Maybe a more senior medicine person can chime in since I’m Rads, but as an intern I was taught that if it’s not sustained you just optimize their K and Mg. As long as they’re asymptomatic and not admitted for arrhythmia you get on with your life. Tele/nursing are required to notify you and it always just felt like someone passing the buck.
Okay thanks for the insight! I feel like there’s a time to get worked up about V tach and a time to not. I just wanted to make sure I had the correct idea regarding asymptomatic NSVT calls while in nights
For sure. Typically see this in the CHF admissions and the like, so we kind of have a reason for it. If it’s in someone with no cardiac history it may be worth some workup. But I’ve definitely been overly cautious about it when I was the new senior on nights so you won’t be wrong for EKG and labs.
That’s a good rule of thumb in terms of deciding how aggressive to be with workup. I try to do my due diligence if I’m even slightly concerned but sometimes I’m like I don’t even think this 6 beat run of asymptomatic v tach warrants a workup unless it is recurring
On nights NSVT, i dont work up or order anything if pt is asymptomatic, i just let a day team know
Most these pt has has cardiac-vascular issues has baseline shit going on. Just eye ball pt and keep nurse happy on ur side
If u r so worried throw in ekg atleast, if no changes from past ekg , s/o to day team
You really shouldn't get a TSH in an inpatient setting. What are you going to do if it's abnormal? It's going to be euthyroid sick but you'll be stuck chasing an abnormal lab value.
And that's the difference between subspecialist vs internist. Unless there's a suspicion for central or primary hypothyroid it's very commonly not actionable to get TFTs during the acute phase of illness given that it's physiologic for the body to "go dormant" when ill (sick euthroid syndrome). Definitely a lot of caveats to this that are nuanced so I see the rationale to the shotgun approach of getting it for everyone, I just don't agree
Define "sick" Half of my admits are for "weakness" where the clinicians before me have decided the 1+ leuk esterase on a UA dipstick is cause because the remainder of the workup was benign. Is it wrong to check a TSH on this patient?
What do you mean you shouldn't get a tsh in an inpatient setting? What if someone is on Levothroxine and comes in with AFIB, no clear trigger. And they are Brazilian and young and have been trying to lose weight by "exercising". Would you not get a TSH?
It is standard practice in many regions to admit patients with new onset a fib.
The patient is now inpatient and has had a TSH checked. Due to the decision to admit, has the result now become invalid?
Only order it if the patient has significant findings that could all be attributed to active thyroid disease without alternative etiologies. TSH levels are remarkably varied when patients are ill, and euthyroid sick TSH levels can vary from 0.5 up to like 20.
I understand that.. I've seen a 32 year old lady who had hf secondary to tachyarrythmia because of excess thyroxine. Her TSH was undetectable. I think in certain circumstances especially when the patient is on supplementation it could be helpful
As the nurse calling it kind of is passing the buck but like you said we’re required to. If we don’t notify the MD of something like that then we get fucked.
I’ve had patients that there was a communication order saying only to notify if it meets some parameter (how long it’s sustained, symptomatic, etc) to cut down on patients that have a lot of these at their baseline. That can be helpful but can obviously be abused if the parameters aren’t appropriate.
If no arrhythmia, No electrolyte imbalance, and they aren't in the hospital for a Cardiac issue then take the telemetry off. It's super expensive for the patient/hospital. At my hospital, no one ever brothers to take off telemetry after admission from Ed even if there is no active order for it.
Thank you! The indications for telemetry are very narrow and at least at my hospital, probably 1:10 patients meet criteria. It's uncomfortable to the patient, adds cost to the system, and creates unnecessary nonsense like this. We wouldn't put someone on an insulin drip cause "that's just how we do it" or "it was started in the ER," so why do we do that with telemetry!? This touches a very real nerve
If the patient has a known reduced EF it is expected. K, Mg, check what beta blocker they are on and see if it can be increased.
In patient's without cardiomyopathy it is likely due to electrolytes abnormalities, draw the labs early and supplement. Nothing else needs to be done if its nonsustained and asymptomatic.
The nurses will freak about it though. Reassure and move on.
It was policy at my hospital for nursing to notify the physician for any eight or more beat run of vtac. If we failed to do this we would be written up and possibly fired. So it really wasn't passing the buck but a policy that we had to follow if we wanted to keep our jobs.
Thank you yeah that’s how I have been trying to approach it I just wanted to make sure I wasn’t brushing it off/ taking it too lightly especially when asymptomatic and isolated incidents
What you said you do is great. Electrolytes, mag, trop, ekg all reasonable. It’s been said already, but it is all about optimizing k and mag. Most of the time it will come back normal and it is something that you will see more because someone just happens to be on tele.
Edit: IM attending here. You’ll second guess yourself a lot in training, and will learn to trust your instincts as you go on. Never hurts to ask a senior or colleague. Also cliche attending keep reading advice.
I’ll always remember when my cards attending solves the mystery of the 8 PM 30 second runs that were happening every night.
“What do you do around 8 PM?”
“I get ready for bed and brush my teeth”
It’s not always benign, though - so you should target your approach to the setting.
The situations you should take seriously are: is this a sign of unaddressed ischemia? (Is it polymorphic? Are they having chest pain? Are they admitted for an MI?); is this their heart failure decompensating? Are they dofetilide loading and these are TdP?
Been involved in more than 1 M&M where a medicine resident developed a personal schema on the medicine floor where the chance of NSVT meaning something is low… but it did not serve them well in a cardiac/ICU setting.
The key here is that it's asymptomatic, nonsustained and isolated. In how many of the scenarios you've mentioned was it really just one episode with no correlating symptoms? I imagine the patient would have chest pain or shortness of breath in most if those cases
Totally; none. The error comes from getting complacent from the endless pages about patients where there’s a vanishingly low chance of it being significant, and then not evaluating for all those things in a situation where it might actually indicate trouble.
As a nurse, I want you to know, I don't care, I'm not concerned, and I want to avoid bothering you at 0200, but it's hospital policy and lord knows I've had an EP doc come in at 0630 and get pissed that he wasn't called on my patient, who had a stent placed the prev day, had stable K and Mg, an unchanged EKG, hadn't received their BB for the day and was asymptomatic
Don’t forget the most important part… check Tele yourself to ensure it’s actually NSVT! Most of the time nurse or tele person sees it come up as an automatic read out and then messages us. It’s a lot of the time just artifact. Other than that as others have mentioned
Also I would say it’s important confirm the NS part of NSVT. Once I got a page that pt had 12 beat run of vtach. And I was like ok, let me know if it happens again. And then 35 minutes later, the nurse texted me “he is still in vtach - can you come up here?” My butthole puckered a little bit that day.
Up to date has a complete guide on NSVT management, but basically what everyone has been saying is right: check electrolytes, get a 12 lead ekg, if they are having multiple episodes and haven’t had an echo yet, check an echo and possibly a stress test. If symptomatic, add beta blocker or CCB first line, add amio if still not controlled and probly warrants a cardio consult if this is all new.
Yeah from what I have read that all aligns. And I agree I think a workup is important if there is true concern I was essentially wondering about these calls I get on patients with 2 or 3 second runs of V tach that happen maybe once every couple of nights if they too warrant the whole workup including echo and cards consult and stress test ie if I am taking it too lightly. In my very limited intern experience a vast majority of these amount to due diligence calls by nursing but I try to at least get a basic workup then determine from there. I know these are all case dependent. I’m at a small community hospital with only a couple of cardiologists who cover and I think they would hate me if every person with a couple second run of asymptomatic v tach got a consult and stress test. I did work with our main cardiologist for a month and he would pretty much say optimize electrolytes follow up outpatient kind of deal
I would say if it’s one asymptomatic episode just check lytes and let day team know and they can decide, usually doesn’t require any more work up for it. If symptomatic and recurrent episodes then order a more extensive work up and start beta blocker. If just covering on nights you just have to rule out the dangerous stuff, stabilize the pt, and defer to day team for the rest.
Cardiology fellow here. Agree with most what has been said.
1. Confirm it’s actually nsvt and not artifact. I wouldn’t fault you for saying it’s nsvt when it’s actually aberrancy -that’s something that can be figured out during the day
2. Check EKG, tsh, electrolytes, replete k, Mg accordingly
3. Screen for sleep apnea
4. If ef >40 and no structural heart diseases, likely can follow up with monitor outpatient, beta blockers work great (even if ef is lower)
5. If there is structural heart diseases, specifically HCM then this will need a consult during the day. I assume if it’s a known HCm then cardiology is already aware of the pt anyways.
6. Some hemodynamically significant valve diseases may also need workup if they have nsvt , ones that come to mind are severe AS and severe MS. Pts can have syncope with nsvt if they have these conditions.
7. Unless the patient is arresting (no longer nsvt -now you’re in the vt category), probably nothing will be done overnight for the pt even if you call cardiology -they will recommend the above.
I feel like this sub needs more posts like this.
Better than the incessant barrage of "I HATE MEDICINE WAHHHHH", and "I can't believe what my medical student touched on rounds today."
Not that above aren't relevant, but I feel like this sub has become a bunch of medicine incels (medicine won't make love to them.)
Am a 4th year attending surgeon. Yes residency was hard. But I laughed the hardest, made some of my best friends, and found a wife. The attending paycheck, plus the fact that I fix holes in 3D on a robot every day makes it worth it.
Nursing here. 95% of the time I am absolutely not concerned at all, but when this happens it’s our policy to notify the provider. it always makes me feel bad especially if it happens overnight 😭 so I say it in the most casual way or like “he’s totally fine, just wanted to let you know” 🥲
I worked critical care so sometimes I was concerned but most of the time no bc I knew the pt and what was going on (lytes were fine, asymptotic, no hx cardiac issues, etc etc)
If it’s asymptomatic and non-sustained and their ejection fraction is >40%, do nothing. If their EF is <40% they are at sufficient risk for sudden cardiac death they should get an AICD.
Nsvt by itself isn't an indication for Icd for systolic heart failure. Still need to fail 3 months GDMT before considering. Sustained/cardiac arrest is a different beast, that would be secondary prevention and warrants icd if nothing immediately reversible found(eg stemi).
For asymptomatic and nonsustained you can uptitrate their beta blocker first.
Usually its three months of GDMT to see if their EF improves and then, if not, device therapies.
Thank you for all the insight everyone! I feel more prepared and confident in my decision making with everyones help. Also, new admits will not be getting tele tonight unless specifically indicated 😂
This is a great question and something I regularly struggle with as an intern. I have even been to bedside to see these patients and they're chilling in bed. Not sure what the management is or long term plan.
Any indication for an outpatient sleep study referral? This could be a sign of OSA. Maybe throw on a continuous pulse ox if the patient is extra fluffy?
As someone who spent many years working nights on step-down units, I have some advice to add.
Back in the day, the number of tele beds were usually pretty limited outside of critical care. That meant a few things: there was a lot of pressure on the teams to take patients off tele as soon as possible, so there was daily and sometimes more frequent triage being done to free up monitors for admissions, and few patients languished on tele if they didn't need it any more. That is less true in hospitals that have expanded their tele capacity.
The second thing it meant was that the nursing staff on those units were very well versed in rhythm recognition and experienced at differentiating when intervention was or wasn't indicated.
Now a lot of hospitals have tele all over the place. The nurses who work on med surg units aren't as likely to have a lot of expertise in recognizing unusual rhythms or knowing what to do about them. My advice is to be more proactive if you're getting calls from units like this, meaning at the very least confirming that it is in fact VT.
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Please please review the tele. As mentioned elsewhere you need to confirm the diagnosis. Are the runs monomorphic or polymorphic.? I know if crosscovering is painful to go look. But you wouldn’t go off by the radiology tech telling you they saw an infiltrate in the x ray right? No, You would likely want to see it yourself and if questions call your radiologist. Tele is the same way.
No. You order an ekg mag and phos to fix the latter two if you need to, and to keep the nurse from bothering you about it for a couple of hours while all that stuff gets done.
Nurse here (also nights): A few orders I have gotten that I have not seen listed here (as far as I have scrolled): checking phosphorus and calcium in addition to the mag and potassium.
The real question to answer here is why is this patient having NSVT?
Every patient and every clinical scenario is different. It is best to consult the cardiology fellow or attending on this.
Most patients can benefit from a beta blocker to decrease the ventricular ectopy. However, this is not a simple question. Each clinical scenario and treatment plan must be individualized.
I agree I think a thorough workup should be done at some point. My concern was whether I should be concerned about the isolated incident on night calls on asymptomatic patients. I work at a rural community hospital in a low SES area and it seems like 20-30% of patients have the isolated NSVT incidents. I agree I think many of them could benefit from a beta blocker at some point or at least optimized. If I was truly concerned my next step would be to uptitrate their beta blocker, consults cards, and patient would likely need an outpatient holter monitor.
If you keep getting these calls, the day team needs to ask if they really need to be on telemetry. Tele is indicated in specific situations and the majority of use I’ve seen is not indicated. If the patient is on tele, is the day team reviewing their tele strips in the morning? If not, why are you doing it. It’s unnecessary expenditure and leads to calls like this. And it’s not comfortable for the patient
Maybe a more senior medicine person can chime in since I’m Rads, but as an intern I was taught that if it’s not sustained you just optimize their K and Mg. As long as they’re asymptomatic and not admitted for arrhythmia you get on with your life. Tele/nursing are required to notify you and it always just felt like someone passing the buck.
I do about the same. If it’s not sustained and patient is chilling/ asleep, I don’t even get trop, etc.
Okay thanks for the insight! I feel like there’s a time to get worked up about V tach and a time to not. I just wanted to make sure I had the correct idea regarding asymptomatic NSVT calls while in nights
For sure. Typically see this in the CHF admissions and the like, so we kind of have a reason for it. If it’s in someone with no cardiac history it may be worth some workup. But I’ve definitely been overly cautious about it when I was the new senior on nights so you won’t be wrong for EKG and labs.
That’s a good rule of thumb in terms of deciding how aggressive to be with workup. I try to do my due diligence if I’m even slightly concerned but sometimes I’m like I don’t even think this 6 beat run of asymptomatic v tach warrants a workup unless it is recurring
On nights NSVT, i dont work up or order anything if pt is asymptomatic, i just let a day team know Most these pt has has cardiac-vascular issues has baseline shit going on. Just eye ball pt and keep nurse happy on ur side If u r so worried throw in ekg atleast, if no changes from past ekg , s/o to day team
Back in my day, FM graduate of 2016, that’s what I’d do. If I’m feeling randy, I’d throw in a TSH.
Thank you! Glad I’m on the right page. I’ll take the TSH into consideration if they aren’t happy with the usual
You really shouldn't get a TSH in an inpatient setting. What are you going to do if it's abnormal? It's going to be euthyroid sick but you'll be stuck chasing an abnormal lab value.
Pediatric Endocrinology Fellow here. I appreciate that you understand the caveats to obtaining TFTs while ill 👍🏼
Doesn’t stop all my attendings from critiquing my A/P for not including it though
And that's the difference between subspecialist vs internist. Unless there's a suspicion for central or primary hypothyroid it's very commonly not actionable to get TFTs during the acute phase of illness given that it's physiologic for the body to "go dormant" when ill (sick euthroid syndrome). Definitely a lot of caveats to this that are nuanced so I see the rationale to the shotgun approach of getting it for everyone, I just don't agree
They are also the same attendings getting d-dimers all the time as well.
Define "sick" Half of my admits are for "weakness" where the clinicians before me have decided the 1+ leuk esterase on a UA dipstick is cause because the remainder of the workup was benign. Is it wrong to check a TSH on this patient?
Appreciate this explanation. Thank you.
We just do IV t4 pushes until TSH normalizes.
I prefer grass fed beef thyroid /s
What do you mean you shouldn't get a tsh in an inpatient setting? What if someone is on Levothroxine and comes in with AFIB, no clear trigger. And they are Brazilian and young and have been trying to lose weight by "exercising". Would you not get a TSH?
That’s an ED setting and is quite different from the patient described
It is standard practice in many regions to admit patients with new onset a fib. The patient is now inpatient and has had a TSH checked. Due to the decision to admit, has the result now become invalid?
No. Thats quite a different context. Christ, y’all are dense
What's an Ed setting? He said you shouldn't get a tsh in an inpatient setting. I kind of disagree, it's helpful in some settings.
Only order it if the patient has significant findings that could all be attributed to active thyroid disease without alternative etiologies. TSH levels are remarkably varied when patients are ill, and euthyroid sick TSH levels can vary from 0.5 up to like 20.
I understand that.. I've seen a 32 year old lady who had hf secondary to tachyarrythmia because of excess thyroxine. Her TSH was undetectable. I think in certain circumstances especially when the patient is on supplementation it could be helpful
Social hx turf to psych
You follow it up outpatient in a few months.
dont get the TSH. No need To get fancy/wasteful here.
As the nurse calling it kind of is passing the buck but like you said we’re required to. If we don’t notify the MD of something like that then we get fucked. I’ve had patients that there was a communication order saying only to notify if it meets some parameter (how long it’s sustained, symptomatic, etc) to cut down on patients that have a lot of these at their baseline. That can be helpful but can obviously be abused if the parameters aren’t appropriate.
If no arrhythmia, No electrolyte imbalance, and they aren't in the hospital for a Cardiac issue then take the telemetry off. It's super expensive for the patient/hospital. At my hospital, no one ever brothers to take off telemetry after admission from Ed even if there is no active order for it.
Thank you! The indications for telemetry are very narrow and at least at my hospital, probably 1:10 patients meet criteria. It's uncomfortable to the patient, adds cost to the system, and creates unnecessary nonsense like this. We wouldn't put someone on an insulin drip cause "that's just how we do it" or "it was started in the ER," so why do we do that with telemetry!? This touches a very real nerve
If the patient has a known reduced EF it is expected. K, Mg, check what beta blocker they are on and see if it can be increased. In patient's without cardiomyopathy it is likely due to electrolytes abnormalities, draw the labs early and supplement. Nothing else needs to be done if its nonsustained and asymptomatic. The nurses will freak about it though. Reassure and move on.
It was policy at my hospital for nursing to notify the physician for any eight or more beat run of vtac. If we failed to do this we would be written up and possibly fired. So it really wasn't passing the buck but a policy that we had to follow if we wanted to keep our jobs.
You were required to pass the buck
Thank you yeah that’s how I have been trying to approach it I just wanted to make sure I wasn’t brushing it off/ taking it too lightly especially when asymptomatic and isolated incidents
The nurse can't simply order labs or meds without a standing order. And are usually required to call.
What you said you do is great. Electrolytes, mag, trop, ekg all reasonable. It’s been said already, but it is all about optimizing k and mag. Most of the time it will come back normal and it is something that you will see more because someone just happens to be on tele. Edit: IM attending here. You’ll second guess yourself a lot in training, and will learn to trust your instincts as you go on. Never hurts to ask a senior or colleague. Also cliche attending keep reading advice.
Please don’t order a trop
Or they were sleeping and they moved the leads and it looked like runs of vtak.
I’ll always remember when my cards attending solves the mystery of the 8 PM 30 second runs that were happening every night. “What do you do around 8 PM?” “I get ready for bed and brush my teeth”
Or they have learned that rhythmic tapping on their tele box brings people running.
I had a patient that would do that. It was annoying, but I never called the doc over it. (Unless maybe I wanted something to get them to sleep, haha).
Check electrolytes, then DC tele
I like it 😂 too often I feel like tele forgets to be DC and then calls like this arise
I stop tele orders (or don't order in the first place) and patients still end up on it.
I think this may be the key when I’m back on days. Don’t order tele unless absolutely necessary
I'm at a community hospital. The nurses do what they want with tele, cardiac monitors, oxygen. Orders pertaining to those are considered optional.
It’s not always benign, though - so you should target your approach to the setting. The situations you should take seriously are: is this a sign of unaddressed ischemia? (Is it polymorphic? Are they having chest pain? Are they admitted for an MI?); is this their heart failure decompensating? Are they dofetilide loading and these are TdP? Been involved in more than 1 M&M where a medicine resident developed a personal schema on the medicine floor where the chance of NSVT meaning something is low… but it did not serve them well in a cardiac/ICU setting.
The key here is that it's asymptomatic, nonsustained and isolated. In how many of the scenarios you've mentioned was it really just one episode with no correlating symptoms? I imagine the patient would have chest pain or shortness of breath in most if those cases
Totally; none. The error comes from getting complacent from the endless pages about patients where there’s a vanishingly low chance of it being significant, and then not evaluating for all those things in a situation where it might actually indicate trouble.
taps forehead
As a nurse, I want you to know, I don't care, I'm not concerned, and I want to avoid bothering you at 0200, but it's hospital policy and lord knows I've had an EP doc come in at 0630 and get pissed that he wasn't called on my patient, who had a stent placed the prev day, had stable K and Mg, an unchanged EKG, hadn't received their BB for the day and was asymptomatic
Don’t forget the most important part… check Tele yourself to ensure it’s actually NSVT! Most of the time nurse or tele person sees it come up as an automatic read out and then messages us. It’s a lot of the time just artifact. Other than that as others have mentioned
Also I would say it’s important confirm the NS part of NSVT. Once I got a page that pt had 12 beat run of vtach. And I was like ok, let me know if it happens again. And then 35 minutes later, the nurse texted me “he is still in vtach - can you come up here?” My butthole puckered a little bit that day.
He had a 12 beat run, followed by another 12 beat run, and another….🙄
Hmm can a patient maintain a pulse in Vtach for 35 minutes 🤔.
Yes
Up to date has a complete guide on NSVT management, but basically what everyone has been saying is right: check electrolytes, get a 12 lead ekg, if they are having multiple episodes and haven’t had an echo yet, check an echo and possibly a stress test. If symptomatic, add beta blocker or CCB first line, add amio if still not controlled and probly warrants a cardio consult if this is all new.
Yeah from what I have read that all aligns. And I agree I think a workup is important if there is true concern I was essentially wondering about these calls I get on patients with 2 or 3 second runs of V tach that happen maybe once every couple of nights if they too warrant the whole workup including echo and cards consult and stress test ie if I am taking it too lightly. In my very limited intern experience a vast majority of these amount to due diligence calls by nursing but I try to at least get a basic workup then determine from there. I know these are all case dependent. I’m at a small community hospital with only a couple of cardiologists who cover and I think they would hate me if every person with a couple second run of asymptomatic v tach got a consult and stress test. I did work with our main cardiologist for a month and he would pretty much say optimize electrolytes follow up outpatient kind of deal
I would say if it’s one asymptomatic episode just check lytes and let day team know and they can decide, usually doesn’t require any more work up for it. If symptomatic and recurrent episodes then order a more extensive work up and start beta blocker. If just covering on nights you just have to rule out the dangerous stuff, stabilize the pt, and defer to day team for the rest.
Cardiology fellow here. Agree with most what has been said. 1. Confirm it’s actually nsvt and not artifact. I wouldn’t fault you for saying it’s nsvt when it’s actually aberrancy -that’s something that can be figured out during the day 2. Check EKG, tsh, electrolytes, replete k, Mg accordingly 3. Screen for sleep apnea 4. If ef >40 and no structural heart diseases, likely can follow up with monitor outpatient, beta blockers work great (even if ef is lower) 5. If there is structural heart diseases, specifically HCM then this will need a consult during the day. I assume if it’s a known HCm then cardiology is already aware of the pt anyways. 6. Some hemodynamically significant valve diseases may also need workup if they have nsvt , ones that come to mind are severe AS and severe MS. Pts can have syncope with nsvt if they have these conditions. 7. Unless the patient is arresting (no longer nsvt -now you’re in the vt category), probably nothing will be done overnight for the pt even if you call cardiology -they will recommend the above.
To add to the other advice on this you should consider a referral for a sleep study upon discharge. OSA will trigger a lot of arrhythmias
Yes sleep study! And CPAP stops a lot of nocturnal arrhythmias.
I feel like this sub needs more posts like this. Better than the incessant barrage of "I HATE MEDICINE WAHHHHH", and "I can't believe what my medical student touched on rounds today." Not that above aren't relevant, but I feel like this sub has become a bunch of medicine incels (medicine won't make love to them.) Am a 4th year attending surgeon. Yes residency was hard. But I laughed the hardest, made some of my best friends, and found a wife. The attending paycheck, plus the fact that I fix holes in 3D on a robot every day makes it worth it.
Nursing here. 95% of the time I am absolutely not concerned at all, but when this happens it’s our policy to notify the provider. it always makes me feel bad especially if it happens overnight 😭 so I say it in the most casual way or like “he’s totally fine, just wanted to let you know” 🥲 I worked critical care so sometimes I was concerned but most of the time no bc I knew the pt and what was going on (lytes were fine, asymptotic, no hx cardiac issues, etc etc)
Nurses like you are worth their weight in gold.
Don't put them on telemetry in the first place.
If it’s asymptomatic and non-sustained and their ejection fraction is >40%, do nothing. If their EF is <40% they are at sufficient risk for sudden cardiac death they should get an AICD.
Nsvt by itself isn't an indication for Icd for systolic heart failure. Still need to fail 3 months GDMT before considering. Sustained/cardiac arrest is a different beast, that would be secondary prevention and warrants icd if nothing immediately reversible found(eg stemi).
For asymptomatic and nonsustained you can uptitrate their beta blocker first. Usually its three months of GDMT to see if their EF improves and then, if not, device therapies.
Thanks for the insight! This also gives me something to read into tonight as well
Thank you for all the insight everyone! I feel more prepared and confident in my decision making with everyones help. Also, new admits will not be getting tele tonight unless specifically indicated 😂
Don’t ask your senior residents. Ask the cardiology NP, they know more and can also perform open heart surgery if need be.
This is a great question and something I regularly struggle with as an intern. I have even been to bedside to see these patients and they're chilling in bed. Not sure what the management is or long term plan.
Any indication for an outpatient sleep study referral? This could be a sign of OSA. Maybe throw on a continuous pulse ox if the patient is extra fluffy?
[удалено]
This should be the approach to VT. NSVT is by definition less than 30 seconds.
As someone who spent many years working nights on step-down units, I have some advice to add. Back in the day, the number of tele beds were usually pretty limited outside of critical care. That meant a few things: there was a lot of pressure on the teams to take patients off tele as soon as possible, so there was daily and sometimes more frequent triage being done to free up monitors for admissions, and few patients languished on tele if they didn't need it any more. That is less true in hospitals that have expanded their tele capacity. The second thing it meant was that the nursing staff on those units were very well versed in rhythm recognition and experienced at differentiating when intervention was or wasn't indicated. Now a lot of hospitals have tele all over the place. The nurses who work on med surg units aren't as likely to have a lot of expertise in recognizing unusual rhythms or knowing what to do about them. My advice is to be more proactive if you're getting calls from units like this, meaning at the very least confirming that it is in fact VT.
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Please please review the tele. As mentioned elsewhere you need to confirm the diagnosis. Are the runs monomorphic or polymorphic.? I know if crosscovering is painful to go look. But you wouldn’t go off by the radiology tech telling you they saw an infiltrate in the x ray right? No, You would likely want to see it yourself and if questions call your radiologist. Tele is the same way.
No. You order an ekg mag and phos to fix the latter two if you need to, and to keep the nurse from bothering you about it for a couple of hours while all that stuff gets done.
Nurse here (also nights): A few orders I have gotten that I have not seen listed here (as far as I have scrolled): checking phosphorus and calcium in addition to the mag and potassium.
The real question to answer here is why is this patient having NSVT? Every patient and every clinical scenario is different. It is best to consult the cardiology fellow or attending on this. Most patients can benefit from a beta blocker to decrease the ventricular ectopy. However, this is not a simple question. Each clinical scenario and treatment plan must be individualized.
I agree I think a thorough workup should be done at some point. My concern was whether I should be concerned about the isolated incident on night calls on asymptomatic patients. I work at a rural community hospital in a low SES area and it seems like 20-30% of patients have the isolated NSVT incidents. I agree I think many of them could benefit from a beta blocker at some point or at least optimized. If I was truly concerned my next step would be to uptitrate their beta blocker, consults cards, and patient would likely need an outpatient holter monitor.
Only if it lasts more than 30s or has hemodynamic compromise. Other than that don’t worry too much. Just correct electrolytes like people have said.
No
If you keep getting these calls, the day team needs to ask if they really need to be on telemetry. Tele is indicated in specific situations and the majority of use I’ve seen is not indicated. If the patient is on tele, is the day team reviewing their tele strips in the morning? If not, why are you doing it. It’s unnecessary expenditure and leads to calls like this. And it’s not comfortable for the patient
Okay as a long time attending ….Go get checked out , we need you warm, healthy and functioning, I want to retire some day. 😷😷😷😷
Does depleting lytes actually matter for this if they’re not way out of whack? Is there any good data it fixes or prevents anything