NSVT Page

Page! From the Tele Tech: "Ms Ectopy had 12 beats of NSVT. RN x3234" [[Walk over to the tele monitors]] [[Call the RN]] [[Pull up the patient's chart]]

You walk over to the tele monitors, and see the following rhythm strip for a period of about 15 seconds, before returning to normal sinus rhythm: <img src="Monomorphic VTach.jpeg" alt="tele strip"> [[Pull up the patient's chart]] [[Call the RN]]

You call the patient's RN to check in on how the patient's doing He says that she's having some chest pain, she had transient lightheadedness during the arrhythmia. Not short of breath. Watching TV. Hasn't had any medications for the last few hours. [[Pull up the patient's chart]] [[Walk over to the tele monitors]]

You pull up the patients chart - what information do you want? Hospital Day 1 (admitted 12 hours ago) [[Read H&P]] [[Look at prior EKGs]] [[Look at Labs]] [[Order tests]] [[Order medications]] [[Call consultant]] Or, [[Call the RN]] [[Walk over to the tele monitors]] Or, [[Things are fine, continue to monitor -> No action final]]

CC: 75F Chest Pain Admitted 12h ago HPI: crescendo angina... PMHx: T2DM, no known CAD Meds: lisinopril, asa Soc: +smoking VS at admission AF, 150/90, HR 90, RR 18, SpO2 94% on RA Exam: HEENT: no jvd CV: rrr, no murmur Pulm: ctab LE: no edema Labs; trop 0.3 Coronary angiogram: left main stenosis 90% A/P: -Unstable Angina: ASA, atorva, plan for LHC and expedited remaining for CABG -Tele .... [[Return to Patient's Chart->Pull up the patient's chart]]

EKG from admission (12h ago) shows... <img src="LVH.gif" alt="baseline ekg"> [[Return to Patient's Chart->Pull up the patient's chart]]

Troponin 0.3 at admission Potassium this morning 3.6 Magnesium 2.2 Calcium 8.8, Albumin 4.0 Other labs unremarkable [[Return to patient's chart->Pull up the patient's chart]]

What test do you want to order? [[Order EKG]] [[Order Troponin]] [[Order BMP and Magnesium]] [[Reuturn to chart without ordering a test->Pull up the patient's chart]]

What medication do you want to order? [[Order Metoprolol ->Order confirmation]] [[Order Heparin ->Order confirmation]] [[Order Magnesium Sulfate ->Order confirmation]] [[Order Potassium Chloride ->Order confirmation]] [[Order Calcium Gluconate]] [[Return to patient's chart->Pull up the patient's chart]]

You call cardiology. What do you want to tell the fellow on call? [[I'm worried about this patient's potassium -> Potassium Final]] [[I'm worried this patient is having ischemia -> Ischemia Final]] [[I'm worried about this patient's QTc -> QTc Final]]

EKG shows: <img src="hyperacute.gif" alt ="current ekg"> [[Return to patient's chart->Pull up the patient's chart]]

Troponin 0.4 ng/dl [[Return to patient's chart->Pull up the patient's chart]]

BMP: notable for potassium 4.2. Magnesium 2.2. Calcium normal. [[Return to patient's chart->Pull up the patient's chart]]

Medication Ordered [[Order another medication ->Order medications]] [[Return to chart ->Pull up the patient's chart]]

You call the cards fellow, who reviews the tele strip and EKGs. With the EKG findings and chest pain, it turns out that the right course of action would have been... [[Debrief]]

The cards fellow pulls up the EKG - nice catch! She agrees with your course of action and thanks you for responding promptly.. [[Debrief]]

The cards fellow pulls up the EKG... seems like the QTc is OK, but there's another important EKG finding.... [[Debrief]]

You take no action. Unfortunately, the patient keeps having chest pain and ventricular ectopy. When the cards team comes in in the morning, they review the EKG and reveal how this case should have been managed... [[Debrief]]

Non-sustained Ventricular Tachycardia can be cause by a variety of pathologies: Active cardiac ischemia Prior myocardial infarction that has led to scar Electrolyte abnormalities Heart Failure Long QT Or, sometimes no apparent cause is identified. WHen paged about NSVT, the general approach: make sure this isn’t something dangerous. Otherwise, no intervention. (CAST trial) First, gather the important information: How long (longer = worse), how fast (faster = worse), and what morphology (polymorphic = worse) Symptoms: Chest pain? (ischemia), Lightheadedness? (perfusion) Second, look into the causes of NSVT that are reversable or dangerous: 1. ischemia (esp if polymorphic). eval w/ EKG, +/- troponin (never troponin without EKG – that tells you about what was going on in the heart 6h ago. We’re interested in now) 2. Long qt (esp polymorphic, then called Torsades de Pointes). eval w/ EKG +/- medlist check 3. Electrolyte abnormalities. eval with BMP (hypo K, hypo Ca), hypo- mag 4. Structural heart disease. Are they here for a CHF exacerbation or could they have one. are they otherwise decompensating? (ideal if can also capture the NSVT on EKG to help differentiate SVT w/ aberrancy) If all the above are either clinically unlikely or not found on the workup - observation is warranted. In this case, the EKG shows hyperacute T-waves in the anterior leads (remember, the first sign of myocardial infarction on an EKG is LOCAL peaked T-waves, caused by the potassium from dying myocardial cells influencing local conduction). Troponin is normal because this just started. <img src="hyperacute.gif" alt ="current ekg"> In this case, new active ischemia leading to electrical instability would likely be a reason to expedite reperfusion, thus involving the cardiology fellow is appropriate. Key points: 1. Evaluate for dangerous causes of NSVT 2. Not all NSVT is either a potassium or magnesium problem 3. EKGs tell you about what is going on in the heart now. Troponin tells you what was going on in the heart 6h ago 4. Peaked T-waves are the first sign of myocardial infarction on EKG The end.

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