Stable or Unstable?

     Assessment and management of ventricular tachycardia with pulses At 0934 on a Sunday morning you are dispatched to a 64-year-old male simply reported as "pale." Upon your arrival, the first responder reports that the patient's wife noticed "he did not look right" after breakfast. Your patient is seated in his easy chair, alert and oriented, with no chief complaint other than his wife's observation of paleness. The first responder also reports that he cannot feel a radial pulse or auscultate a blood pressure, which you confirm. The patient is already on oxygen, 12 liters per minute via non-rebreather mask. The heart monitor shows ventricular tachycardia at 190 beats per minute.

     How do you treat this patient? He has no complaint, yet has no blood pressure. Hypotension—low blood pressure—is a sign of hemodynamic instability, so you must prepare for the worst. Clearly, this patient needs immediate care. His hypotension means cardioversion is indicated; however, he is not in obvious distress, so should you medicate? Sedation is preferred before cardioversion, so why not try a round of antiarrhythmics first? This article will help clarify hemodynamic instability regarding ventricular tachycardia management when pulses are present.

WHAT IS VT?

     Ventricular tachycardia is a serious and often fatal dysrhythmia that can occur with or without pulses. Each year over 300,000 patients die from sudden cardiac death, which includes ventricular tachycardia and ventricular fibrillation. This represents nearly one-half of all cardiac-related deaths. Estimating the actual number of patients is difficult because not all patients who experience ventricular tachycardia seek medicial aid before going into cardiac arrest. Untreated, pulsed v-tach can quickly deteriorate into ventricular fibrillation.

     Too often, paramedics are trained to look for ventricular tachycardia on the cardiac monitor and then determine if the patient is stable or unstable. Instead, a well-trained provider at any level of care should look at the patient, not the cardiac monitor, to determine the patient's stability. For example, there are patients with stable and unstable chest pain. Patients experiencing shortness of breath can be stable. Nonetheless, a stable patient may still require field management, advanced life support and an ambulance. Thus, determining whether a patient is stable or unstable cannot be the deciding factor for whether an EMT-Basic requests ALS or a paramedic initiates ALS care. Stable patients can still be in distress and have serious medical problems. Thorough medical providers must anticipate what may go wrong and have interventions in place to either prevent or be ready for those potential problems. Use your experience, good judgment and consultation with online medical control to determine the best patient care and transport priority.

CAUSES OF VT

     Ventricular tachycardia is one of the more commonly treated life-threatening dysrhythmias in the United States. Myocardial ischemia and infarction are the leading causes of ventricular tachycardia with pulses.1 When myocardial tissue is deprived of adequate oxygenation, it becomes irritable and experiences an increase in its automaticity. Irritated and oxygen-deprived myocardial cells can stimulate a heart to contract. An increase in irritability and automaticity allow multiple foci to stimulate cardiac contractions. Cardiomyopathy, the dilation and hypertrophy of the left ventricle, is directly correlated to an increased risk of sudden cardiac death and ventricular fibrillation. Many forms of heart disease can cause VT, including aortic stenosis heart failure, structural deterioration, congenital disorders, myocarditis and cardiomyopathy.