I had the opportunity to be a true senior resident a couple of months ago.
The patient was a 70ish year-old AA female, found down at home, pulseless and apneic. Rhythm was PEA, EMS started ACLS and brought her to King. I was the blue side senior, so I went to the critical area to help out. The critical area was full, and the juniors were overwhelmed. The first rhythm was PEA...gave epi and atropine. Then v-tach. We shocked her twice. Now sinus tach...for a second, then back to v-tach. Charge the paddles...
...paramedics provide some additional history. ESRD, HTN, DM, among other things. Meds include a beta-blocker, but no digoxin. Okay, lets give the patient bicarb and calcium chloride. Epi, CPR, check pulse. Is that a pulse??
A very weak carotid pulse is palpated. Check BP. 60/p. Hmmm, let's go ahead and start a dopamine infusion. What's the HR? 52. Let's try transcutaneous pacing. Pads on chest, set the machine...and...it works!! BP 110/59, HR at a perfect 60 bpm. The TC pacemaker isn't going to hold, perhaps we'll set up for a transvenous, just in case. Anterior approach to the internal jugular (avoid the carotid artery)...insert cordis catherter, perfectly. Now we have great access for CVP, and TV pacing. Call CCU...and wait.
A-line (that I also placed) indicates the BP is dropping. Now the TC pacemaker isn't capturing. Grab the attending, Dr. Salem. Get the TV pacer...we float it to the appropriate place in the right ventricle. Instantly, her BP is back up to normal limits...her radial pulse is strong, and her HR is at 60 again.
Wow, this stuff really works.