Ventricular Tachycardia

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Essential Information

     Since v-tach with a pulse can suddenly become pulseless v-tach, all EMS providers need to be able to look at the patient - not the cardiac monitor - to determine if the patient is stable or unstable. Use this lesson plan to facilitate a classroom training session for your service about the v-tach with pulses article (Stable or Unstable). Before your classroom training and practice session, ask members to read the article and come to the classroom with questions. (Remember, you can make and distribute copies of the article for education purposes.)

Time Needed: 1 to 2 hours

Classroom Training Objectives

• Discuss causes of ventricular tachycardia with pulses.
• Explain differences between stable and unstable ventricular tachycardia with pulses.
• Explain important ventricular tachycardia with pulses findings.
• Review and practice interventions for ventricular tachycardia with pulses.

Group Training Outline

1. Introduce training topic - ventricular tachycardia with pulses - and review important definitions.
   1. Ventricular tachycardia
   2. Hemodynamic stability
   3. Myocardial ischemia
   Teaching Tip: Ask members to define these terms in their own words.
    
2. Discuss these causes of v-tach with pulses:
   1. Aortic stenosis
   2. Heart failure
   3. Structural deterioration of the heart
   4. Congenital heart disorders
   5. Myocarditis
   6. Cardiomyopathy
   7. Electrolyte imbalances
   
    
3. Ask the class to specifically describe how each of these signs of instability would look or sound if a patient was experiencing:
   1. Altered mental status
   2. Loss of consciousness
   3. Shock
   4. Hypotension
   5. Pulmonary edema
   6. Worsening chest pain
   7. Respiratory distress
   
    
4. Apply patient assessment concepts to determining patient stability.
   1. Chief complaint
   2. History of present illness
   3. SAMPLE
   4. Associated signs and pertinent negatives
   Teaching Tip: Ask members to provide associated signs and pertinent negatives that would support conclusion of stable or unstable.
    
5. Use a provider or manikin to demonstrate the locations on the body pertinent to physical exam findings (JVD, diaphoresis, hypoxemia, peripheral cyanosis, rales) associated with v-tach with a pulse.
    
6. ALS provider rhythm analysis - discuss relative criteria for v-tach.
   Teaching Tip: Discuss and review v-tach rhythm strips. Also review rhythms that may be confused with v-tach.
    
7. Discuss assessment techniques for:
   1. Difficult to palpate radial pulse
   2. Difficult to auscultate blood pressure
   3. Physical exam of medical patients
   
    
8. Discuss and explain interventions for VT with pulses. Encourage members to supply specific explanations of how each intervention is applied based on your local protocols.
   1. All providers:
      1. Patient reassurance
      2. Position of comfort
      3. Supplemental oxygen
      4. Monitor SpO2
      5. Monitor vital signs
   2. ALS providers:
      1. IV access for fluids and medications
      2. 12-lead ECG rhythm confirmation
      3. Medication administration
      4. Synchronized cardioversion
   Teaching Tip: Discuss interventions in the context of your local protocols and medical director authorization.
    
9. Patient assessment hands-on skills practice.
   1. Vital sign assessment: blood pressure, radial pulse, mental status
   2. Lung sound auscultation
   3. History taking
       
10. ALS provider manikin simulation practice based on your local protocol for synchronized cardioversion.
     
11. Debrief and summary.
     

End training by summarizing key differences between stable and unstable.

1. Discuss what was done well to understand assessment of instability
2. Answer member questions about v-tach with pulses by asking: "What questions do you have about assessment and treatment of v-tach with pulses?"
3. Conclude the training session with a short reminder about the importance of recognizing an unstable patient, identifying and treating life threats with the tools and protocols you have, and for BLS responders to call for additional resources for unstable patients

Patient Assessment Training Scenarios

• Select one-third of the group to be patients. The remaining two-thirds will work in two-person treatment teams.
  1. Assign half of patients to be stable and the other half to be unstable.
  Teaching tip: Ask patients to come up with a scenario, symptoms and exam findings appropriate to their condition (stable or unstable).
  2. After patients are prepared provide dispatch information to rescuers: "Male/female patient complaining of weakness."
  3. Rescuers need to perform a complete patient assessment to determine if the patient is stable or unstable. Rescuers report their plan of interventions to the instructor.
  Teaching tip: After all groups are complete ask each rescue team these questions: Was your patient stable or unstable? How did you know? What did you do for your patient?
   
• Select another one-third of group to be patients. The remaining two-thirds will work in two-person treatment teams.
  1. Assign all members to be unstable. During assessment practice all patients will experience sudden cardiac arrest.
  2. After patients are prepared provide dispatch information to rescuers: "Male/female patient complaining of chest pain."
  3. Rescuers need to begin a patient assessment to determine if the patient is stable or unstable. During the secondary assessment rescuers need to recognize sudden cardiac arrest and provide appropriate initial assessment interventions for a patient in pulseless v-tach.
  Teaching Tip: In a large group review components of pulseless v-tach algorithm.
   

     Greg Friese, MS, NREMT-P, is an e-learning specialist, author, presenter and paramedic. He and his team have authored and edited hundreds of online education lessons. Find out more about Greg and the work he does at www.gregfriese.com. Connect with him at www.twitter.com/gfriese or https://emsunited.com/profile/GregFriese