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Megacode Scenario 1

You are called to see a 57-year-old female patient admitted to the orthopedic ward following a motor vehicle accident. Her past medical history is notable for a history of hypothyroidism since adolescence, for which she takes levothyroxine.

She is complaining of palpitations. On examination, you find:

• Cardiovascular: irregularly irregular pulse, heart rate of 94. Blood pressure of 94/48

• Skin: Warm with normal capillary refilling time.

• Respiratory: rate of 20 breaths per minute, lungs are clear and equal bilaterally

• CNS: Patient alert and oriented

1. Identify the rhythm. a-fib.jpg
a. Stable Ventricular Tachycardia.
b. Unstable Ventricular Tachycardia.
c. Atrial Fibrillation.
d. Atrial Flutter.
2. What are the diagnostic features of atrial fibrillation on an ECG?
a. Absence of P wave and a widely variable ventricular response.
b. Irregular PR interval.
c. Tall T wave.
d. Presence of Q wave.
3. While you are evaluating the patient, she suddenly becomes unstable with a blood pressure of 74/36. What would be your next immediate step?
a. Intravenous Amiodarone.
b. Intravenous Sotalol.
c. Immediate defibrillation.
d. Immediate synchronized cardioversion.
4. What is the recommended initial energy using a biphasic waveform defibrillator when cardioverting unstable atrial fibrillation?
a. 50 – 100 J
b. 120 – 200 J
c. 200 – 300 J
d. 360 J
5. What is your most important concern before cardioversion if the atrial fibrillation has been present for more than 48 hours?
a. Hypotension.
b. Sudden cardiac arrest.
c. Systemic embolization.
d. Congestive heart failure.
6. You successfully cardioverted the patient to a normal sinus rhythm. Out of the following available drugs what would have been your initial drug of choice for treatment if patient was hemodynamically stable?
a. Intravenous Adenosine 12 mg bolus.
b. Intravenous Amiodarone 150 mg.
c. Intravenous Sotalol 1.5 mg/kg.
d. Metoprolol 5 mg orally.
7. Major goals in the management of atrial fibrillation include all of the following except:
a. Ventricular rate control.
b. Assessing need for anticoagulants.
c. Restoring sinus rhythm.
d. All of the above.
e. None of the above.
8. The patient suddenly becomes unconscious with no palpable pulse, but the cardiac monitor still shows sinus rhythm. You begin CPR. What is your next course of action out of the following?normal-sinus-rhythm.jpg 
a. Repeat cardioversion.
b. Intravenous epinephrine.
c. Intravenous atropine.
d. Defibrillation.
9. What is the condition of having no palpable pulse with an organized rhythm present on the monitor called?
a. Ventricular fibrillation.
b. Ventricular tachycardia.
c. Asystole.
d. Pulseless electrical activity.
10. Before the 2010 ACLS guidelines, which of the following drugs was commonly used in the treatment of PEA?
a. Magnesium.
b. Calcium.
c. Atropine.
d. Isoprotrenol.
11. After CPR and IV epinephrine, the patient regains consciousness and goes into a symptomatic sinus bradycardia (heart rate 40). You decide to give atropine. What is the initial dose of atropine you will consider? sinus-bradycardia.jpg
a. 0.5 mg.
b. 0.6 mg.
c. 1.0 mg.
d. 1.2 mg.
12. The patient has a worsening symptomatic bradycardia (heart rate 34) with complaints of dizziness and confusion. Atropine has failed to elicit any response. Of the following, which would be the next logical action?sinus-bradycardia.jpg
a. Transcutaneous pacing.
b. Transvenous pacing.
c. Implantable cardiac pacemaker.
d. Cardioversion
13. Transcutaneous pacing fails to elicit any response and the patient continues to worsen. What would be your next step?
a. Start Epinephrine infusion 2-10 mcg/min
b. Start Norepinephrine infusion 1-2 mcg / min
c. Start Phenylephrine infusion 1-2 mcg/min
d. Start Dopamine infusion 5-15 mcg/minute
14. Transcutaneous pacing may be indicated for all of the following except?
a. Symptomatic bradyarrhythmia
b. Standby pacing.
c. Bradyarrhythmia with or without escape rhythm.
d. Severe hypothermia.
15. Which of the following is not a common cause of pulseless electrical activity?
a. Tension Pneumothorax.
b. Thromboembolic phenomenon.
c. Hyperkalemia.
d. Hypomagnesemia.
16. What is one of the most common neurological complications encountered in patients suffering from atrial fibrillation?
a. Stroke.
b. Cerebral Hemorrhage
c. Seizures.
d. Migraine.
17. What is National Institute of Neurological Disorders and Stroke critical time goal for instituting treatment in a patient with stroke (from time of ED arrival)?
a. 30 minutes.
b. 45 minutes.
c. 60 minutes.
d. 90 minutes.
18. What does time zero mean in terms of determining time goals in patients suffering from stroke?
a. The first time symptoms were noted by an observer.
b. Last time the patient was known to be neurologically intact.
c. The time of arrival in the hospital.
d. The time when seen by a specialist.
19. All of the following are contraindications for fibrinolytic therapy in treating stroke except:
a. Intracranial hemorrhage.
b. Current use of an anticoagulant with INR >1.7.
c. Spine surgery or head trauma within last three months.
d. Venous puncture at non compressible site with in previous 7 days.
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