What is the next best step for a patient in ventricular tachycardia (VTach)?

Management of Ventricular Tachycardia

Direct current cardioversion is the next best step for patients presenting with ventricular tachycardia and hemodynamic instability. 1

Assessment of Hemodynamic Stability

The first critical step in managing ventricular tachycardia (VT) is to determine whether the patient is hemodynamically stable or unstable:

Signs of Hemodynamic Instability:

• Hypotension
• Acute altered mental status
• Signs of shock
• Ischemic chest discomfort
• Acute heart failure symptoms
• Syncope

Management Algorithm

For Hemodynamically Unstable VT:

1. Immediate synchronized cardioversion (Class I recommendation) 1

   • Provide sedation first if the patient is conscious but hypotensive
   • Start defibrillation at maximum output
   • Do not delay cardioversion if the patient is extremely unstable

2. If a defibrillator is not immediately available:

   • Precordial thump may be considered for witnessed, monitored unstable VT (Class IIb) 1

For Hemodynamically Stable VT:

1. Establish IV access and obtain a 12-lead ECG
2. Electrical cardioversion is still the first-line approach even in stable patients 1
3. If cardioversion is not immediately available, consider pharmacological options:
   • Amiodarone: 150 mg IV over 10 minutes; can repeat as needed for recurrent VT 1, 2
   • Procainamide: 20-50 mg/min until arrhythmia suppressed (maximum dose 17 mg/kg) 1
   • Sotalol: 1.5 mg/kg IV over 5 minutes (avoid in patients with prolonged QT) 1

Important Considerations

• Even "stable" VT should not be considered benign - it is associated with high mortality and may deteriorate to a more malignant arrhythmia 3
• For in-hospital cardiac arrest due to VT, immediate defibrillation should be attempted 1
• For out-of-hospital cardiac arrest, CPR with chest compression should be performed immediately until defibrillation is possible 1

Medication Details

Amiodarone

• Indicated for treatment of hemodynamically unstable VT refractory to other therapy 2
• Initial dose: 150 mg IV over 10 minutes
• Follow with maintenance infusion of 1 mg/min for first 6 hours 1
• Can be used in patients with heart failure or suspected ischemia 1

Procainamide

• Avoid in patients with severe heart failure or acute myocardial infarction 1
• Monitor for QRS widening and hypotension

Pitfalls to Avoid

1. Delaying cardioversion in unstable patients while attempting pharmacological therapy
2. Misdiagnosing VT as SVT with aberrancy - when in doubt in a hemodynamically unstable patient with wide-complex tachycardia, treat as VT
3. Using AV nodal blocking agents (calcium blockers, beta-blockers, digoxin) in patients with pre-excited atrial fibrillation, as these may accelerate ventricular response 1
4. Administering adenosine for irregular or polymorphic wide-complex tachycardia 1

Post-Conversion Care

After successful termination of VT:

• Monitor for recurrence
• Evaluate for underlying causes (ischemia, structural heart disease)
• Consider specialist consultation for long-term management strategies, including possible catheter ablation or ICD implantation 1

Remember that even apparently stable VT carries significant mortality risk and requires prompt, definitive treatment 3.