Stacey EP NP

Thanks for commenting, you are correct, WRS is a typo. Not sure how I missed that, should be QRS.

As a nurse on the cardiac step-down unit, you have been trained to pay attention to the loud, ever-sounding "ding, ding, ding" of the telemetry (tele) monitor. Sometimes it can be heard as many times as a call light bell on a 30-bed unit over the span of a 12hr day shift. So much so that you begin to drown out the sound, but don't let it be you ignoring the tele alarm when your co-worker yells out, "Your patient is in VT!” and everyone rushes to the room with a crash cart in tow. It is not uncommon to witness this scenario when caring for cardiac patients but don't call the cardiologist just yet. Wide complex tachycardia (WCT) is an umbrella term, defined as a wide QRS>120ms, with a heart rate >100bpm indicating tachycardia. Ventricular tachycardia (VT) is not the only reason you may see a wide complex fast rhythm on the tele monitor. Thus, determining true VT from other rhythms is a necessary skill for the prudent cardiac nurse, as this determination will direct the immediate actions of care staff and further clinical course, as well as outcomes for the patient. What To Do First As soon as there is any indication that your patient may be in sustained VT, the first thing you, as the registered nurse, must do is evaluate your patient! Are they alert and talking to you? Are they breathing? Do they have a pulse? Stable (baseline blood pressure and oxygen level) vs unstable (hypotension and hypoxia) Get an EKG (electrocardiogram) to give more in-depth and detailed information on the arrhythmia. Further details found on the EKG are analyzed by the physician or cardiologist to determine the etiology of the rhythm. SVT (supraventricular tachycardia) with Aberrancy Differentiating whether the WCT stems from the upper chambers (atria) vs that of the lower chambers (ventricles) of the heart proves to be a difficult, yet critical determinant in the selection of appropriate interventions for patient evaluation and care. SVT with aberrancy is a tachyarrhythmia that stems from the atria and demonstrates a wide QRS but is NOT true VT. Aberrant conduction patterns are often "representative of typical right and left bundle" configurations (JAHA, 2020). Useful clues to indicate a likely diagnosis of SVT with aberrancy rather than true VT are provided by EKG as well as patient history and are as follows: Presence of prior tachyarrhythmia (atrial tachycardia, atrial fibrillation/flutter, or Wolf Parkinson White) In the case of Afib RVR (rapid ventricular rate) with aberrancy, the rhythm remains irregular in contrast to true VT, in which the pattern is inherently regular Baseline left or right bundle branch block, as seen on previous EKG, with identical morphology to the WCT Terminated by Adenosine and/or vagal maneuvers Another possible though uncommon cause of tachycardia with evidence of QRS widening is Pacemaker mediated tachycardia (PMT). Sometimes a patient's pacemaker will increase the ventricular rate in an attempt to track an intrinsic atrial arrhythmia. To identify if the tachycardia is pacemaker mediated, first assess; does my patient have a pacemaker or other implanted cardiac device? Are there pacer spikes? If unsure, obtain EKG and device interrogation. Artifact Often appears as random and irregular, unexplainable 'junk' on the tele monitor. When you check on your patient, you find them returning from the bathroom and shuffling the covers on their bed, causing interference with monitor signals; meanwhile, the patient denies any acute symptoms. Artifact often only affects one tele lead with the other leads reading the patient's baseline rhythm. No intervention is required unless the artifact is persistent, indicating the need for tele lead adjustment or reattachment with new stickers. True Ventricular Tachycardia Staying true to its nomenclature, VT stems from the ventricle and is classified as either sustained (>30 seconds) or non-sustained (<30 seconds). Key signs of true VT (see image1) include a monomorphic, (identical or uniform) very wide QRS complex (160ms+) seen in all 6 precordial leads (V1–V6) on EKG that change deflection (above or below axis) from baseline rhythm with heart rate (HR) at least 140-180 beats per minute. Characteristic AV dissociation, P and QRS complexes at different rates, is commonly noted in fast VT as well as slow VT, which encompasses all classic criteria though at an unusually slow HR. True VT should be suspected in patients with the following: Age >35 yr. Coronary artery disease Cardiomyopathy Existing arrhythmias (atrial fibrillation, premature ventricular conduction, etc.) Family history of sudden cardiac death Structural heart problems (Valve disorders) Electrolyte imbalances; particularly potassium or magnesium Sustained VT with an extremely elevated HR can lead to impaired cardiac output and resultant: Hypotension Syncope and collapse Loss of pulse VT can progress to sustained ventricular fibrillation (VF) and result in sudden cardiac death therefore, the nurse must quickly determine if the patient is stable vs unstable and act accordingly. Immediate treatment for a patient in sustained VT or VF with no pulse is to initiate CPR, then defibrillate from either the crash cart or an automated external defibrillator (AED). Initiation of anti-arrhythmic medications, such as amiodarone or lidocaine, is indicated in confirmed VT or VF. If the patient is found to be stable, then you still must take action and contact the physician with anticipation of expert (cardiology) consultation. Making the Decision In the end, it is not solely your responsibility as the bedside nurse to differentiate all of the complex arrhythmias that your patient may have, but it is your responsibility to know when to act emergently and when to keep calm in order to protect your patient. When it comes to wide complex tachycardia, always be alert, and before anything else, evaluate your patient! Especially in patients with known risk factors for VT, you can safely assume that the majority of the time, it is true VT. A prudent rule of thumb to follow is "If in doubt, treat as VT!”2. Determine if it is sustained or non-sustained and if your patient is stable or unstable to guide your next moves. Always look for possible reversible causes such as electrolyte imbalances or drug use, particularly cocaine or methamphetamine, indicative of toxic‐metabolic etiology. The tele monitor will continue to ding whether it is a true emergency or not ... that's its job; it's your job to know what to do with the information provided. References/Resources 1 Ventricular Tachycardia – Monomorphic VT (image): Life in the Fast Lane 2 VT versus SVT (Robert Buttner and ED Burns): Life in the Fast Lane Wide Complex Tachycardia Differentiation: A Reappraisal of the State‐of‐the‐Art: Journal of the American Heart Association Monomorphic Ventricular Tachycardia: Cleveland Clinic Wide Complex Tachycardia – Diagnosis: CARDIOGUIDE Wide Complex Tachycardia: Management: CARDIOGUIDE Ventricular Tachycardia: Mayo Clinic

As a typical high schooler with your whole life ahead of you, parents and educators advise you to pick a career and start striving towards achieving your chosen path. With a passion for helping those in need and an interest in healthcare, you decide to pursue nursing but are unsure where to start. The Transition from High School to College With a curious mind and a desire to continuously enhance your knowledge, you will not be satisfied until you achieve a high level of education in your pursuit of clinical and career competence. You have decided to pursue a master's level program but don't know where to start or which program to choose, as the options are endless. First, you must determine where to obtain your associate degree in nursing (ADN). The best option is to choose a local community college that will save you money and be easily accessible from home, although some universities do offer entry-level degrees; research what your area has to offer. Refer to the following list of recommended steps to take: Get good grades; a 4.0 average is ideal, as nursing school entry is competitive Prospect for community colleges offering Associate degree in nursing (ADN) programs Complete your ADN degree and certification test to become a registered nurse (RN) and begin working. Higher education programs always prefer nursing experience for an advanced-level degree. Apply to university Traditional Pathway to Advanced Practice Nursing Although an often noted worthy investment, the pursuit of the specialized education required to obtain an advanced practice registered nurse title has historically proven time-consuming and laborious. Whether your passion was a pursuit of adding initials behind your name, such as the following: Certified Nurse Midwife (CNM) Certified Registered Nurse Anesthetist (CRNA) Nurse Practitioner (NP) Clinical Nurse Specialist (CNS) The traditional course of earning an associate degree, then a bachelor's degree, and finally, after many 10-page written papers and hours of clinical rotations, earning a Master's degree and passing board exams; after 7-8 years of education, you would be granted your desired credentials. Thankfully, this process can be expedited with new developments in nursing program structure and curriculum. What Distinguishes the RN-MSN Program from Others? The nursing professors at most universities are advanced practice nurses and have been in your shoes. They resonate with the mental struggle you are experiencing. That is why they strive to assist students like you with a passion for learning and achieving great heights, with their fast-track RN (associate degree nurse) to MSN (master's degree) program designed to expedite your transformation from novice to expert. Related: 10 Best Master of Science (MSN) Programs in 2023 Read on to explore this path to your future nursing career. Customizable schedule—while there are many options for fully in-person or online courses, most fast-track programs are hybrid, creating more flexibility Taught by nurses, for nurses. In-person clinical rotations with advanced practice providers remain a staple in the RN-MSN program An RN-MSN degree allows you to bypass the Bachelor of Science in Nursing (BSN) or other bachelor's degree options Reduced education costs and time to graduation Qualify for financial aid or scholarships as with any other program Meets requirements to sit for approved board certification exams upon graduation Designed with the working nurse in mind—go at your own pace, apply your own experience to class teachings, take a break then come back when ready Will You Take the Fast Track? While there are many pathways and colleges to choose from when pursuing a degree in nursing, universities offering RN-MSN hybrid programs are suitable for those desiring advanced-level degrees that accommodate a school-work-life balance. If you want to 'dip your feet' into nursing with an associate degree, then start earning money right away before pursuing advanced-level education, the RN-MSN route is for you. References/Resources Pursue Your Passion for Nursing: All Nursing Schools Online RN to Master of Science in Nursing: Arizona State University (ASU) Earn Your Master of Science in Nursing (MSN) Degree: Saginaw Valley State University How to Become an APRN: NurseJournal