NAPLEX® Review Question of the Week: Unbreak My Heart

This acute emergency requires your pharmacologic expertise. Are you ready for the challenge?
NAPLEX® Review Question of the Week: Unbreak My Heart
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JL is a 62-year-old female who was found unresponsive in a mall parking lot. She was taken to the ER by ambulance. The medical team has been performing CPR for about 10 minutes, and JL has received defibrillation shocks twice based on her EKG that demonstrates that she is in ventricular fibrillation. 

PMH: Unknown

Labs/Vitals:

Ht: 5’ 8”

Wt: 182 lbs

BP: 64/43 mmHg

HR: 150 BPM

Temp: 98.1 F

Glucose: 83 mg/dL

Last labs from one month ago while hospitalized at same hospital:

Scr: 2.1 mg/dL

Na: 142 mEq/L (135-145 mEq/L)

Cl: 96 mEq/L (96-106 mEq/L)

K: 3.8 mEq/L (3.5-5 mEq/L)

Ca: 9 mg/dL (8.5-10.5 mg/dL)

Mg: 2 mg/dL (1.8-2.6 mg/dL)

Phosphorus: 3.1 mg/dL (2.8-4.5 mg/dL) 

Medications Administered during current episode of care:

Epinephrine 1 mg every 3 minutes (3 doses so far)

Narcan 8 mg intranasal - no change in response

NS 1 liter IV bolus 

What would be your next step to help JL in conjunction with continued CPR?

A. Amiodarone 300 mg IV bolus

B. Atropine 1 mg IV bolus

C. Adenocard 6 mg IV bolus

D. Continue epinephrine

Answer with rationale:

Ventricular fibrillation is when the ventricle cannot perfuse blood to the body. Without correction, the patient will die and thus rapid correction is critical. The most important step of acute cardiac life support (ACLS) is giving appropriate CPR while activating emergency services if not already done. The rate and depth of CPR should be 30 compressions 2 inches deep followed by 2 breaths (100-120 compressions/minute). In addition, ventricular tachycardia or fibrillation are known as "shockable rhythms" in that defibrillation can provide significant benefit to correct their abnormal rhythm. Examples of ACLS scenarios where defibrillation is not helpful would be asystole or paroxysmal supraventricular tachycardia (PSVT). Therefore the next action is to defibrillate someone like JL who is in ventricular fibrillation, allowing the heart to reset its rhythm. The final step of ACLS is to ensure correct medications are given based on the ACLS algorithm. The algorithm for ventricular tachycardia/fibrillation from the American Heart Association can be found here: https://www.aclsmedicaltraining.com/adult-cardiac-arrest-vtach-and-vfib/.  

Answer A is correct. This dose would be the correct first dose of amiodarone for ventricular fibrillation followed by 150 mg IV bolus if needed. For stable patients requiring IV amiodarone, the dosing is generally a 150mg IV bolus given over 10 minutes, followed by a drip of 1mg/min IV for 6 hours, followed by 0.5mg/min for 18 hours. 

Answer B is incorrect. This medication and dose would be the correct dose for bradycardia with a pulse.

Answer C is incorrect. This would be the correct medication and dose for tachycardia with a pulse in a stable patient. A repeat dose of 12mg can also be administered if necessary. Adenosine when administered will demonstrate a brief flatlining of the EKG  which is normal but should resolve within a few seconds due to the short half-life. Although flushing after administration of all ACLS medications is suggested, it is extremely important to flush with NS after adenosine because it gets rapidly metabolized by red blood cells. 

Answer D is incorrect. At this point, JL has already received 2 shocks, so ACLS guidelines suggest starting either amiodarone or lidocaine since refractory to measures provided so far.

Brand/Generics Covered:

Epinephrine (Adrenalin), Naloxone (Narcan), Amiodarone (Pacerone), Atropine (Various including Atropen for organophosphate poisoning), Adenosine (Adenocard)

NAPLEX Competencies Covered:

1.1 - Laboratory findings

1.5 - Signs or symptoms of medical conditions

2.2 - Brand or generic

3.4 - Drug dosing

5.5 - Instructions or techniques for drug administration

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