VTACH + VFIB | A Nurse’s Guide to Ventricular Arrhythmias

Ventricular arrhythmias like VTACH and VFIB occur in and out of the hospital. The only difference is, people aren’t hooked up to the monitors. So instead of catching the arrhythmia, the patient goes unresponsive.

VTACH and VFIB are HUGE deals, and these ventricular arrhythmias are deadly! Knowing how to recognize VFIB and VTACH is essential for any nurse in the inpatient or ER setting.

What is a Ventricular Arrhythmia (VTACH or VFIB)?

Ventricular arrhythmias are those originating from the ventricles. Since the ventricles are responsible for pumping blood to the lungs and throughout the body, ventricular arrhythmias are often deadly.

When talking about ventricular arrhythmias, we are primarily talking about VTACH (ventricular tachycardia), or VFIB (ventricular fibrillation). Ventricular escape rhythm is a backup rhythm for very slow heart rates, but that rhythm won’t be discussed in this article.

What Causes Ventricular Arrhythmias?

Ventricular arrhythmias are usually caused by coronary artery disease (CAD). Any lack of blood flow (i.e. a heart attack) will cause ventricular cells to be deprived of oxygen. When the cardiac myocytes become hypoxic, they become irritable and prone to firing when they shouldn’t, which leads to PVCs, VTACH, and even VFIB.

Other causes of ventricular arrhythmias include:

• Severe electrolyte abnormalities
• QT prolongation from medications
• Aortic stenosis or dissection
• Blunt chest trauma
• Genetic or inherited syndromes

VTACH is a tachycardic rhythm originating within the ventricles. This produces very fast heart rates which may or may not be perfusing.

AKA they might not have a pulse. 

If they do have a pulse, the patient may be asymptomatic. More likely they will experience:

• Chest pain
• Shortness of breath
• Dizziness
• Syncope.

If VTACH is pulseless, the patient will go unresponsive and be a CODE BLUE.

VTACH essentially is a “run” of PVCs that just doesn’t stop, or takes some time to spontaneously stop.

There are different types of VTACH based on its morphology or how it looks. These include Monomorphic VTACH and Polymorphic VTACH.

Monomorphic VTACH originates from the same ventricular focus. This means that the same ventricular cells or region of cells are functioning as the pacemaker for this rhythm.

They create the impulse, and the rest of the heart follows the lead.

Monomorphic VTACH will have the following features:

• Regular (R-R interval)
• HR 100-330bpm (often near 200)
• Wide QRS (>140ms or 3.5 small boxes)

P waves are absent in 40% of cases, but sometimes can be seen in no relation to the QRS complex (termed AV dissociation).

This means you may be able to see superimposed P waves throughout the VTACH.

The morphology of Monomorphic VTACH will look different depending on which ventricle it originates from – the left or the right.

Knowing the difference between these doesn’t exactly matter because the management is exactly same. Just be aware that there can be more than one general “look” to Monomorphic VTACH.

Polymorphic VTACH originates from multiple different ventricular foci.

This means that different ventricular cells or regions of cells are sending electrical impulses picked up by the rest of the heart. This leads to an irregular deadly rhythm.

Polymorphic VTACH has the following features:

• Irregular
• Wide but differing QRS morphologies
• No distinguishable P waves

Torsades creates a ribbon-like effect, where it looks like it’s twisting in on itself.

The most common polymorphic VTACH is called Torsades De Pointes which literally means twisting of the points. This is usually caused by a prolonged QT interval, often from electrolyte abnormalities or medications.

Torsades de Pointes is an unstable rhythm and often will degenerate into VFIB.

QT Prolongation

QT prolongation is the main cause of Torsades and is defined when the QT interval is >440ms in men and >460ms in women.

However, dangerous ventricular arrhythmais are unlikely to occur until >500ms.

QT prolongation is caused by:

• Electrolyte abnormalities: Hypomagnesemia, hypokalemia, hypocalcemia
• Medications (Antipsychotics, certain antibiotics, antiemetics)
• Ischemia
• Congenital or acquired disorders

VFIB is similar to polymorphic VTACH, but on a much wider scale. Essentially, all of the ventricular cells are irritable and it produces a disorganized chaotic arrhythmia that does not perfuse the body and is a CODE BLUE.

This will degenerate into asystole unless rapidly reversed.

VFIB is usually caused by CAD, with active or previous myocardial infarction being a primary cause. The other causes of ventricular arrhythmias like severe electrolyte abnormalities, hypoxia, or trauma (See Hs & Ts below).

VFIB has the following features:

• Irregular
• No organized pattern

There is either coarse (>3mm amplitude), or fine (<3mm amplitude) fibrillation.

Okay – so now we know how to identify these rhythms, but what do we actually need to do about them?

Well first off – know that you will NOT be dealing with this alone.

These situations are true emergencies, and a Code Blue or RRT should be called, and various other nurses and Providers should show up to manage the arrhythmia.

Secondly, the management of these emergent arrhythmias is extensively overviewed in ACLS, which hopefully your unit will enroll you in.

ACLS guidelines should always be followed, and you can review those here. But I do want to briefly outline 5 basic steps when dealing with a dangerous ventricular arrhythmia within the hospital setting.

1. Check for a Pulse / Breathing

   If you see a ventricular arrhythmia on the monitor, you should immediately assess your patient first. This involves going to their room (preferably running), and seeing if they’re responsive and awake.

   If they are not responsive, immediately assess for a carotid pulse and check for breathing at the same time. This is the first step in BLS and ACLS.

   In true VFIB, the patient will always be unresponsive and pulseless. Sometimes if they take their lead wires off then artifact can look like asystole or VFIB.

   VTACH is hit or miss. Sometimes the patient will be completely asymptomatic and “fine”, but this isn’t a sustainable rhythm and can degenerate quickly into VFIB.

   If VTACH is pulseless, it’s treated just like VFIB.

2. Call an RRT or Code Blue

   If the patient is pulseless, call for help and call a CODE BLUE.

   If the patient has a pulse but in VTACH, an RRT should be called as this is still an emergent rhythm and the patient can go down at any minute.

   Calling these codes within the hospital is the equivalent of “activating the emergency response system” in BLS.

   This will get everyone who needs to be there ASAP. Hopefully an ICU attending as well as nurses will come to help the Code or RRT.

3. Start CPR if Needed

   If the patient is pulseless, when you scream out for help, immediately start compressions.

   High-quality compressions are super important in bringing the patient back to a perfusing rhythm.

   As taught in ACLS, compressions should be at a rate of 100-120bpm, at least 2 inches or ⅓ depth of the chest.

   30 compressions for every 2 breaths until the patient is intubated, and then continuously.

4. Give Life-Saving Treatment

   Which medications and treatments given will depend on whether we are dealing with VTACH with a pulse, or pulseless VTACH or VFIB.

   Defibrillation is the ultimate goal with unstable or pulseless ventricular arrhythmias because defibrillation can restore a perfusing rhythm.

   Each minute you wait, the chances of restoring a perfusing rhythm drop dramatically.

   Epinephrine is always given in pulseless codes as well, 1mg IV every 3-5 minutes.

   Antiarrhythmics are important during ventricular arrhythmias that can also chemically convert the patient’s heart rhythm. Amiodarone is most often recommended, but sometimes lidocaine or others can be given.

5. Reverse any known causes (Hs & Ts)

   In ACLS you are taught all about Hs and Ts.

   Basically, this is an acronym to help you brainstorm potential causes for these deadly arrhythmias (as well as asystole or PEA).

   You can read more about the Hs & Ts below.

   Once potential causes are found, these should actively try to be reversed.

Hypovolemia from hemorrhage or shock can cause cardiac arrest, although must be severe

Hypoxia from pulmonary embolisms or respiratory failure

Hydrogen Ions aka acidosis from severe DKA or respiratory failure

Hyperkalemia, usually secondary to severe ESRD or AKI

Hypokalemia, usually from severe GI losses, diuretics, and decreased Intake

Hypothermia, usually from environmental exposures, hypoglycemia, or severe sepsis

Tension Pneumothorax usually from penetrating trauma or spontaneous

Tamponade (cardiac), usually from chest trauma, MI, or pericarditis

Toxins such as overdoses from opioids, benzos, TCAs, BB, or CCB

Thrombosis such as large pulmonary embolisms or myocardial thrombosis / infarction

Hopefully this gave you a solid understanding of V TACH and VFIB, and your role as the nurse to help manage these deadly ventricular arrhythmias.

If you want to learn more, I have a complete video course “ECG Rhythm Master”, made specifically for nurses which goes into so much more depth and detail.

With this course you will be able to:

• Identify all cardiac rhythms inside and out
• Understand the pathophysiology of why and how arrhythmias occur
• Learn how to manage arrhythmias like an expert nurse
• Become proficient with emergency procedures like transcutaneous pacing, defibrillation, synchronized shock, and more!

I also include some great free bonuses with the course, including:

• ECG Rhythm Guide eBook (190 pages!)
• Code Cart Med Guide (code cart medication guide)
• Code STEMI (recognizing STEMI on an EKG)

Check out more about the course here!

You may also like:

• How to Read an ECG Rhythm Strip
• STEMI & NSTEMI: A Nurse’s Comprehensive Guide
  
• Vagal Maneuvers: How to Stop your Patient’s SVT