A Shocking Front Nine

A 42-year-old woman is playing golf with her family and friends on a late Sunday afternoon.She has no past medical history, but she has been a smoker for the past 20 years.On the golf course, she collapses suddenly.Bystander cardiopulmonary resuscitation is administered immediately, and emergency medical services arrive within 10 minutes.The initial rhythm is polymorphic ventricular tachycardia with no palpable pulse.She is defibrillated once, and cardiopulmonary resuscitation is performed for an additional 3 minutes with return of spontaneous circulation.She is initially combative and inconsistently follows verbal commands, and she is promptly intubated for airway protection.She is taken to a local community hospital emergency department for medical stabilization before being transferred to our intensive care unit for further management.At our facility, her temperature is 98.3°F, pulse is 140 bpm, blood pressure is 134/66 mm Hg, and respiratory rate is 26 breaths per minute with oxygen saturation of 95% while on 60% FIO 2 on the ventilator in assist-control mode with a tidal volume of 500 mL.She is sedated but not paralyzed.Corneal, gag, and deep tendon reflexes are intact.She withdraws to painful stimuli but does not follow commands.There is no thyromegaly or lymphadenopathy.Jugular venous pressure is 8 cm H 2 O, and carotid pulses are 2؉ without bruits.Cardiac examination reveals no right ventricular lift and a nondisplaced point of maximal impulse.She is tachycardic, with normal S1 and S2 sounds.There is no appreciable murmur, rub, or gallop.She has mechanical breath sounds but has otherwise clear lungs on auscultation.The abdomen is nondistended and free of bruits with normal bowel sounds with no tenderness, rebound, guarding, or organomegaly.Her extremities are warm, with 2؉ femoral, popliteal, dorsalis pedis, and posterior tibial pulses, normal capillary refill, and no clubbing, cyanosis, or edema.Laboratory tests reveal normal electrolytes, intact renal function with blood urea nitrogen of 11 mg/dL and creatinine of 1.0 mg/dL, and mild anemia with hemoglobin of 10.9 g/dL and hematocrit of 33.4%.Her cardiac