What is the next step in managing a patient with ventricular tachycardia (V-tach) who remains pulseless after one defibrillation shock and a dose of epinephrine (Epi)?

Management of Pulseless Ventricular Tachycardia After Initial Shock and Epinephrine

After one defibrillation shock and a dose of epinephrine in a patient with pulseless ventricular tachycardia, the next step is to immediately deliver a second shock at the same or higher energy level. 1

Immediate Actions for Persistent Pulseless VT

1. Deliver second shock immediately

   • Biphasic: Use manufacturer's recommended dose (typically 120-200J) or maximum available energy
   • Monophasic: 360J 1

2. Resume CPR immediately after shock

   • Perform high-quality CPR for 2 minutes without interruption
   • Push hard (at least 2 inches/5 cm) and fast (100-120/min)
   • Allow complete chest recoil
   • Minimize interruptions in compressions 1, 2

3. Consider antiarrhythmic medication during this CPR cycle

   • Amiodarone: First dose 300 mg IV/IO bolus
   • OR Lidocaine: First dose 1-1.5 mg/kg IV/IO if amiodarone unavailable 1, 2

Rhythm and Pulse Check After 2 Minutes

After completing 2 minutes of uninterrupted CPR following the second shock:

1. Check rhythm
2. If VT/VF persists:
   • Deliver third shock at same or higher energy
   • Resume CPR immediately for 2 minutes
   • Consider second dose of antiarrhythmic (Amiodarone 150 mg or Lidocaine 0.5-0.75 mg/kg) 1
3. If organized rhythm appears, check pulse
   • If pulse present: Begin post-cardiac arrest care
   • If pulseless: Resume CPR and treat as PEA 1

Important Considerations

• Do not delay shock delivery to check for pulse after defibrillation attempts. Research shows most patients remain pulseless for over 2 minutes after defibrillation 3

• Continue epinephrine administration every 3-5 minutes throughout the resuscitation 1, 2

• Minimize interruptions to chest compressions to less than 10 seconds for rhythm checks and defibrillation 2

• Consider reversible causes (Hypovolemia, Hypoxia, Hydrogen ion/acidosis, Hypo/hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade, Toxins, Thrombosis-pulmonary, Thrombosis-coronary) 1

• Advanced airway management can be performed during CPR without interrupting chest compressions 1, 2

Pitfalls to Avoid

1. Delaying the second shock - The 2020 AHA guidelines emphasize immediate shock delivery for persistent VF/pVT 1

2. Interrupting CPR to check for pulse after defibrillation - Research shows most patients remain pulseless for over 2 minutes after defibrillation 3

3. Excessive ventilation - Can increase intrathoracic pressure and decrease venous return 1

4. Failure to change compressors every 2 minutes or sooner if fatigued, which can lead to poor quality CPR 1, 2

5. Administering epinephrine too frequently - More frequent administration than recommended (every 3-5 minutes) has been associated with development of secondary VF/VT 4

The evidence strongly supports immediate delivery of a second shock followed by high-quality CPR for persistent pulseless VT after initial shock and epinephrine administration, with consideration of antiarrhythmic therapy during the subsequent CPR cycle.