What is the management of ventricular tachycardia (VTach) with a pulse?

Management of Ventricular Tachycardia with Pulse

The management of ventricular tachycardia (VT) with pulse should follow a structured approach based on hemodynamic stability, with synchronized cardioversion being the first-line treatment for unstable VT and antiarrhythmic medications for stable VT.

Initial Assessment: Hemodynamic Stability

The first step in managing VT with pulse is determining whether the patient is hemodynamically stable or unstable.

Signs of Hemodynamic Instability:

• Systolic BP ≤ 90 mmHg
• Chest pain
• Heart failure
• Heart rate ≥ 150 beats/min

Management Algorithm

For Unstable VT with Pulse:

1. Immediate synchronized cardioversion 1

   • Initial energy: 100 J
   • If unsuccessful, increase in stepwise fashion to 200 J, then 360 J
   • Ensure proper sedation before cardioversion

2. If cardioversion fails:

   • Administer IV amiodarone: 150 mg over 10 minutes, followed by infusion of 1 mg/min for 6 hours, then 0.5 mg/min for 18 hours 2, 3
   • Consider double sequential cardioversion for refractory cases 4

For Stable Monomorphic VT with Pulse:

1. First-line pharmacological therapy:

   • IV procainamide: 20-30 mg/min up to 12-17 mg/kg, followed by infusion of 1-4 mg/min 1, 2

2. Alternative medications:

   • IV lidocaine: 50 mg over 2 minutes, repeated every 5 minutes to total dose of 200 mg, followed by infusion at 2 mg/min 1, 2
     • Particularly effective when VT is associated with acute myocardial ischemia 1
   • IV amiodarone: 150 mg over 10 minutes, followed by infusion (for refractory cases) 1, 3
   • IV sotalol: 100 mg (superior to lidocaine in some cases) 2
   • IV magnesium: 8 mmol bolus followed by 2.5 mmol/h infusion (especially for VT associated with acute MI) 1, 2

3. If medications fail:

   • Proceed to synchronized cardioversion
   • Consider transvenous catheter pace termination for VT refractory to cardioversion or frequently recurrent despite medications 1

For Polymorphic (Irregular) VT with Pulse:

• Treat as VF using unsynchronized high-energy shocks (defibrillation doses) 1
• Do not use synchronized cardioversion as it may not deliver a shock 1

Important Considerations

1. Drug Administration:

   • Administer drugs through intravenous route
   • Follow peripheral vein administration with 20 ml bolus of saline 1
   • For amiodarone concentrations >2 mg/mL, use a central venous catheter 3

2. Monitoring:

   • Close monitoring of blood pressure and cardiovascular status is essential, especially with procainamide in patients with congestive heart failure 1
   • Continuous cardiac monitoring for at least 24-48 hours post-treatment 2

3. Avoid:

   • Calcium channel blockers (verapamil, diltiazem) should not be used to terminate wide-QRS-complex tachycardia of unknown origin 1

4. Long-term Management:

   • Consider ICD implantation for prevention of sudden cardiac death in patients with documented sustained VT 2
   • Catheter ablation may be appropriate for recurrent VT 2
   • Beta-blockers should be administered during hospital stay and continued thereafter in all patients without contraindications 2

Caution

• Intravenous amiodarone at high concentrations and rapid infusion rates can result in hepatocellular necrosis and acute renal failure 3
• Amiodarone may cause transient hypotension in already unstable patients 4
• When treating VT, always presume wide-QRS tachycardia to be VT if diagnosis is unclear 1

Remember that approximately half of patients with stable VT treated with amiodarone will convert to sinus rhythm while under care, but procainamide may have increased efficacy for stable VT 5.