Potentially unstable rhythms

UM Review RN, ASN, RN · Jan 17, 2006

Awwww, gee thanks.:imbar

chadash · Jan 18, 2006

Awwww, gee thanks.:imbar

gosh! I reallly really mean it! :rolleyes:

ark-two · Feb 17, 2006

A HR of 55 and asymptomatic is a stable rhythm. Athletes tend to have HR slower at rest and even lower at sleep. We've had several patients who at sleep are in the 30's and 40's and are asymptomatic. When you wake them up their HR jumps back up to sinus. Your mother's HR of 55 is symptomatic and needs attention ex: pacing or poss atropine. V-tach can be stable or unstable depending on pulse and s/sx. stable- pacing unstable code-defib

Torsades in usually corrected with mag-we usually see this with alcoholics.

Vfib is always unstable and needs immediate attention-defib. People can also have non-sustained v-tach. We had a patient with 60 beats of v-tach and stable. After the 60 beats he went right back to SR- He scared us to where we were all in the room checking on him when our MW told us he was back in SR.

ZASHAGALKA, RN · Feb 17, 2006

3. If the poor homeless guy is having torsades to the monitor, I believe that our first action would be to give the man some Magnesium, per ACLS protocol, and of course, have the Code Cart right up close and personal, along with the Code Team.

Mag would be a follow-up action, after conversion.

1st action would be ACLS protocol for unstable V-tach (of which torsades is a form) - almost certainly a 200j 'shock' - defib - followed in rapid sequence by a 300j and 360j shock if that doesn't convert. (possibly a precordial 'thump' if electricity isn't immediately available but I think they aren't emphasizing that anymore.)

You wouldn't 'sync' (cardiovert) because the 'twisting of the points' doesn't allow for a stable 'hit' on the R - R relationship, if that makes sense to you. (other forms of v-tack have a steady, if fast, relationship to the R's of the QRS complex that can allow for a sync shock, also called cardioversion - normally more focused and safer than a general defib (non-sync'd shock). Also, the steadiness of v-tach can allow for the possibility of it to be 'stable' - pt is not yet significantly hemodynamically threatened. Stable V-tach can first be treated with drugs (Adenocard, Amiodarone, etc.) or cardioversion. Torsades does not have that steady R-R relationship, so torsades is inherently unstable.)

Also, isuprel (increases heartrate) or overdrive pacing could be of assistance if you get them to convert because slow heart rates, or rather, the pauses within them, can cause someone to go right back into torsades.

Torsades is almost always either an inherited potential, or a non-cardiac (prescription drug induced, electrolyte imbalance, etc.) condition. So, torsades is easier to get a permanent 'fix' on because it doesn't normally result from extensive cardiac damage.

~faith,

Timothy.

Editorial Team / Admin · Feb 17, 2006

V-tach can be stable or unstable depending on pulse and s/sx. stable- pacing unstable code-defib
.

No, V-tach is never paced. Stable is treated first with drugs and then sync cardiovert if continues/not improved. Unstable V-tach is always sync cardiovert. Pulseless V-tach is immediate defibrillation.

chadash · Feb 18, 2006

No, V-tach is never paced. Stable is treated first with drugs and then sync cardiovert if continues/not improved. Unstable V-tach is always sync cardiovert. Pulseless V-tach is immediate defibrillation.

Is v tach considered stable when there is an accompanying pulse and no symptoms,

and Really really unstable when pulseless. (defib-and-go-through-his-pocket -for-loose-change-unstable)

and is the inbetween unstable V tach when there is a pulse, but the patient is having symptoms?

shadowflightnurse · Feb 18, 2006

V tach can actually be paced, on a very rare occasion. If it is a stable polymorphic VT with a wide complex, then you can try overdrive pacing. Hardly seen on a regular basis, but it is out there. Patient's prone to this type of VT often will have a PM/AICD because pacing the VT has a potential to cause VF.

Editorial Team / Admin · Feb 18, 2006

Is v tach considered stable when there is an accompanying pulse and no symptoms,
and Really really unstable when pulseless. (defib-and-go-through-his-pocket -for-loose-change-unstable)
and is the inbetween unstable V tach when there is a pulse, but the patient is having symptoms?

Hello, chadash,

V-Tach is considered stable without s/s, yes. A pulse is present.

Pulseless V-Tach is I suppose you could say the most unstable, yes. They are dead without defibrillation attempts to convert the lethal rhythm and attempts at correcting the underlying etiology.

Yes, the "in-between" V-Tach is considered unstable (pt. has a pulse) and with s/s.

Editorial Team / Admin · Feb 18, 2006

V tach can actually be paced, on a very rare occasion. If it is a stable polymorphic VT with a wide complex, then you can try overdrive pacing. Hardly seen on a regular basis, but it is out there. Patient's prone to this type of VT often will have a PM/AICD because pacing the VT has a potential to cause VF.

Hello, shadowflightnurse,

For potentially unstable rhythms (the title of this thread), the treatment is drugs for stable V-Tach (the arrhythmia in question) and sync-cardiovert for unstable V-Tach.

As for the pacing. This is not utilized in the general tx of V-Tach in the patient being seen in the situation as outlined here. Treatment is using ACLS guidelines.......stable, drugs and unstable, sync-cardioversion.

You are referring to Antitachycardia Pacing for V-Tach (ATP). Yes, this is fairly reliable for slow V-Tach with a low risk for acceleration. There is a defib backup with this approach.

One would not be interested in "burst" and/or "ramp" pacing of ATP when caring for the individual in V-Tach as is the OP question regarding stable and/or unstable .... or, potentially unstable rhythm/s.