, which frequently involves a ventriculotomy or patching (e.g., in Tetralogy of Fallot). These myocardial scars serve as a nidus for reentrant arrhythmias later in life, making sustained monomorphic ventricular tachycardia a well-known late complication. The electrocardiogram description (wide QRS complex tachycardia with a uniform morphology) confirms ventricular tachycardia. Because the patient is exhibiting clear signs of hemodynamic instability—including severe hypotension, poor perfusion (diaphoresis), and altered mental status (agitation)—immediate synchronized direct current cardioversion is required to restore normal sinus rhythm and prevent progression to pulseless cardiac arrest.

Adım Adım Çözüm

Analyze the electrocardiogram findings in the context of the patient's history.

The patient has a wide QRS complex tachycardia with uniform morphology, indicating monomorphic ventricular tachycardia (VT). His history of a repaired congenital heart defect (likely Tetralogy of Fallot) puts him at high risk for right ventricular scarring and subsequent arrhythmias.

Identifying the rhythm is the first step in applying the correct pediatric/adult advanced life support algorithm.

Assess the patient's hemodynamic status.

The patient exhibits hypotension (

72/40 \text{ mm Hg}

), agitation, and diaphoresis.

Hemodynamic instability dictates whether the management should be pharmacologic (for stable patients) or electrical (for unstable patients).

Determine the definitive next step in management.

Immediate synchronized direct current cardioversion is selected.

For any unstable tachyarrhythmia with a palpable pulse, synchronized cardioversion is the immediate standard of care to restore cardiac output and prevent cardiac arrest.

Anahtar Kavram

Patients with repaired congenital heart disease (such as Tetralogy of Fallot) are at high risk for late ventricular arrhythmias; hemodynamically unstable ventricular tachycardia must be treated immediately with synchronized cardioversion.

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Cevap

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