Megacode: Unstable Ventricular Tachycardia Part 4

After placing the monitor/defibrillator in the synch mode, the joule setting on the above patient in increased and a synchronized shock is delivered.   The patient remains in refractory ventricular tachycardia.  Blood pressure: 92/52.  Heart rate: 185.  Respiratory rate: 14. Oxygen saturation: 94% on 2L/min via nasal cannula. The patient remains sedate from the versed and fentanyl.  IV fluids are infusing at 150ml/hr. 

Ventricular tachycardia with markers for synchronized cardioversion

Cardioversion of symptomatic ventricular tachycardia

16.  The second cardioversion attempt is unsuccessful.  What is the next appropriate step?

a.       Deliver an unsynchronized shock at 360 Joule for refractory VT

b.      Place the monitor back in the synch mode and deliver another synchronized shock

c.       Administer adensosine 12mg rapid IV push

d.      Give a bolus does of amiodarone 300mg. 

17.  What QRS width (seconds) determines the difference between a wide complex tachycardia and a narrow complex tachycardia?

a.       0.08 seconds

b.      0.10 seconds

c.       0.12 seconds

d.      0.20 seconds

18.  Name 5 precautions that should be considered prior to performing carotid sinus massage?

a.       Avoid carotid massage in older adults

b.      Never perform bilateral carotid massage

c.       Listen for bruits before carotid massage- contraindicated if bruits are present

d.      It should not be continued for more than 10 sec.

e.      Patient should be on cardiac monitor

f.        Should have IV access before attempting vagal maneuvers

19. What signs and symptoms might be observed in an unstable patient with wide complex tachycardia that would require synchronized cardioversion?

a.       Chest pain

b.      Syncope

c.       Shortness of breath

d.      Cold and clammy skin

e.      Decreased level of consciousness

f.        Hypotension

g.       Pulmonary congestion

20.  Explain the technique for performing a Valsalva maneuverer

a.       Document the dysrhythmia before treating

b.      Explain the procedure to the patient

c.       Instruct the patient to inhale and hold their breath and

d.      Bear down as if to have a bowel movement, and to hold this position for 20-30 seconds

e.      Document any rhythm changes on the monitor.

Answers

16. The second cardioversion attempt is unsuccessful. What is the next appropriate step?

b. Place the monitor back in the synch mode and deliver another synchronized shock

17. What QRS width (seconds) determines the difference between a wide complex tachycardia and a narrow complex tachycardia
c. 0.12 seconds

18. Name 5 precautions that should be considered prior to performing carotid sinus massage?
a. Avoid carotid massage in older adults
b. Never perform bilateral carotid massage
c. Listen for bruits before carotid massage- contraindicated if bruits are present
d. It should not be continued for more than 10 sec.
e. Patient should be on cardiac monitor
f. Should have IV access before attempting vagal maneuvers

19. What signs and symptoms might be observed in an unstable patient with wide complex tachycardia that would require synchronized cardioversion?
a. Chest pain
b. Syncope
c. Shortness of breath
d. Cold and clammy skin
e. Decreased level of consciousness
f. Hypotension
g. Pulmonary congestion

20. Explain the technique for performing a Valsalva maneuverer.
a. Document the dysrhythmia before treating
b. Explain the procedure to the patient
c. Instruct the patient to inhale and hold their breath and
d. Bear down as if to have a bowel movement, and to hold this position for 20-30 seconds
e. Document any rhythm changes on the monitor.