The Case:

A 40-year-old female presents to the emergency department for palpitations and lightheadedness. She has a history of depression on citalopram, migraines on amitriptyline, and was recently prescribed tramadol after she broke her wrist. She is well-appearing, and while being placed on the monitor, she becomes anxious, stating the symptoms are recurring. An ECG is performed, with Figure 1 serving as a representative EKG. The patient is awake and talking. Defibrillator pads are placed and 2 g IV magnesium is administered twice each over ten minutes resulting in the termination of the prior rhythm. A repeat EKG is obtained and is similar to that in Figure 2. The patient remains stable, but then degenerates again into an aberrant rhythm.  What do you do next?

Adam Roussas, MD and Robert Feldman, MD