# V Tach Cardioversion



## truetiger (Jul 13, 2010)

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?


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## Hockey (Jul 13, 2010)

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...


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## themooingdawg (Jul 13, 2010)

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...


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## Hockey (Jul 13, 2010)

themooingdawg said:


> 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


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## Shishkabob (Jul 13, 2010)

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.


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## MSDeltaFlt (Jul 13, 2010)

truetiger said:


> 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.


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## firecoins (Jul 13, 2010)

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


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## truetiger (Jul 13, 2010)

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


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## MrBrown (Jul 13, 2010)

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.


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## MSDeltaFlt (Jul 13, 2010)

truetiger said:


> 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*?


 


Linuss said:


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


 
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.


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## 8jimi8 (Jul 13, 2010)

MSDeltaFlt said:


> 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.
> 
> ...



Dang now there's a golden nugget right there.


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## socalmedic (Jul 13, 2010)

truetiger said:


> ...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"


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## rhan101277 (Jul 13, 2010)

MSDeltaFlt said:


> Stable VT vs Unstable VT
> 
> Unstable VT includes these 2 things:
> 
> ...



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.


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## Epi-do (Jul 13, 2010)

rhan101277 said:


> 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.


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## MSDeltaFlt (Jul 13, 2010)

Epi-do said:


> 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.


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## rhan101277 (Jul 13, 2010)

Epi-do said:


> 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.


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## 82-Alpha599 (Jul 14, 2010)

MrBrown said:


> 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)


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## TomB (Jul 14, 2010)

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


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## Mex EMT-I (Dec 1, 2010)

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.


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## 18G (Dec 1, 2010)

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.


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## jgmedic (Dec 1, 2010)

rhan101277 said:


> 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.



Our LP12's and fire's Zolls always have this problem, had a firemedic about to push amiodarone on a lady not too long ago, until we reminded him to ask about a pacer, but damn, it looked like VT on the screen until we printed a strip.


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## Melbourne MICA (Dec 2, 2010)

*Vt*

Late as usual but my two bobs worth.

VT is classified as a lethal arrhythmia therefore calling VT "stable" is a semantic exercise reflecting only VT with a pulse and half decent BP (>100sys) and the premise you have a little time to treat before the pt becomes "unstable" or worse goes into VF and arrests. Yes in rare cases some pts have tolerated VT for prolonged periods.

However the only course of action for EMS is to treat and Ts as expeditiously as possible with perfusion state, specifically BP the criterion which simply delineates drugs or electricity mainly because Amiodarone, the typical drug of choice has many side effects not the least of which is to trash BP hence the need to cardiovert with a low BP. Whether the pt has pain, SOB feels faint or not is largely irrelevent and typically they will have one or more of these in any case - that sort of says something about VT never being "stable" in the first place.

VT can be deadly at any rate (always above 100 and more typically 120-150).

It's just imperative the rhythm is correctly assessed (using Brigadas if you know this approach) or simply wide rapid and regular. VT may or may not show P waves (not likely as a rule). The rule of thumb is to treat as VT even if you think it might be SVT with aberrancy. You really don't want to give either adenosine or calcium channel blockers like verapamil to a VT pt. 

Pacemaker history must be ascertained though as others have pointed out breakthrough VT is a not uncommon scenario when the pacemaker cannot overide the VT rate - the pt needs to be treated irrespective of pacemaker if they have VT.

MM


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## TomB (Dec 2, 2010)

I mostly agree but will make two points.

1.) Failure to "rule-in" VT with Brugada's does not "rule-out" VT. That point cannot be overemphasized.

2.) Adenosine is acceptable for hemodynamically stable regular wide complex tachycardia according to the 2010 AHA ECC Guidelines.

Tom


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## socalmedic (Dec 2, 2010)

not only is adenosine acceptable, it is now the recommended treatment for all wide complex tachycardias.


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## Melbourne MICA (Dec 3, 2010)

*Vt*

Interesting point boys about adenosine. We don't use it here - it was knocked back for use in our SVT protocol because our medicos were apparently worried about the odd asthmatic who might get a bad reaction. Its pretty standard here to see the hospital docs use amiodarone for the VT with a BP and then electricity if crashing though a lot go stright to cardioversion usually with good results ie reversion with a good perfusion state. I can't say I've ever seen anyone use adenosine in the Ed's for VT - but certainly for SVT's - standard approach. I'll read up some more especially the AHA reference that was cited.

Cheers and thanks

MM


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## TomB (Dec 3, 2010)

socalmedic said:


> not only is adenosine acceptable, it is now the recommended treatment for all wide complex tachycardias.



It is certainly not recommended for irregular polymorphic wide complex tachycardia.


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## MrBrown (Dec 3, 2010)

socalmedic said:


> not only is adenosine acceptable, it is now the recommended treatment for all wide complex tachycardias.



Bro seriously stop smoking crank it is making you say inappropriate things and embarras yourself


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## mikie (Dec 3, 2010)

socalmedic said:


> not only is adenosine acceptable, it is now the recommended treatment for all wide complex tachycardias.



Isn't that something new in the 2010 ACLS update?


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## truetiger (Dec 3, 2010)

ACLS
No more atropine in PEA and asystole.
Chronotropic drug infusions are an alternative to pacing
Adenosine for treatment and diagnosis for regular monomorphic wide-complex tachycardia. 
New policy: ROSC, titrate oxygen to SpO2 of at least 94%. Start weaning off oxygen ASAP. Avoid hyperoxia. 
Supplemental oxygen is not needed for patients with ACS absent signs of respiratory distress (on a side note, this mirrors what is taught in Harrison's Internal Medicine, Rosen's Emergency Medicine, and Tintinalli's Emergency Medicine).


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## mikie (Dec 3, 2010)

*If only!*



truetiger said:


> ACLS
> No more atropine in PEA and asystole.
> Chronotropic drug infusions are an alternative to pacing
> Adenosine for treatment and diagnosis for regular monomorphic wide-complex tachycardia.
> ...



now if only the AHA committee could sum it up that simply...


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## JPINFV (Dec 3, 2010)

truetiger said:


> ACLS
> No more atropine in PEA and asystole.
> Chronotropic drug infusions are an alternative to pacing
> Adenosine for treatment and diagnosis for regular monomorphic wide-complex tachycardia.
> ...



You know... I thought that looked familiar, especially the part about Harrison's, Rosens, and Tints. 
http://connect.jems.com/forum/topics/aha-emergency-cardiac-care

Edit: Note: Not trying to has out a copy or paste... just pointing out who wrote it.


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## socalmedic (Dec 4, 2010)

TomB said:


> It is certainly not recommended for irregular polymorphic wide complex tachycardia.



absolutely correct. i will edit my post to reflect the correct statement.

"Adenosine is recommended in the initial diagnosis 
and treatment of stable, monomorphic, wide-complex tachycardia"-AHA ECC 2010 guidelines.


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