Rosh Emergency Medicine Practice Test

For a patient with polymorphic wide QRS complexes and altered consciousness, what is the most appropriate next management step?

1. Establish intravenous access and administer an adenosine bolus

2. Establish intravenous access and administer procainamide

3. Immediate defibrillation

4. Immediate synchronized direct current cardioversion

The correct answer is: Immediate defibrillation

In the context of a patient presenting with polymorphic wide QRS complexes in conjunction with altered consciousness, immediate defibrillation is crucial due to the high risk of life-threatening arrhythmias, such as Torsades de Pointes, especially when the patient is unstable (indicated by altered consciousness). This condition can lead to ventricular fibrillation, which is potentially fatal. Immediate defibrillation delivers an electrical shock intended to reset the heart's electrical activity, allowing it to resume a normal rhythm. The urgency of restoring normal heart function in a patient with altered consciousness emphasizes the need for this action, as the patient is likely experiencing poor perfusion and a compromised hemodynamic state. In contrast, other management options, such as administering medications like adenosine or procainamide, or performing synchronized cardioversion, are more appropriate for stable patients or different arrhythmia types. For example, adenosine is effective for certain types of narrow-complex tachycardias but may not be appropriate for wide QRS complexes or unstable patients. Procainamide, while useful in the management of wide complex tachycardias, is not the immediate action indicated in a life-threatening situation. Synchronized cardioversion also typically requires the rhythm to