when to start compressions?

Specialties CCU

Published

I was just told a story about a patient who went into torsades. the patient was conscious with a pulse, mental status intact, but I can't tell you about pressures. at what point does a ACLS protocol say to start chest compressions? Would you ever start compressions if the patient was talking to you and still had a pulse?

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I just want to add that compressions were started by the attending, this us at a major university hospital in Philadelphia. I take ACLS next month, so can someone walk me through the thought process here so I know how a more advanced practitioner would approach this situation? I've been working as an RN in a cardiac CICU for 6 months and I was not there so assume I have no more details. Thanks!

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Specializes in CICU.

Precordial thump?

SN - if someone started compressions on me while conscious I would punch them in the throat.

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Precordial thump?

SN - if someone started compressions on me while conscious I would punch them in the throat.

LOL---Most definitely.

You would never do compressions on someone who is talking to you.

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Specializes in CTICU, CT-Stepdown.

If the patient is conscious and has a pulse then they are tolerating this rhythm, it would be considered a stable tachycardia but for how long is another story, but you would want to quickly manage that condition and try to get them back in a more stable rhythm otherwise they will soon become unresponsive and pulseless. Then in the ACLS protocol you do chest compressions first on an unresponsive and pulseless pt one round of 30 compressions and then defibrillate. As torsades is a polymorphic VT r/t hypomagnesemia so you would give magnesium, I believe its a loading dose of mag and then starting an infusion.

I am relatively new to the ICU as well and I been doing CTICU for a little under a year, and CT-stepdown for a bit and I should say I have seen torsades once, but the pts had a BIVAD so their pressures did not budge and all we did was give amio boluses, two I believe and it wasn't my pt but I was helping out. If I remember correctly the pt was going in and out of VT and then had a run of torsades when I was in the room helping the nurse whose pt is was. So it can also depend on what else the pt has going on and provider preference too as I have seen things done, not by the book of ACLS in the unit all the time.

https://www.acls.net/acls-tachycardia-algorithm-stable.htm

Above is a link to the ACLS algorithm for stable VT and torsades is way at the bottom, now if there are other ICU peoples that have seen this rhythm more often they might be able to give you more info on how it is managed in their experience. But that is what you would do according to ACLS, basically you wouldn't start ACLS and definitely not chest compressions (BLS) until your pt decompensated and was dead ie. no pulse and not responsive. Otherwise you have one ****** off pt as others have commented on above :)

Hope that helps.

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Specializes in Critical Care.
LOL---Most definitely.

You would never do compressions on someone who is talking to you.

I have on many occasions, good quality CPR will produce some level of consciousness at times despite no underlying perfusing rhythm.

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I just want to add that compressions were started by the attending, this us at a major university hospital in Philadelphia. I take ACLS next month, so can someone walk me through the thought process here so I know how a more advanced practitioner would approach this situation? I've been working as an RN in a cardiac CICU for 6 months and I was not there so assume I have no more details. Thanks!

Classic case of treating the monitor instead of the patient! If the patient is awake and alert.. they are adequately perfused. You would start compressions when the patient is unresponsive and without a palpable rhythm.

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As a nurse who works in the ICU, I can tell you, you do not start compression on somebody who is talking to you and conscious. Blood pressure and pulse should obviously be assessed if a patient is in torsades. If no pulse, they are not going to be talking to you, nor have a blood pressure as well. Been there, done that brings up a good point, assess the patient first!!! Precordial thump can be used, but most of the time a magnesium rider is all it takes. Basic nursing/medical sense, treat the patient not the rhythm. Good pulse, good blood pressure, no LOC changes, treat as a stable ventricular tachy rhythm. Hope this helps!

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From the telemetry floor:

S/p cardiac arrest with multiple broken ribs. Reperfusion dysrythmias noted, asymptomatic. Pt. enters sustained v tach. Room full of cardiac nurses and cardiac NP. Attending on cell with NP. Zoll set up bedside. 10 minutes into v tach pt. blood pressure starts getting soft, pt. has that look that he's about to go from a/o to out. Me: "Mr. so and so, stay with me, tell me a story." Eyes open, pt. talks coherently to me for about 30 seconds, eyes start to go back. Me: "I do not have a carotid." NP jumps once on chest, textbook compression. Pt.'s eyes open, swearing. Pt. interacting with me. Serious, quick, debate about cardioverting with nothing feel good on board happening bedside. Someone runs to try to get anesthesia for sedation. While debate going on, I notice pt. starting to swoon again. Me: "We are loosing him again." Nurse Manager: Shut the door. NP: Shock. Loudest scream I ever heard. NP: I am so sorry Mr. so and so. Me: "Did we just cardiovert or defibriliate?" Anesthesia walks in for the cardioversion.

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Specializes in ICU.
If the patient is conscious and has a pulse then they are tolerating this rhythm, it would be considered a stable tachycardia but for how long is another story, but you would want to quickly manage that condition and try to get them back in a more stable rhythm otherwise they will soon become unresponsive and pulseless. Then in the ACLS protocol you do chest compressions first on an unresponsive and pulseless pt one round of 30 compressions and then defibrillate. As torsades is a polymorphic VT r/t hypomagnesemia so you would give magnesium, I believe its a loading dose of mag and then starting an infusion. I am relatively new to the ICU as well and I been doing CTICU for a little under a year, and CT-stepdown for a bit and I should say I have seen torsades once, but the pts had a BIVAD so their pressures did not budge and all we did was give amio boluses, two I believe and it wasn't my pt but I was helping out. If I remember correctly the pt was going in and out of VT and then had a run of torsades when I was in the room helping the nurse whose pt is was. So it can also depend on what else the pt has going on and provider preference too as I have seen things done, not by the book of ACLS in the unit all the time. ... snip ....
Yeah, mechanical devices like the VADs really change things up. I had a patient who was in VTach for 4 days. Multiple shocks (probably disconnecting the controller, I don't recall exactly) and multiple drug interventions. The VAD just kept on keeping on, so the patient was still awake (I wasn't getting him out of bed though!). Ultimately, I think he went asystole and they turned him off. RIP
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For New CCU nurses one valuable piece of advice would to always be vigilant about possible problems associated with pt and their type of disease process. Staying one step ahead of a code or arrhythmia will save your patients life. If you notice a pt is throwing bigeminy, couplets or triplets of PVC's (premature ventricular contractions) get your cardiologist on the phone and alert him that your patients heart is irritated and sending out signals. A good currant assessment is the most important tool a nurse can have. If the monitor is showing a arrhythmia but, the patient is showing no signs or symptoms go and check your leads. Never fear that your "asking" a dumb question.....there are no dumb questions in nursing. Everyday is a learning experience.

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Specializes in ICU.

I think one of the toughest codes I initiated was when I was sitting a patient up for the first time after a CABG. It was midnight, and I had just handed him a cup of water for his first drink when his eyes rolled back and the monitor alarmed VTach with essentially no blood pressure. CRAP! :eek: Man, one second he asking for water and the next I'm doing CPR on the guy yelling for help! It took him a month, but he finally walked out of there to LTAC. One of those instants in time one never forgets.

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