V Tach Cardioversion

[truetiger]

I've been reading through a few different ACLS books in an attempt to brush up before my practical and written. All of them make it pretty clear that for a narrow complex tachycardia, 150 is the magic number for pharmacological or electrical therapy. I've become confused when it comes to V Tach, some books say its from 150-250, others say it begins at 100. At what rate would you consider treatment for stable/unstable v tach?

 

[Hockey]

Where I work, protocol is 100 for both biphasic and monophasic. Monophasic goes 100, 200, 300, 360.

Biphasics go 100, 150, 200...

If the patient is stable, go with drug therapy...but v tach...well..you know how it goes...

 

[themooingdawg]

Yeah, ithink it heavily depends on where you are and the protocol, but i think with AHA it should be standard all across. What i learned was for cardioversion on pulse V tach is starting off at 100, and going on from there. If patient is symptomatic to the v tach, you definitely want to do cardioversion right off the bat before you get into any drug treatments. If the patient is doing fairly well with it, you can always administer 150mg of amiodarone...

 

[Hockey]

Yeah, ithink it heavily depends on where you are and the protocol, but i think with AHA it should be standard all across. What i learned was for cardioversion on pulse V tach is starting off at 100, and going on from there. If patient is symptomatic to the v tach, you definitely want to do cardioversion right off the bat before you get into any drug treatments. If the patient is doing fairly well with it, you can always administer 150mg of amiodarone...

Yup. Everywhere that I've been exposed to for wide complex tach is 100J to start with. I'm not a big fan of the drug route for the wide complex tach. I haven't been impressed the 2 times I've seen it

 

[Shishkabob]

Err... I'm pretty confident he's asking for rate, and not joules to cardiovert, guys.




tiger--- vtach with a pulse, or "stable" vtach, doesn't stay stable for long. Technically you're supposed to try the drugs first, but I don't know of a medic or doctor who won't instantly shock vtach when they see it (if you don't already have an IV started) (though there might be some here who might disagree)


Rate is irrelevant, as vtach is bad, be it at 100, 200, or 500 beats a minute.





As far as other tachy rhythms... I hate when people put a finite number on them. You can be unstable at 100, or stable at 180. If they are unstable, fix it. If they are stable, you have a bit more time to fix it, if it all.

 

[MSDeltaFlt]

I've been reading through a few different ACLS books in an attempt to brush up before my practical and written. All of them make it pretty clear that for a narrow complex tachycardia, 150 is the magic number for pharmacological or electrical therapy. I've become confused when it comes to V Tach, some books say its from 150-250, others say it begins at 100. At what rate would you consider treatment for stable/unstable v tach?

Stable VT vs Unstable VT

Unstable VT includes these 2 things:

1. Wide complex tachycardia (3 small blocks wide or wider). Learn the rates of from the book.

2. Plus positive sign and symptoms (CP, SOB, no radial pulse, cool clammy skin, etc, etc, etc).

Stable VT only has wide complex VT.

If they have ANY of those signs or symptoms, light 'em up. If they don't, then just push your anti-arrhythmic. But do me, us all, especially the pt a favor. Make damn sure the pt does not have a pace maker before you start shocking them. Expose the chest and look for a pace maker.

 

[firecoins]

He's def asking about heart rate and not joules.

 

[truetiger]

Linuss, that was exactly what I was looking for, thanks.

 

[MrBrown]

There is no magic number, the degree of haemodynamic compromise determines treatment; the more compromised the patient the more important it is to cardiovert. This is particularly true if the rhythm is thought to be VT.

 

[MSDeltaFlt]

I've been reading through a few different ACLS books in an attempt to brush up before my practical and written. All of them make it pretty clear that for a narrow complex tachycardia, 150 is the magic number for pharmacological or electrical therapy. I've become confused when it comes to V Tach, some books say its from 150-250, others say it begins at 100. At what rate would you consider treatment for stable/unstable v tach?

Err... I'm pretty confident he's asking for rate, and not joules to cardiovert, guys.




tiger--- vtach with a pulse, or "stable" vtach, doesn't stay stable for long. Technically you're supposed to try the drugs first, but I don't know of a medic or doctor who won't instantly shock vtach when they see it (if you don't already have an IV started) (though there might be some here who might disagree)


Rate is irrelevant, as vtach is bad, be it at 100, 200, or 500 beats a minute.





As far as other tachy rhythms... I hate when people put a finite number on them. You can be unstable at 100, or stable at 180. If they are unstable, fix it. If they are stable, you have a bit more time to fix it, if it all.

Did a little more research. For testing purposes there is a magic number. That magic number is 150.

For stable VT >150 (i.e. at 151 and higher), and without serious signs and symptoms, give your anti-arrhythmics until you max out your dosages and/or pt becomes unstable. Unstable means with serious signs and symptoms: hypotension, signs of inadequate tissue perfusion, C/O CP/SOB, yadda.

For unstable VT, HR >150, serious signs and symptoms, go immediately to synchronized cardioversion. Give antiarrythmics if cardioversion is not available. If pt has LOC, go straight to UNsynchronized cardioversion.

I'm sure you know all of this, but for testing purposes, the magic number is 150 beats per minute.

 

[8jimi8]

Did a little more research. For testing purposes there is a magic number. That magic number is 150.

For stable VT >150 (i.e. at 151 and higher), and without serious signs and symptoms, give your anti-arrhythmics until you max out your dosages and/or pt becomes unstable. Unstable means with serious signs and symptoms: hypotension, signs of inadequate tissue perfusion, C/O CP/SOB, yadda.

For unstable VT, HR >150, serious signs and symptoms, go immediately to synchronized cardioversion. Give antiarrythmics if cardioversion is not available. If pt has LOC, go straight to UNsynchronized cardioversion.

I'm sure you know all of this, but for testing purposes, the magic number is 150 beats per minute.

Dang now there's a golden nugget right there.

 

[socalmedic]

...for a narrow complex tachycardia...

are you refering to SVT or V-tach?

if you are refering to SVT, your treatment should be dictated by the level of hemodynamic compromise, if they are AOx4 w/ good distal perfusion i would start with adenosine. if they are any sort of altered i would go to electrical cardioversion.

also there is no magic number for SVT either. some books say 180 for adults some say 150, however SVT is defined as "narrow complex tachycardia with the absence of a P-wave"

if you are refering to V-tach w/ pulses, refer to your protocol as all v-tach is unstable regardless of rate. V-tach is defined as "wide complex tachycardia, with the absence of p-waves"

 

[rhan101277]

Stable VT vs Unstable VT

Unstable VT includes these 2 things:

1. Wide complex tachycardia (3 small blocks wide or wider). Learn the rates of from the book.

2. Plus positive sign and symptoms (CP, SOB, no radial pulse, cool clammy skin, etc, etc, etc).

Stable VT only has wide complex VT.

If they have ANY of those signs or symptoms, light 'em up. If they don't, then just push your anti-arrhythmic. But do me, us all, especially the pt a favor. Make damn sure the pt does not have a pace maker before you start shocking them. Expose the chest and look for a pace maker.

Well you can shock people with a pacemaker. The pacemaker could be defective and if you just let them sit there unresponsive they will go on and die.

 

[Epi-do]

Well you can shock people with a pacemaker. The pacemaker could be defective and if you just let them sit there unresponsive they will go on and die.

I don't mean to speak for MSDeltaFlt, but I took his post to be a reminder that pt's with pacemakers are going to normally have a wide complex when it is firing. Therefore, a wide complex with SOB, for example, may not be unstable v-tach, but something else all together. I don't think he was implying that you can't shock a patient with a pacemaker, just that you need to make sure you do a thorough assessment to know what you are dealing with.

 

[MSDeltaFlt]

I don't mean to speak for MSDeltaFlt, but I took his post to be a reminder that pt's with pacemakers are going to normally have a wide complex when it is firing. Therefore, a wide complex with SOB, for example, may not be unstable v-tach, but something else all together. I don't think he was implying that you can't shock a patient with a pacemaker, just that you need to make sure you do a thorough assessment to know what you are dealing with.

Thanks, Epi. That is exactly what I was trying to say.

 

[rhan101277]

I don't mean to speak for MSDeltaFlt, but I took his post to be a reminder that pt's with pacemakers are going to normally have a wide complex when it is firing. Therefore, a wide complex with SOB, for example, may not be unstable v-tach, but something else all together. I don't think he was implying that you can't shock a patient with a pacemaker, just that you need to make sure you do a thorough assessment to know what you are dealing with.

I see, I didn't mean to jump the gun MSDeltaFlt. Guess I should have thought a bit more. With the new pacemakers it maybe difficult to see the pacing spikes.

Thanks Epi for your explanation.

 

[82-Alpha599]

There is no magic number, the degree of haemodynamic compromise determines treatment; the more compromised the patient the more important it is to cardiovert. This is particularly true if the rhythm is thought to be VT.

Agreed.

Regardless of the rate, the rhythm needs to be corrected immediately.
A good rule of thumb i go by is if they are still perfusing adequately use drugs, perfusing poorly synchronized defib.

"stable v-tach" I love how we say it like its no big deal.

oh, hes having a stable MI (that don't seem to work)

 

[TomB]

What is your source for the "magic number" being 150? The only thing I've seen in the literature that's even close is something like "rate related symptoms under 150 beats/min are rare" which is more of a precautionary statement than a "magic number". Patients on oral antiarrhythmics often present with VT in the 140s. You often see this in patients with an ICD who present with a wide complex tachycardia and you wonder, "Why isn't the ICD firing?" but it's because the oral antiarrhythmics are keeping the VT below the lower rate limit for the tachy functions of the device. Incidentally, when discussing "stability" in the context of a wide complex tachycardia we're talking about hemodynamic stability and sometimes a wide complex tachycardia is well tolerated by the patient. Other times not. But make no mistake -- bolusing a patient with amiodarone can make easily make a stable patient unstable. It's risk/benefit. Remember, step 1 is always "identify and treat reversible causes" and make sure it's not a compensatory tachycardia. Sinus tachycardia should always be in the differential diagnosis (220 - heart rate = maximum theoretical rate of ST).

Tom

 

[Mex EMT-I]

Hi.

(sorry for reviving this thread but i was reading it and i tought this could help a little the next reader that bumps into this)

First of all I don´t mean to ansewer for the person who posted the magic number. I don´t know where he came up with that but:

In the ACLS that magic number (150) appears in the algorithm for tachychardia with pulse.

It states that "normally" patients with PR below 150 will not develop serious signs and symptoms.

But also states that the key factor in deciding if it is stable or unstable is patient presentation.

Regards.

 

[18G]

I've always been taught and read from numerous sources that hemodynamic compromise usually doesn't begin to occur until rates hit 150 or higher. This makes sense given the decrease in end-diastolic volume (decreased ventricular filling) with high heart rates over 150. Granted, there are always patient specific factors that will make compromise began at rates lower than 150... but as a general rule 150 is the commonly stated "magic number" and is the usually stated threshold for Sinus Tachycardia. If over 150 begin to think SVT.