Paced and Vtach

Or maybe I should ask: what do you do when patient is 100% paced and has runs of Vtach? Thanks again in advance!

As always...it depends. "Runs" of v-tach shouldn't be ignored unless it is some known baseline for the patient that does not cause instability and is not due to some correctable problem like a dislodged pacer lead irritating the heart, ischemia or electrolyte problem just to name 3.

It would be pretty important to determine if the patient were being paced in asynchronous mode because that could lead to an R on T event in the setting of v-tach potentially leading to v-fib. If the pacer were to be inhibited by ventricular activity, there would be no pacing, so the v-tach in this patient would be no different than if he did not have a pacer.

Bottom line is that the physian responsible needs to know that this is occurring and if the patient becomes unstable, DCCV is required, pacemaker or not.

Yeah what?! Agreed with offlabel.. Theres numerous problems that could be going on.

Paced patients are supoosed to have suppressed ventricles when they're being paced, not VT.

Even if they have an ICD, burst pacing and shocks are ALERTS.. Events that need a doctors attention.

Furthermore if the patient goes into a 'short run' of VT more than 4 times in 24 hours thats technically a VT Storm. Its very ominous and important.

If a nurse called a doctor and said something like:

"Your patient is in VT storm, but he's got a pacemaker so I didn't think it was too important to let you know..."

Someone will go after that nurses license.. And rightly so.

It would be no different then saying "The patients potassium was down to 2.1 but the doc already ordered a K+ infusion so I assumed he already knew what was going on.." These just aren't the assumptions anyone should be making.

Next time that sort of thing happends if you feel. That, for whatever reason the patient isnt getting the attention they need you pick up,the ohone and call the physician and tell him. Especially if this is a cards patient.. Even if you're wrong and it's nothing, even if it hurts someones feelings or insults the charge nurse or whatever. The safety of the patient takes priority!

If anyone really wants to give you grief about it they should take it up with the hospital administrators, Board of Nursing, JCO.. Im sure they'd love to hear about how they don't like nurses communicating safety concerns because it hurts their feelings. That discussion would end great for sure.

Dumb question: When a patient is being paced, whether PPM, transvenous or other, and has runs of Vtach, I hear nurses say "patient is paced, so it is ok." But - shouldn't steps be taken? If patient isn't being paced, I would normally check the patient, check electrolytes as first steps. Shouldn't I do the same?

Thank you in advance!

FW

You should always care about VT even when someone is paced. Granted there are some VTs which do not affect the blood pressure as much as others (RVOT VT), most will cause some bit of hypotension, causing dizziness, syncope and possible callapse. You should always consider the cause, electrolye imbalance, hypoxemia, MI just to name a few.