#sustained VTach

[mcatmemoranda]

This is for sustained VTach:

Sustained monomorphic ventricular tachycardia (SMVT) is defined as a regular, wide (≥120 milliseconds) QRS complex tachycardia with uniform and stable QRS morphology at a rate of more than 100 beats per minute that lasts for 30 seconds or longer or causes hemodynamic collapse within 30 seconds.

●All patients with SMVT should have a brief immediate assessment of the symptoms, vital signs, and level of consciousness to determine if they are hemodynamically stable or unstable. Differentiation between a hemodynamically unstable versus stable patient depends upon hemodynamic compromise, such as hypotension, altered mental status, chest pain, or heart failure (HF).

●Patients with SMVT who are hemodynamically unstable and pulseless, or who become pulseless during the course of evaluation and treatment, should be managed according to standard advance cardiac life support (ACLS) resuscitation algorithms, with immediate high-energy countershock and cardiopulmonary resuscitation (CPR). Patients should initially be treated with a synchronized 120 to 200 joule shock from a biphasic defibrillator or a 360 joule shock from a monophasic defibrillator.

●For patients with wide complex tachycardia (WCT) who are hemodynamically unstable, but still responsive with a discernible blood pressure and pulse, we recommend urgent cardioversion (following administration of sedation) (Grade 1B).

●For patients with SMVT who are hemodynamically stable on presentation, after recording a 12-lead ECG we generally prefer to begin with an intravenous antiarrhythmic agent and reserve electrical cardioversion for refractory patients or for those who become unstable.

•If pharmacologic cardioversion is the chosen approach, we administer intravenous amiodarone, procainamide, or lidocaine.

•If electrical cardioversion with appropriate procedural sedation is the chosen approach, intravenous analgesics or sedatives should be cautiously administered if the blood pressure will tolerate their use. If the QRS complex and T wave can be distinguished, an attempt at synchronized cardioversion can be performed with a synchronized shock of 100 joules using either a biphasic or monophasic defibrillator.

●Treatment of underlying conditions associated with VT, such as myocardial ischemia, electrolyte disturbances, drug proarrhythmia, and HF, as well as decreasing the sympathetic facilitation of SMVT, are important components of the acute management of VT.

●Chronic therapy of patients with SMVT usually requires utilization of multiple therapeutic modalities, including the implantable cardioverter-defibrillator (ICD), antiarrhythmic drugs, radiofrequency catheter ablation, and/or arrhythmia surgery.

•In the absence of a clearly identifiable and reversible cause for SMVT, nearly all patients with a history of SMVT will be candidates for ICD insertion for secondary prevention of sudden cardiac death, unless the patient refuses or the risks of ICD insertion are felt to outweigh the potential benefits. (See 'ICD therapy' above.) •Nearly all patients who experience SMVT have an indication for therapy with a beta blocker, including patients with a prior myocardial infarction, patients with HF and reduced LV systolic function, etc. Beta blockers provide some level of protection against recurrent SMVT, primarily by reducing myocardial oxygen demand and blocking sympathetic input to the heart. (See 'Beta blockers' above.) •Antiarrhythmic drugs may also be used to improve quality of life in patients with frequent SMVT leading to ICD shocks, or in those patients who are not candidates for, or who decline, ICD implantation. Amiodarone has generally been the most effective antiarrhythmic drug for preventing ventricular arrhythmias (and associated ICD shocks). (See 'Antiarrhythmic drugs' above.) •For patients with recurrent SMVT resulting in ICD shocks despite treatment with an antiarrhythmic drug, we suggest radiofrequency ablation (RFA) rather than the addition of a second antiarrhythmic agent (Grade 2C). RFA is also an alternative to antiarrhythmic drugs as the initial therapy for SMVT. In addition, RFA, with or without antiarrhythmic drug therapy, is an option for patients with SMVT who are not candidates for or who refuse ICD implantation. (See 'Radiofrequency catheter ablation' above.)

#sustained VTach #VTach

[populationpensive]

Loss

I just got off 3 night shifts. The first two were completely bonkers. Yesterday was thankfully boring, but the day before literally half my patients were trying to die. My pod turned into a freaking CVICU. Errrbody was going into Vtach or Afib with RVR. It was nuts.

I spent the last 3 hours of a shift trying to save a guy who was going into cardiogenic and septic shock. When we admitted him, I knew that he wasn't going to live much longer- probably wouldn't die on my shift, but probably in the next few days. He was elderly with lots of comorbities, on CRRT. But he was a totally different patient from the start of shift until the end of shift.

It started when I was looking at his monitor around 2200 when I saw ST depression. I get a formal ECG and troponin - the ST depressions are confirmed at his high sensitivity troponin was 111. It is quite common for trauma patients to have significant demand ischemia, even young patients, because the injuries really take a toll. I was suspicious that this was the case. But his trops were much higher than the typical demand ischemia. I decided to trend the troponin and repeat the ECG in a couple of hours.

Meanwhile, his vent settings are climbing and his pressures are getting soft. At that time he was on 0.04 of levophed and 0.04 of vaso. We get a respiratory culture since his secretions are thickened and icky.

At around the same time he got his repeat ECG and troponin, his pressures are getting worse - now he is on 0.12 of levophed and 0.04 of vasopressin. I tell his nurse that we will add dobutamine when his levo gets to 0.2. It wasn't maybe 10 minutes later that he got to this point. So a 3rd pressor is added. His ABG is awful. He is acidemic and has a large bicarb deficit. So, a bicarb drip is added.

Troponin comes back at 111 and his ECG is showing a STEMI. I call the cards fellow and he is like "can this patient be transported to cath lab?" Dude, no. He is unable on 3 pressors, CRRT, and bicarb infusion. As I'm having this conversion, the nurse is putting pads on him - he has had runs of non-sustained Vtach and his pressures aren't great. Card fellow gets off the phone to talk to his staff. It's around this time I get a phone call from micro telling me that this dude is growing fungi in his lungs.

I go to the patients room and tell the nurse we need to prepare to code the patient. We disconnect the CRRT and put a Lucas on him. Meanwhile, I am calling the patients SO at like 0430 in the morning and telling her that her husband, who is still full code, is actively dying. He is having a heart attack, his liver and kidneys are failing, his white count is almost 50, and his is growing fungi in his lungs. I told her "he is going to go into cardiac arrest in a few minutes" and I try to explain the futility of doing CPR on a near octogenerian with all the problems he has. She is insistent that we code him.

Meanwhile, the ICU fellow comes back and I tell him about this convo with the wife. He calls our staff who is basically like "we can't code that guy - he will die and it's cruel to do that to him." The ICU fellow calls the wife back and was waaaaay more blunt with her than I was. He actually said "so, just to confirm, you're saying you want us to do chest compression which will break all his ribs, bruise him, and lead to a traumatic death?" It was insane - never have I heard someone be so blunt. I've had similar discussions but my delivery is different. The fellow didn't fuck around with this. Wife thankfully makes the guy DNR.

Card fellow gets back to me - we all agree that in light of everything going on with this patient, i.e. multisystem organ failure, that a trip to cath lab is futile.

At this point, he is on 0.6 of levophed, 0.04 of vasopressin, and 20 of dobuatmine. Stopping the CRRT actually helped his pressures marginally. We kept him like this until the wife could arrive. Once he was compassionately extubated and pressors off, he died within 5 minutes.

The ICU fellow and I discussed this case and we aren't really sure we could have done anything differently. The fellow was impressed that I caught his ECG abnormality and was working it up. I made a lot of these decisions myself and he was like "there isn't anything we could do - this patient was dying slowly and he declared himself today."

While his death was sad, it was inevitable given his traumatic injuries and all his comorbidites. While I lost him, I truly tried to do everything I could for this patient in spite of the sparse chance of survival that he had.

I am reminded of Captain Jean-Luc Picard in moments like this:

#pablr #originstory #pa-c #critical care #medicine #physician associate #pre-pa #physician assistant #caspa #icu #exhausted

[jellypawss]

i was in sustained vtach for two minutes today and my vagus nerve trick didn’t pace me at all. Absolutely terrified.

#worst its ever been #and i dont have insurance here in florida #fucking hell #if it went on longer i could have died then #tw heart condition #tw heart #nurses on tumblr #heallthblr

[redpandahappypanda]

When I have patients go into new onset rapid afib, or sustained SVT, or sustained vtach, I listen to the 'Decisive Battle' music from Final Fantasy Six, because I am a giant nerd and I feel like watching/documenting and reporting arrhythmias like that feels like a boss battle. Like, a battle that I can win.

So often the battles I watch are decided way before they ever start. These hearts are too old, too damaged. They're drawn out, long. They're repeated, fruitlessly, over and over.

#frustrating #i guess the repeat and ongoing battles are victories in their own way #but we get so many readmissions #they keep coming back over and over again

[open-waters]

Heart monitor results are in - several episodes of non-sustained VTach, undertermined whether or not of polymorphic or monomorphic morphology due to only being about 10 beats long each time. Given my long QT history it may or may not be associated...I am...tired of this and constantly questioning whether my treatment is adequate or if we are just waiting for an SCA to do something different.

[mcatmemoranda]

Sustained V tach lasts more than 30 seconds

#vtach #sustained v tach #sustained vtach

[mcatmemoranda]

Always get a stress test on any pt with sustained Vtach

Carvedilol, bisoprolol, and metoprolol decrease mortality in pts with CHF

#CHF #Vtach

[populationpensive]

Vacation

Spent the past week in the resident side of the unit because another new hire started and nice she is straight out of school, she needs a bit more guidance. So, I got to have a somewhat vacation because the resident side was overstaffed, i.e. significantly lower pt load for me. And my friend works there so we got to lurk around together!

I casually had a patient who went into asymptomatic Vtach yesterday. He was more disturbed that he went from no one in his room to like 4 people in his room. Got some labs and an ECG which were pretty unremarkable except for a prolonged Qtc. We put this dude on some olanzepine and haldol at night because he gets EXTREMELY agitated at night. I don't blame him - he's been bed bound for weeks due to an unstable spinal fracture (long ass story of why that isn't fixed yet). But having him on a precedex drip all the time isn't exactly...sustainable. Anyway, the antipsychotics definitely helped a little but unfortunately got pulled because of the prolonged Qtc. *shrug*.

I maintain that he would benefit the most from an SSRI or buspar. When psychiatry was brought on board they weren't down with this idea. It's actually a bone I have to pick with our psych service and I saw this shit on burn all the time. In these polytrauma patients with a long course of recovery and high risk of depression/anxiety, there is ZERO reason to wait to prescribe these medications. Zero. Our psych team will sit there and be like "meh this is classified as adjustment disorder in the DSM V so no SSRIs" and it drives me up the wall. It just means we end up putting them on shit that isn't helpful (or worst don't prescribe anything) and waste time waiting for SSRIs to kick in when they are finally willing to prescribe. In burn when I was following these patients for months, I'd often just start them on an SSRI at burn week 2-3 (with permission of my staff and the pt/family) because it takes weeks for these meds to kick in. The patients are usually intubated and sedated the first two weeks anyway. *sigh* Anyway.

I'll be with the palliative care service all week. Kind of excited about being able to sleep in since I don't need to report to work until 0830 (my shifts start at 0630), but I'm also just going to wander/shadow them. I am concerned I will get bored. Our palliative care service is fabulous at my hospital - they really are instrumental in an ICU setting to put the focus on the patient and their wishes. I value that a lot. But I'm also probably not going to have any active role in their conversations so it's just not going to be...involved?

Completely unrelated, I am thinking about getting a new iPad. I've had my mini since 2017 when I started rotations. It's held up well and I needed the small one in school because it fit in my white coat pocket easily. Now I just want a bigger screen lol. Some of the apps crash on me randomly and it doesn't hold a charge anymore. But, since Mr Poppen and I just bought solar panels for our house, I think I might have to wait on the new iPad. \_o_/

#pa-c #pablr #physician assistant #physician associate #pre-pa #pa school #pa-s #medblr #medicine #critical care pa-c #originstory