Ventricular tachycardia

Editorial Team / Admin · May 16, 2015

Remember how they teach us in nursing school to treat the patient and not the monitor? There are a few things that can make a heart rhythm appear to be VT on the monitor when it's really sinus (or something else). The key one that comes to mind is brushing teeth. It could be what printed out was artifact. However, what was the assessment of the patient? Sometimes people have brief runs of multiple PVCs or (if I remember correctly) it's considered a run of VT if it's over 6 beats- but isn't pulseless. The patient may feel as though they're having palpitations. The assessment is important in deciding how to proceed.

RNKPCE · May 16, 2015

Patients can have self limiting runs of vent tach. They can be asymptomatic but often they may be lightheaded, syncopal or actually pass out. Yes I would notify the MD if this was new and maybe if it wasn't new depending how long it was. They might want to check K+ and Mg+. Everybody is initially in some normal kind of rhythm before they aren't.

mialamia · May 17, 2015

Thanks for the reply. She was sleeping for the most part. She might've gotten up to use the bathroom; I don't know for sure though. She doesn't have a hx of being tachy, however she does have a hx of a-fib. I'm just unsure of what to do in these situations. This isn't the first time I've questioned myself about it and thought about it after. I know I have to use my clinical judgement but at the same time, what if there is something wrong, but the patient appears stable and fine.

Larry3373 · May 17, 2015

Typically small runs of nonsustained vtach are harmless. As a pp replied, I would want to know what the k and mg levels were as abnormalities of these electrolytes can lead to cardiac arrest (vfib or vtach). Afib usually causes frequent pvcs that can lead to r on t and then torsades. You can have the appearance of vtach on the monitor just by tapping on one of your leads or shivering. If it is sustained vtach you have to assess the patient and check for a pulse follow ACLS protocols from there. Some patients frequently go into vtach and are totally asymptomatic. That's the point of an AICD.

Larry3373 · May 17, 2015

Also hypoxia can cause frequent pvcs that can lead to runs of vtach. Make sure the patient has their oxygen on if they're normally O2 dependent. Too much opioids can cause respiratory depression and hypoxia as well. In that case you would wake the patient up and make them breathe or give narcan. If it is a new thing for the patient and you are sure it's not artifact, get a set of vitals and call the doctor. It could also be the case that the patient didn't get their anti arrhythmic meds that day (cordarone). Just throwing some scenarios out their, not necessarily r/t your patient's situation.

calivianya, BSN, RN · May 17, 2015

You said the patient has a history of a-fib - you should trace out the person's strip and see if the "V-tach" is perfectly regular. V-tach is usually pretty regular unless it's torsades, which looks totally different from regular V-tach. If the V-tach is irregular, it may actually be a-fib with ectopy - which looks a heck of a lot like V-tach but isn't quite the same thing. I have seen a lot of my patients with active a-fib flip into into a-fib with ectopy with HRs over 130-140. The QRS widens just like V-tach, and I've reported possible V-tach to my physicians, but gotten shot down. Now, I just say, "the patient went into a tachyarrythmia with a wide QRS." You live and you learn, I guess. It still usually looks like V-tach to me.

Either way I would let the physician know and show him/her the strip because it is a rhythm change.

txnursetrb26 · May 17, 2015

Check your hospital policy. I work on a tele floor and the hospital has a policy to call if pt has more than 6 beats of VT. However, one time had pt having 2+ minutes of it frequently (going for AICD) and the EP said don't call unless it lasts for over 2 minutes ðŸ˜± I was freaked but he was ok.

VANurse2010 · May 17, 2015

If it was self-limiting and asymptomatic - i wouldn't make a special call to the doctor. The policy in one of my old jobs was 10 beats before calling the MD. This all depends on the overall acuity and reason for hospital stay etc. Of course, labs should be reviewed as has been mentioned.

ixchel · May 17, 2015

As others have said, there is the great big clinical picture.

*labs - how are the electrolytes? Have replacement electrolytes been ordered? If so, and if more are due, hang tight. Non-sustained vtach is normal. Abnormal would be a symptomatic patient - can't breath, chest pain, pulse leanest, anxiety. On a cardiac and respiratory unit, never forget that anxiety is a symptom, not a diagnosis. (Usually.)

*trend - labs over time, and have the runs of vtach already been occurring without escalation or symptoms? Do they always resolve? If the answers to this one leave you uneasy, nervous, scoot a crash cart closer to their room.

*symptoms - shortness of breath, diaphoresis, nausea, anxiety, labored breathing, HR above 130s-140s that is sustained over a period of time, the patient generally looking like poo, or even just your own spidey sense imploring you to feel over your head, grab your charge nurse. That second pair of eyes can steady your hand.

Look in PRNs for verapamil, mag, diltiazem, amlodipine, or beta blockers. Check BP, and administer the meds (individually, of course). Pick the med with the highest parameter set on HR. That way if it comes down, but not enough, you still have options. Give a good 30 minutes before going to the next med, and know your vitals machine and tele are accurate.

It's scary. And you're going to feel nervous every scary rhythm you get until you've seen them stay okay without too much fuss. I actually had a lady I though for sure was going to tank quicker than I could handle today. She went from her normal 90s-110s with funky changing P waves. Still a sinus rhythm, though. Then she decided she'd pop up into the 130s-140s. It didn't want to come down and she had no scheduled meds for her HR. Her MD made sure we had verapamil on order. Then after about 30 minutes and me deciding once and for all she wasn't coming down, she jumped up, nauseous, diaphoretic, HR 180s-190s and not coming down at all. The thing that calms me most is the meds. No matter what we do to des slate these things, ever if we give meds immediately, there is this period of time when all you can do is just wait. So dose 1 verapamil down, back to 130s-140s. Verbal one time for one more dose. BP was stable, part isn't was calming a bit but still not okay. Gave a dose of benzos to help ease her anxiety. Few minutes later, there was no change in HR. Second verapamil in, 30 minutes later, HR perfectly control. But now instead of a sinus tach, which seemed to be somewhere between WAP/MFT and SVT, she was now afib/flutter with small bursts of RVR.

Anyway, my point is (I think there was a point?), look at the patient. Sometimes our cardiologists are okay with 130s on an afib patient if they are adequately anticoagulated. If they're asymptomatic, the cards will consider letting it run its course, especially if it could be respiratory or infection/fever based. Get those things under control, the HR may even convert to SR.

Vtach, you run into similar needs. Electrolytes, symptoms, tracing the potential causes. Consider the Hs and Ts. Are you able to asses and correct any of these? Generally, for me, if I get a small run on the monitor, I look at the other leads if they're connected. I had a guy look vfib last week. Was a patient given to a nurse on his second day off orientation. I went ahead and did the being scared for him since he was in the middle of something. lol The charge nurse came running in with me. The guys pulse was okay, no symptoms, normal electrolytes, and when the charge opened his tele screen, it turned out that one lead was the only one showing any dysrhthmia. The rest were perfect.

When you get scared that something is about to go wrong quickly, grab the charge nurse and/or step back. What could cause this? Body temperature, ABGs and effective breathing, afib... Each of these and more will effect the rest.

And this thing will keep being scary for awhile. The other nurses know that and will love to help you anytime, I promise.

Guest219794 · May 17, 2015

Have a quick question for anyone experienced with tele monitoring. I had a patient last night who was normal sinus on the monitor for the whole night. Well, one of my colleagues pointed out to me a strip that printed out of her clearly in the v-tech mode. She showed this to me after, but the patient remained sinus rhythm. Should I have contacted someone or does this happen to some patients?

Last night I had somebody show me a strip that clearly showed the patient in v-tach. Like many nurses, he looked only at lead II. While I am not great at determining Bundle Branch Blocks, I can pick out the easy ones.

Below is a strip I found online, somewhat similar. Picture the lower waveform, imagine it twice as fast- looks just like V-tach. Above it is a notched tracing, indicating a bundle branch.

Monitors are not great at determining ventricular rhythms, they tend to just measure the QRS, not analyze it.

Most nurses only look at lead II, which is not very useful. In fact, most nurses I know couldn't tell you how or why to choose a V lead to monitor. Many, if not most simply put the brown electrode vaguely in the middle of the chest, and call it The V Lead.

http://co.grand.co.us/DocumentCenter/Home/View/624

psu_213, BSN, RN · May 17, 2015

As others have said, I could be a bunch of different things other than V tach. Could have been artifact--it would help to have a rhythm strip for a second lead? It could have been a fib or a flutter with aberrant conduction (i.e. A fib with a BBB). That can give you a fairly fast rhythm with a wide QRS and no p-waves. Best determined with a 12-lead. A lot of times, a dose of atropine will slow the pt's rate down for a moment and you can get a better look at what is going on between the QRS complexes and this can give you a clue. (Obviously an MD would be there and order the doseâ€¦).

Also, does your unit have a written policy about how many beats of V tach are required before you call the MD? This prevents calls to the MD for self limiting episodes of V tach in the middle of the night.