Case Studies in Ventricular Tachycardia
The following case studies supplement the article Stable or Unstable? by Kevin Collopy in the June issue of EMS Magazine. To access the article, click here. For a lesson plan based on the article that also appears in the June issue, click here.
For the following cases, determine whether the patients are stable or unstable, then decide treatments appropriate for ventricular tachycardia.
Case #1
In the initial scenario of the article in the June issue, the patient presents with no complaints other than his wife's observation that he does not look right. He has no palpable pulses or blood pressure, is awake and oriented, and presents with ventricular tachycardia on the monitor. Although he is hypotensive, his brain is being perfused adequately (he has no mental status changes) and his condition is not deteriorating. As the patient sits there comfortably, he is, in fact, stable.
ALS treatment for this patient includes establishing IV access and administration of lidocaine 1.5 mg/kg. A second dose of lidocaine 0.75 mg/kg successfully converts the patient's rhythm to a sinus tachycardia at a rate of 116 beats per minute. He is transported nonemergently to the emergency department for follow-up care.
Case #2
You are called to a private residence for a patient who fainted. Upon arrival, a very anxious young woman directs you to her 35-year-old husband, who is lying on the floor being cared for by first responders. They state the patient complained of shortness of breath, then collapsed. He is currently responsive to painful stimuli and on oxygen via non-rebreather mask at 12 liters per minute. He is pale and diaphoretic. This patient is unstable because his brain is not receiving adequate oxygenation to maintain normal mental status. After you quickly apply a cardiac monitor, he is in ventricular tachycardia at a rate of 184.
ALS treatment for this patient includes immediate synchronized cardioversion at 75J, followed by an amiodarone bolus of 150 mg and then a drip at 1 mg/min.
Case #3
You respond to a skilled nursing facility for a 62-year-old male with palpitations, who says he has felt his "chest fluttering" for the past hour. The patient is in rehabilitation following a quadruple bypass. His vital signs are:
- Blood pressure 142/90
- Respirations 18 and regular; patient denies shortness of breath
- Radial pulse 92.
Case #4
A call comes in to the fire department's central station for an unknown medical problem. Upon arrival, you find the on-duty fire captain clutching his chest and gasping for air. He is awake, but is only able to speak one word at a time. Firefighter first responders have removed his shirt and put him on high-flow oxygen, and tell you he began having crushing chest pain a minute before the respiratory distress. He is diaphoretic, has a labored respiratory rate of 28 and a radial pulse of 64 and bounding. The fire captain is unstable due to the combination of worsening chest pain and respiratory distress. Diaphoresis with chest pain, respiratory distress and being able to speak one word at a time are signs of hemodynamic compromise. The cardiac monitor shows ventricular tachycardia at a rate of 192.
ALS treatment is immediate synchronized cardioversion. Delaying cardioversion for sedatives would be unwise, as he is unlikely to compensate much longer.
Case #5
St Joe's Urgent Care calls for a patient complaining of chest pain. You find a 52-year-old female complaining of slight dyspnea and 2 out of 10-rated chest "heaviness." Seated in a chair, she speaks to you in complete sentences. Despite her complaints, she does not appear to be in distress. She has a cardiac history of two previous heart attacks.
The patient's vitals are:
- A&Ox4
- Blood pressure 124/82
- Respiratory rate 22 and regular; lungs are clear
- She is on oxygen by nasal cannula
- Radial pulse rate: too rapid to count.
This patient is currently stable; however, she is at high risk for becoming unstable. The cardiac monitor shows ventricular tachycardia at a rate of 166 beats per minute.
She receives a combination of BLS and ALS treatments to manage the chest pain and the ventricular tachycardia. She is given: 324 mg aspirin, 4 mg IV morphine, 1" nitro paste and 0.4 mg nitro SLx3, and 150 mg of amiodarone administered over 5 minutes. Interestingly, after rhythm conversion, her 12-lead ECG shows ST segment elevation consistent with a lateral wall myocardial infarction. Conservative care in this case likely preserved myocardial tissue.
Case #6
An ALS squad intercepts with a BLS ambulance caring for a patient with tachycardia. A supine, obese, 72-year-old female is moving spontaneously, but responds to all questions by shouting her name, "Elaine." The BLS squad says her vitals are: heart rate 178, blood pressure 220/162 and respiratory rate 18. The patient's husband reports she has been acting appropriately all evening and never had any complaints. Based on her vital signs and altered mental status, this patient is unstable. The cardiac monitor shows ventricular tachycardia. Paramedics sedate the patient with 5 mg of Versed and perform synchronized cardioversion, which converts the patient's rhythm to atrial fibrillation at a rate of 92. Sedation is appropriate because she is awake; however, it is clear her brain is not receiving adequate oxygenation, which is causing her altered mental status.
