How well do you know your ACLS? Scenarios for the week of December 12, 2022

How well do you know your ACLS? Scenario for the week of December 12, 2022

You are working on the telemetry floor, caring for a patient who had 1 stent placed in her LAD tlast week. Your patient is a 47 year old diabetic female who uses an insulin pump.  Her blood sugar is 114, her respiratory rate is 16, BP 118/74 and her pulse ox is 96% on room air.  She pushed her call bell, and you walk into her room to find her very anxious, her respiratory rate is now 30 and she reports crushing chest pain. She says she just can't catch her breath and she's pale, diaphoretic and her O2 sat has dropped to 89%. You place her on 2L O2 per NC and get a quick BP. Her BP is now 76/44 and you assess her rhythm on the cardiac monitor in lead II. 

What do you think is happening with this patient?

A. The stent placed last week has occluded

B. She is having a new heart attack

C. She is having symptoms of congestive heart failure

D. The stent has slipped, and is causing her chest pain

The answer is B. The stent took care of the blockage in that one area of her LAD, and now she's having another heart attack. You'll need to call the doctor for an order for an EKG, update the doctor on the patient's status and vital signs after placing her on oxygen and get an order for labs, including a troponin level which should be repeated every 8 hours for a series of three times. 

As a heart attack starts and the cardiac cells start to die, the byproduct of the cell death produces troponin. It can take a few hours for the troponin to get into the blood stream so you want to check her labs three times, each 8 hours apart as the first blood level could be 0.0. If the second troponin comes back 4.2, you know she is actively having a heart attack as the troponin level has increased. 

An EKG can show exactly where the blockage is so the patient can be taken back to the cath lab for another stent, or more stents, or other emergency procedures to save the heart muscle.

The highest treatment priority right now, is to treat her tachycardia (with a pulse). She is not stable because of her symptoms, and her low blood pressure. You should call for a "Rapid Response Team" or an RRT overhead so that code team members are on the way to assist you. Arrangements should be quickly, made to prepare for cardioversion. You need to get her stabilized before you can transfer her to the cath lab.

To prepare for cardioversion, You'll need to place at minimum, 3 ECG leads.  If the patient already has leads on that are connected to their telemetry box, or their bedside monitor, you will need three more ECG leads and connect them to the crash cart defibrillator. These three leads will mark the "R" wave of her QRS when the "Synch" button is pushed before delivering a shock. This will prevent the shock from landing on the T-wave which could cause the patient to go into ventricular fibrillation or VFib which could lead to the patient's death. 

Remember to put the white ECG lead on the right side of the chest, just under the center of the collar bone. The black goes in the same place on the left of the chest and the red lead goes under the left armpit about half way between the level of the belly button and the center bottom portion of the rib cage. "White on the RIght and smoke over fire."      You will also need to attach the defibrillator pads. The three ECG leads mark the R wave and the defib pads deliver the shock.

See the little arrows at the top of the highest point of the heartbeat. This shows that the shock will be synchronized with the R wave. We will charge the defibrillator to 100 joules, clear the patient and make sure no one is touching them, make sure the synch is on and deliver the shock. Most of the time, one synchronized shock will convert the rhythm to sinus rhythm. If the rhythm does not slow down, deliver another shock and increase the joules to 120. Clear the patient and deliver another synchronized shock. Continue increasing the joules, delivering only synchronized shocks until the rhythm converts to sinus rhythm.

The rhythm above is called Ventricular Tachycardia. You could also call it "Monomorphic" V-Tach. Mono means one and morphic means shape. You can see that each heartbeat looks the same. If there were lots of different shapes we would call it polymorphic meaning more than one shape. 

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Patient Care and Health Information from the Mayo Clinic says:

Ventricular tachycardia - Symptoms and causes - Mayo Clinic

Ventricular tachycardia is a heart rhythm problem (arrhythmia) caused by irregular electrical signals in the lower chambers of the heart (ventricles). This condition may also be called V-tach or VT.

A healthy heart typically beats about 60 to 100 times a minute at rest. In ventricular tachycardia, the heart beats faster, usually 100 or more beats a minute.

Sometimes the rapid heartbeat prevents the heart chambers from properly filling with blood. As a result, the heart may not be able to pump enough blood to the body. If this happens, you may feel short of breath or lightheaded, or you may lose consciousness.

Ventricular tachycardia episodes may be brief and last only a couple of seconds without causing harm. But episodes lasting more than a few seconds (sustained V-tach) can be life-threatening. Sometimes ventricular tachycardia can cause the heart to stop (sudden cardiac arrest).

Treatment for ventricular tachycardia may include medication, a shock to the heart (cardioversion), catheter procedures or surgery to slow the fast heart rate and reset the heart rhythm.

Symptoms

When the heart beats too fast, it may not pump enough blood to the rest of the body. So the organs and tissues may not get enough oxygen. Signs and symptoms that occur during an episode of ventricular tachycardia are due to a lack of oxygen and may include:

• Chest pain (angina)
• Dizziness
• Pounding heartbeat (palpitations)
• Lightheadedness
• Shortness of breath

Ventricular tachycardia may go away on its own within 30 seconds (nonsustained V-tach) or last more than 30 seconds (sustained V-tach or VT). Brief episodes may not cause any symptoms. But sustained VT can cause serious problems, including:

• Fainting
• Loss of consciousness
• Cardiac arrest (sudden death)

Causes

Ventricular tachycardia is caused by faulty heart signaling that triggers a fast heart rate in the lower heart chambers (ventricles). The fast heart rate doesn't allow the ventricles to fill and squeeze (contract) to pump enough blood to the body.

Many things can cause or contribute to problems with heart signaling and lead to ventricular tachycardia. These include:

• Prior heart attack or other heart condition that caused scarring of heart tissue (structural heart disease)
• Poor blood flow to the heart muscle due to coronary artery disease
• Congenital heart diseases, including long QT syndrome
• Imbalance of substances in the blood called electrolytes — such as potassium, sodium, calcium and magnesium
• Medication side effects
• Use of stimulants such as cocaine or methamphetamine

Sometimes, the exact cause of ventricular tachycardia can't be determined (idiopathic ventricular tachycardia).

How does the heart beat?

Typical heartbeat     Open pop-up dialog box

To better understand the cause of ventricular tachycardia, it may be helpful to know how the heart typically works.

The heart is made of four chambers — two upper chambers (atria) and two lower chambers (ventricles).

The heart's rhythm is controlled by a natural pacemaker (the sinus node) in the right upper chamber (atrium). The sinus node sends electrical signals that typically start each heartbeat. These electrical signals move across the atria, causing the heart muscles to squeeze (contract) and pump blood into the ventricles.

Next, the signals arrive at a cluster of cells called the AV node, where they slow down. This slight delay allows the ventricles to fill with blood. When the electrical signals reach the ventricles, the chambers contract and pump blood to the lungs or to the rest of the body.

In a typical heart, this heart signaling process usually goes smoothly, resulting in a resting heart rate of 60 to 100 beats a minute.

In ventricular tachycardia, faulty electrical signaling in the heart's lower chambers causes the heart rate to increase to 100 or more beats a minute.

Risk factors

Any condition that puts a strain on the heart or damages heart tissue can increase the risk of ventricular tachycardia. Lifestyle changes or proper medical treatment for the following conditions and events may lower the risk:

• Heart disease
• Medication side effects
• Severe electrolyte imbalances
• Use of stimulant drugs such as cocaine or methamphetamine

A family history of tachycardia or other heart rhythm disorders makes a person more likely to develop ventricular tachycardia.

Complications

Complications of ventricular tachycardia depend on:

• How fast the heart is beating
• How long the rapid heart rate lasts
• Whether there are other heart conditions

Possible complications of ventricular tachycardia include:

• Frequent fainting spells or unconsciousness
• Heart failure
• Sudden death caused by cardiac arrest

Ventricular fibrillation

A dangerous condition related to ventricular tachycardia is ventricular fibrillation (V-fib). In V-fib, the lower heart chambers contract in a very rapid and uncoordinated manner.

This irregular rhythm happens most often in people with heart disease or a prior heart attack. It may also occur in those with electrolyte imbalances (such as high or low potassium levels).

Ventricular fibrillation may cause sudden cardiac arrest and lead to death if not treated immediately.

Prevention

The best ways to prevent tachycardia are to maintain a healthy heart and prevent heart disease. If you already have heart disease, monitor it and follow your treatment plan. Be sure you understand your treatment plan, and take all medications as prescribed.

Take the following steps to keep the heart healthy:

• Eat a balanced, nutritious diet. A diet low in saturated and trans fats and rich in fruits, vegetables and whole grains helps keep the heart healthy.
• Exercise and maintain a healthy weight. Being overweight increases the risk of developing heart disease. As a general goal, aim for at least 30 minutes of moderate exercise every day.
• Control blood pressure and cholesterol levels. Make lifestyle changes and take medications as prescribed to manage high blood pressure (hypertension) or high cholesterol.
• Control stress. Avoid unnecessary stress and learn strategies to manage and reduce stress.
• Don't use illegal drugs. Don't use stimulants, such as cocaine. If you need help stopping drug use or misuse, talk to your health care provider about an appropriate program for you.
• Go to scheduled health checkups. Have regular physical exams and report any new signs or symptoms to your health care provider.
• Limit alcohol. If you choose to drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women and up to two drinks a day for men. Some people may need to avoid alcohol entirely. Ask your health care provider how much alcohol, if any, is safe for you.
• Limit caffeine. If you drink caffeinated beverages, do so in moderation (no more than 1 to 2 beverages daily).
• Stop smoking. If you smoke and can't quit on your own, talk to your health care provider about strategies or programs to help you break a smoking habit.
• Use over-the-counter medications with caution. Some cold and cough medications contain stimulants that may increase the heart rate. Always tell your health care provider about the medications you take, including those bought without a prescription.