Emergency Medicine : Managment of Ventricular Tachycardia

Managment of Ventricular Tachycardia in Adult
Approach

1. No pulse
1. Treat as Pulseless Ventricular Tachycardia
2. Unstable
1. Treat as Unstable Ventricular Tachycardia
2. Administer Synchronized Cardioversion
3. Stable
1. Assess QRS Complex morphology
2. Treat per protocols below
1. Monomorphic Ventricular Tachycardia
2. Polymorphic Ventricular Tachycardia

Monomorphic Ventricular Tachycardia

1. Normal Cardiac Function
1. Medications: First line
1. Procainamide 20-30 mg/min to max total 17 mg/kg
2. Sotalol
2. Medications: Second line
1. Amiodarone 150 mg IV bolus over 10 minutes
2. Lidocaine 0.5 to 0.75 mg/kg IV push
3. Administer Synchronized Cardioversion
2. Reduced cardiac function with poor ejection fraction
1. Amiodarone 150 mg IV bolus over 10 minutes
2. Lidocaine 0.5 to 0.75 mg/kg IV push
3. Administer Synchronized Cardioversion

Polymorphic Ventricular Tachycardia

1. Normal baseline QT Interval
1. General Measures
1. Treat Myocardial Ischemia
2. Correct electrolyte disturbance
2. Medications
1. Beta Blocker
2. Amiodarone 150 mg IV bolus over 10 minutes
3. Lidocaine 0.5 to 0.75 mg/kg IV push
4. Procainamide 20-30 mg/min to max total 17 mg/kg
5. Sotalol
6. Administer Synchronized Cardioversion
2. Prolonged baseline QT Interval (torsades de pointes)
1. General Measures
1. Correct electrolyte disturbance
2. Medications
1. Magnesium Sulfate
2. Overdrive cardiac pacing
3. Isoproterenol
4. Phenytoin
5. Lidocaine 0.5 to 0.75 mg/kg IV push

CARDIOVERSION

 

PRE-PROCEDURE

INTRODUCTION

External direct current cardioversion (DCC) is the application of a brief pulse of direct electrical current across the chest wall of a patient with an appropriate rapid dysrhythmia, causing momentary depolarization of most cardiac cells. Synchronized cardioversion refers to an electrical energy discharge synchronized with the QRS complex, avoiding energy delivery in the early phase of repolarization when the ventricular myocardium is susceptible to ventricular fibrillation (VF). Unsynchronized cardioversion refers to an unsynchronized discharge of energy and is only recommended for extremely unstable patients. DCC is usually effective almost immediately, has few side effects, and is often more successful than pharmacological therapy.¹

INDICATIONS Unstable patient with reentrant tachycardia Stable patient with supraventricular tachycardia CONTRAINDICATIONS Sinus tachycardia Atrial fibrillation lasting longer than 36-48 hours without appropriate anticoagulation therapy Digoxin toxicity Junctional and multifocal atrial tachycardia EQUIPMENT (KNOW YOUR INSTRUMENT) ECG monitor/defibrillator Paddles and pads Conductive materials Resuscitation supplies (adjuncts to defibrillation) Intravenous access Advanced airway management equipment Antidysrythmic drugs Procedural sedation drugs (KNOW YOUR HOSPITAL'S POLICY AND PROTOCOL) ANATOMY The heart lies behind the sternum with the base at about the third intercostal space, just to the right of the sternum, and the apex in the fifth intercostal space, inferior to the nipple and usually just medial to the nipple. Anteroposterior placement (for self-adhesive defibrillator electrode pads) Anterior pad: just to the left of the sternum at the point of maximum impulse (PMI) Posterior pad: to the left of the spine, just below the left scapula Anterolateral placement (for pads or paddles) Left lateral pad: left fourth or fifth intercostal space, midaxillary line Right anterior pad: to the right of the sternal margin, second or third intercostal space