What is the treatment for pulseless ventricular tachycardia (VTach)?

From the Guidelines

To treat pulseless ventricular tachycardia (VT), immediately begin high-quality CPR and apply defibrillation as quickly as possible, as this is the most critical step in improving survival and outcomes, as noted in the 2018 American Heart Association guidelines 1.

Key Treatment Steps

• Deliver an initial shock of 120-200 joules with a biphasic defibrillator or 360 joules with a monophasic device.
• Continue CPR immediately after defibrillation for 2 minutes before reassessing rhythm.
• Establish IV/IO access and administer epinephrine 1 mg IV/IO every 3-5 minutes throughout the resuscitation.

Antiarrhythmic Medication

• If VT persists after the initial shock, consider either amiodarone or lidocaine as the first-line antiarrhythmic, with amiodarone given at 300 mg IV/IO, followed by a second dose of 150 mg if needed, or lidocaine at 1-1.5 mg/kg IV/IO initially, followed by 0.5-0.75 mg/kg if necessary, as recommended in the 2018 update 1.

Addressing Reversible Causes

• Address potential reversible causes such as electrolyte abnormalities (particularly hypokalemia and hypomagnesemia), hypoxia, acidosis, or drug toxicity.
• Magnesium sulfate 1-2 g IV/IO should be considered, especially if torsades de pointes is suspected. Pulseless VT is treated as a cardiac arrest because the ineffective contractions fail to generate adequate cardiac output, leading to tissue hypoperfusion and death if not promptly corrected, highlighting the importance of immediate and effective intervention, as emphasized in the guidelines 1.

From the FDA Drug Label

Amiodarone hydrochloride injection is indicated for initiation of treatment and prophylaxis of frequently recurring ventricular fibrillation (VF) and hemodynamically unstable ventricular tachycardia (VT) in patients refractory to other therapy. The recommended starting dose of amiodarone is about 1000 mg over the first 24 hours of therapy, delivered by the following infusion regimen: In the event of breakthrough episodes of VF or hemodynamically unstable VT, use 150 mg supplemental infusions of amiodarone (mixed in 100 mL of D5W and infused over 10 minutes to minimize the potential for hypotension)

The treatment for pulseless VTach is amiodarone. The recommended dose is:

• 1000 mg over the first 24 hours of therapy
• 150 mg supplemental infusions for breakthrough episodes of VF or hemodynamically unstable VT, infused over 10 minutes 2, 2 Key points to consider:
• Use a central venous catheter for amiodarone concentrations greater than 2 mg/mL
• Do not exceed an initial infusion rate of 30 mg/min
• Monitor the patient closely for signs of hypotension and adjust the dose as needed 2

From the Research

Treatment of Pulseless VTach

• The optimal treatment for pulseless ventricular tachycardia (VTach) is uncertain, but antiarrhythmic drug therapy, such as amiodarone or lidocaine, may be used in conjunction with cardiopulmonary resuscitation (CPR) and defibrillation 3.
• A large randomized controlled trial found no difference in survival to hospital discharge or neurological outcome between amiodarone, lidocaine, and saline for the treatment of refractory VF/pVT out-of-hospital cardiac arrest, but survival was improved with antiarrhythmic drugs compared to saline in patients with witnessed arrest 3.
• Defibrillation is a crucial treatment for pulseless VTach, and biphasic external defibrillation is a recommended approach for adults in ventricular fibrillation or pulseless VTach 4.
• Amiodarone has emerged as a leading antiarrhythmic therapy for the treatment and prevention of ventricular fibrillation and VTach due to its proven efficacy and safety, and is the most effective drug available to assist in resuscitation in patients with shock refractory out-of-hospital cardiac arrest and hemodynamically destabilizing ventricular arrhythmia 5.

Key Considerations

• The benefit of antiarrhythmic drugs appears to be for those patients in whom initial early CPR and defibrillation attempts fail and the antiarrhythmic drug is given early 3.
• Other interventions, such as percutaneous coronary intervention and extra-corporeal CPR, may provide additional survival benefit when defibrillation attempts and antiarrhythmic drugs are not effective 3.
• The optimal energy selection and safety of biphasic defibrillators should be considered in the practical use of these devices 4.
• The pharmacokinetics and electrophysiologic profile of amiodarone are complex, and its optimal and safe use requires careful patient surveillance with respect to potential adverse effects 5.