Management of an 8-Beat Run of Ventricular Tachycardia
For a patient with an 8-beat run of ventricular tachycardia (VT), immediate assessment of hemodynamic stability is essential, with cardioversion recommended for unstable patients and appropriate pharmacological therapy for stable patients. 1
Initial Assessment
- Immediately evaluate hemodynamic stability - check for hypotension, altered mental status, chest pain, heart failure signs, or syncope 1
- Obtain a 12-lead ECG if the patient is hemodynamically stable 1
- Assess for underlying structural heart disease, acute myocardial ischemia, or electrolyte abnormalities 1
- Any wide-QRS tachycardia should be presumed to be VT if the diagnosis is unclear 2
Management Algorithm Based on Hemodynamic Status
For Hemodynamically Unstable Patients:
- Perform immediate direct current cardioversion with appropriate sedation 2
- Begin with maximum output for defibrillation to ensure successful termination 1
- If standard cardioversion fails, consider double sequential cardioversion to avoid worsening hypotension with medications 3
For Hemodynamically Stable Patients:
- Intravenous procainamide is reasonable for initial treatment of stable sustained monomorphic VT (Class IIa recommendation) 2
- Intravenous amiodarone is appropriate for patients with heart failure or suspected ischemia 2, 4
- Intravenous lidocaine might be reasonable for VT specifically associated with acute myocardial ischemia (Class IIb recommendation) 2
- Beta-blockers are useful for recurrent polymorphic VT, especially if ischemia is suspected 2
Medication Administration
- For amiodarone: Initial loading dose of 150 mg over 10 minutes, followed by maintenance infusion 4
- For procainamide: 10 mg/kg IV at 50-100 mg/min over 10-20 minutes 5
- Monitor closely for hypotension during medication administration 2
- Avoid calcium channel blockers such as verapamil and diltiazem as they should not be used to terminate wide-QRS-complex tachycardia of unknown origin (Class III recommendation) 2
Post-Conversion Management
- Monitor for recurrence of VT, as this is common 1
- Correct potentially causative or aggravating conditions such as hypokalemia and ischemia 2
- Consider further diagnostic workup to identify underlying structural heart disease 1
- For recurrent episodes, consider referral for electrophysiology study and possible catheter ablation 5
Common Pitfalls to Avoid
- Delaying cardioversion in unstable patients while attempting pharmacological conversion 1
- Using calcium channel blockers in patients with VT due to structural heart disease 2
- Inadequate monitoring after successful conversion 1
- Amiodarone is only moderately effective for acute conversion of stable VT, with only about 52% of patients converting during paramedic care 6