when to start compressions?

MR. STRANGE · Sep 21, 2013

??????

beckster_01, BSN, RN · Oct 1, 2013

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.

Lol... Best story ever. Although not for that patient, poor guy. Should've told him to quit walking the line and make up his mind already so you could do something about it.

Mully · Oct 3, 2013

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.

Really, from my understanding, this patient should have been shocked right away instead of the textbook NP compressions. Shocking is the best tx for VT, assuming that's what they were still in when he went out?

Anyways, to the OP,

One of the most important things to remember is whether what you're seeing on the monitor is causing symptoms or not. All ways around, wide complex tachyarrhythmias are emergent situations, but treatment is dictated by whether or not they are symptomatic, and how symptomatic they are.

ChaseZ · Oct 10, 2013

You can attempt to cardiovert Torsades de Pointes but it will most likely fail. With a synchronized cardioversion the device tracks the R wave of the QRS complex in an attempt to precisely deliver the shock during depolarization and avoiding the refractory period. In Torsades or Polymorphic VT the axis is constantly changing, hence the "Twisting of the points", and only monomorphic for short periods of time which is usually not long enough for the device to synchronize and shock. Therefore the shock would be unsynchronized or defibrillation.

Did the patient get any magnesium during that time? That is the first line treatment for TDP with a pulse. After that check electrolytes and QT prolonging drugs. Bonus: Anyone know the defining difference between polymorphic VT and TDP?

In regards to compressions; The idea is that there is a minimum coronary perfusion pressure that must be met for a rhythm to be converted back into normal sinus rhythm. Anything below that will most likely result in V fib or Asystole post shock. This is why it is so important to provide quality compressions immediately before shocking. Continue compressions while charging and stop only briefly for the shock and continue immediately after. You will notice some people stop compressions after seeing a normal rhythm on the monitor only to lose pulses a few seconds later. This is because the heart is still stunned and can not maintain an acceptable CPP. Having said that, if the patient has a pulse then the CPP should be adequate and there is no reason to do compressions.

Anesthesia is great to have for a cardioversion but in an emergent situation just shock them. The NP was at the bedside, could she not have ordered some IV versed? Even after the fact Versed can cause some retrograde amnesia. Most Elective cardioversions are done with Versed and Fentanyl. There shouldn't be an issue pushing that on the floor during an emergency.

cjdmomma · Oct 11, 2013

I just want to say that I am one test away from graduating... all the nurses that have commented on here are amazing..

I don't even know what some of the words you are saying even mean... lol

Someday I will learn all this stuff, right?

Mully · Oct 14, 2013

cjdmomma - Congrats on graduation! Now the actual learning begins...

Get a job on a relatively highly acute unit, preferably one where you're required to take ACLS. Basically everything we're talking about in this thread is learned in ACLS.

blondesareeasy · Oct 22, 2013

I like your Bill Murray graphic.

eatmysoxRN, ASN, RN · Oct 23, 2013

I'd grab a 12 lead if they weren't attached to a monitor that had 12 leads. Monitors can show crazy stuff. Check the equipment.

whichone'spink, BSN, RN · Mar 27, 2014

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.

I wonder what was his ultimate outcome.

ktliz · Mar 29, 2014

Great thread. Just this week I had a patient in torsades requiring compressions and defibrillation. Following the code, we started a milrinone drip with a loading dose. Apparently his heart did not like that loading dose because he went into a rhythm that had me ready to jump on his chest, until I looked down at the patient and he was looking at me quizzically. Once I composed myself, I realized it wasn't even vtach, just an aberrant tachyarrythmia.

eCCU · Mar 30, 2014

Great thread. Just this week I had a patient in torsades requiring compressions and defibrillation. Following the code we started a milrinone drip with a loading dose. Apparently his heart did not like that loading dose because he went into a rhythm that had me ready to jump on his chest, until I looked down at the patient and he was looking at me quizzically. Once I composed myself, I realized it wasn't even vtach, just an aberrant tachyarrythmia.[/quote']
I like to get 12 lead especially if they are still chatting with me! Why? I have had vtach on the monitor but upon 12 lead it was WPW or SVT on very rare occasions in my career I have seen brugada and once in my lifetime occasion as my electrophysiologist said arrhythmogenic right ventricular dysplasia! Now that was totally cool!