Term 3 week 5 (w/c 28/05/12)
This week it’s a daylight case. It’s 18:30 in the evening. The Cardiology registrar is on the phone asking for your attendance for a cardioversion.
We will start with the question what one feature crosses your mind?
Please take turns and only put one feature per tweet. This will encourage our new followers and make it easier for junior and non anaesthetic colleagues.
Thanks for all the contributions yesterday.
The cardiology registrar has provided you with bait of history via the CCU sister. The patient requiring cardioversion is 27 years old. He has a narrow complex tachycardia of acute onset. He has dystrophia myotonica. The blood pressure is 85 systolic and the rate is 190 ish. There is some urgency to this.
Before you get to CCU what are you thinking about now?
You have now arrived in CCU.
The 27 year old man has the characteristic signs of dystrophia myotonica. He has frontal balding and early cataracts. One might observe that these are the least of his worries.
Currently he is complaining of chest pain, sweaty and hypotensive, having become acutely unwell approximately 55 minutes ago. He had just finished a full hospital meal and began to feel faint. He was admitted to the hospital with shortness of breath yesterday.
The cardiology registrar has given adenosine three times with no effect and now feels that the next stage is cardioversion. The patient is fully conscious and feeling very frightened.
Have you got a clear plan A?……. More info tomorrow.
The final piece of the jigsaw is going to make it very complicated. The patient is overweight as he has not really led a particularly fit and healthy lifestyle. The cardiology registrar had placed little more than a perilous 22g intravenous catheter on the anterior surface of the wrist prior to attempting a central venous access. Despite the use of ultrasound and his familiarity with subclavian approach he only managed to aspirate a syringe full of air from the chest. He tells you this as you make your anaesthetic plan.
Have you got a final anaesthetic plan? This is the end of the story.
There are no trick questions in #gasclass. It is an educational tool only. Everyone’s opinion is as valid as the next person. Follow the conversation by using (or searching for) the hashtag #gasclass on twitter. We welcome input from all specialities and you can send us a direct message if you would prefer to remain anonymous.
@gasclass
gasclass 
I am afraid I am going to be slightly predictable in a military way and suggest Ketamine and then shock or even just shock without the ketamine. This chap sounds peri arrest and his management has gone down the side of the ALS algorythm that has got signs of shock in it so is an emergency. Before doing anything you need to check that it is not a tension pneumothorax that is causing his shocked state I would think it unlikely as in my experience it takes quite a while to build up enough pressure to tension if you are breathing spontaneously however a matter of seconds if you put a tube down. With his myotonica you do not want to go near him with Sux, volatiles or benzodiazepines. Theoretically Ketamine my make his tachycardia a bit worse but it also might push his BP up. After hopefully cardio verting him with some electricity ( you may not be able to sync cardiovert him as he is going too fast) you can address his iatrogenic chest problem. It might be a bit glib to say just cardiovert him as I have got a feeling that myotonic’s are prone to cardiomyopathy and it all might go horribly wrong so I would probably try and get cardiothoracics interested if it did and see whether one of those balloon pumps might get me out of the poo. As regards access again I might be a bit predictable and suggest intra osseus there is a gun I am told on the arrest trolley in theatres and if not I would send my fastest SHO down to A and E as I know there is one down there.
Brett
Sorry I have just read the instructions and realised I have written too much