MCEM OSCE Part C: Arrythmia Management

If you are encountered with a patient with an AF or 2 degree/3 degree heart block, and asked to manage the patient, you are supposed to follow the following steps:

(The likely hint in the scenario would be that there would be a mannequin and you will be asked to demonstrate your skill to cardiovert or pace the patient. If there is a live patient, the patient would be stable and you do not have do either of these.)

• Introduce
• Transfer the patient to the Resuscitation area
• Establish Monitoring, IV access, Nasal Oxygen, and re-obtain vitals
• Ask for Labs: Venous Blood Gases for electrolytes, glucose, CBC, U & Es, Septic screen, thyroid functions for A Fib,
• CXR
• 12 Lead EKG
• Like to know if the patient has any chest pain, dizziness, SOB, syncope
• Obtain history of underlying lung disease, heart disease, thyroid disease, recent illnesses, duration of onset of symtpoms <48 ekgs="" hrs="" li="" old="">
• Medications, allergies, last meal, previous anesthesia and complications
• For AF if patient is unstable Cardiovert:

1. Consent
2. Anesthesia backup
3. Prepare airway trolley
4. Procedural sedation: Fentanyl and Midazolam
5. Attach Pads
6. Synchronize
7. Get the people and Oxygen away
8. Current 100 mA
9. Check Pulse
10. 12 Lead EKG
11. Reassess Patient
12. Consult Cardiology and Admit in ITU
13. At this moment, tell the examiner that I would like to Calculate the CHAD2 Score and get a bedside echocardiogram done.

CHAD2: CHF, Hypertension, Age > 75, DM, TIA/Stroke
CHAD gets 1 each, TIA/Stroke gets 2
0 - 1: Aspirin, 2: Grey Zone (Aspirin or Warfarin), 2+ Warfarin

• For Blocks:

1. Assess Risk of Asystole: Recent Asystole arrest, Ventricular Pause > 3 secs, 2nd degree heart block, 3rd degree heart block with Wide QRS
2. IV Atropine 0.5 mg, Can repeat in 5 minutes
3. IV Glucagon 2 mg if Beta/Calcium channel blocker toxicity
4. Arrange for TCP
5. Consent
6. Anesthesia backup
7. Prepare airway trolley
8. Procedural sedation: Fentanyl and Midazolam
9. Clean/dry/shave chest
10. Attach Pads and leads (2 cm away because of risk of arcing)
11. Mode: Pacing/Demand
12. Rate: 80/minutes
13. Current 10 mA in increment upto 50 - 100 mAmp
14. Look for Capture
15. Check Pulse
16. 12 Lead EKG
17. Reassess the patient (Tell the examiner that there is no risk of electrical hazard in touching patient during pacing)
18. Consult Cardiology for Invasive IJV Pacing
19. Reassess Patient
20. Consult Cardiology and Admit in ITU