Tachyarrhythmia scenario
15/1/26
candidate brief
Penelope is a 72yo who has self-presented to ED with palpitations. She is just being triaged now and the triage nurse has called you to the triage room as her heart rate is 180.
actor brief
You are 72yo and started having palpitations about 2 hours before, and while you were waiting for triage you started getting heaviness in the centre of your chest and left shoulder. You have AF but that is usually well controlled. You have had similar palpitations before but never with chest pain.
PMH: AF, hypertension
DHx: digoxin 500mcg, amlodipine, ramipril
NKDA
examiner brief
Patient initially in waiting room with palpitations
When triage obs are taken, HR 147 → 12 lead ECG is taken and shown to candidate
The triage nurse has transferred the patient to a trolley
If asked for, another registrar can show up to help with sedation
Initial obs:
SpO2 99% on air, RR 24
HR 160, BP 130/90
GCS 15/15
- Washes hands, introduces self
- Confirms patient identity
- Identifies team competencies
- Takes brief history from patient
- Past medical history
- Drug history, allergies
- Asks for 12 lead ECG when possible
- Moves patient to appropriate clinical area
- Explains procedure to patient
- Recognise need for cardioversion - ischaemic-sounding pain
- Considers sedation/chooses appropriate agent
- Applies appropriate monitoring (AAGBI for sedation)
- pre-oxygenate
- Appropriate pad placement
- Chooses appropriate energy (70-120J for flutter; max energy for AF)
- synchronises monitor to R wave
- Delivers shock safely - checks around patient, oxygen away
- check for pulse and rhythm on screen after shock delivered
- clear communication within team
- Requests appropriate investigations
- Hands over to cardiology registrar over the phone
- Leads team well
- Global mark from examiner
"this is a synchronised shock at 120J. Everyone stand clear, oxygen away, charging."
"that was one shock, back into sinus rhythm."