What is the immediate treatment for ventricular tachycardia (Vtach) resuscitation?

Immediate Treatment for Ventricular Tachycardia (VTach) Resuscitation

For patients presenting with ventricular tachycardia and hemodynamic instability, immediate direct current cardioversion is the recommended first-line treatment. 1

Assessment of Hemodynamic Status

• For patients with sustained VTach, treatment depends on hemodynamic stability 1
• Assess for signs of hemodynamic instability:
  • Hypotension
  • Altered mental status
  • Signs of shock
  • Chest pain
  • Heart failure 1

Treatment Algorithm for VTach

Hemodynamically Unstable VTach (Pulseless VT)

1. Begin high-quality CPR immediately

   • Push hard (at least 2/3 of anterior-posterior chest diameter)
   • Push fast (at least 100 compressions/minute)
   • Allow complete chest recoil
   • Minimize interruptions in compressions 1

2. Apply monitor/defibrillator as soon as available 1

3. Defibrillation

   • For adults: Use maximum output of defibrillator 1
   • For children: First shock 2 J/kg; second shock 4 J/kg; subsequent shocks ≥4 J/kg (maximum 10 J/kg or adult dose) 1
   • Use biphasic waveform if available (higher first-shock success rate >90%) 1

4. Resume CPR immediately after shock delivery

   • Do not pause to check rhythm or pulse immediately after shock 1
   • Continue CPR for approximately 2 minutes (or 5 cycles) before reassessing rhythm 1

5. Establish IV/IO access for medication administration 1

6. Administer medications

   • Epinephrine: 1 mg IV/IO every 3-5 minutes 1
   • Amiodarone: For shock-refractory VF/pulseless VT
     • Initial dose: 300 mg IV/IO bolus
     • Consider additional 150 mg IV/IO for persistent VF/VT 1, 2
   • Lidocaine: May be considered as an alternative to amiodarone
     • 1-1.5 mg/kg IV/IO initially 1

Hemodynamically Stable VTach with Pulse

1. Prepare for synchronized cardioversion

   • Sedate patient if conscious 1
   • Use synchronized cardioversion (timing shock to QRS complex improves success and reduces risk of deterioration to VF) 3

2. Consider antiarrhythmic medications if time permits

   • Amiodarone: 150 mg IV over 10 minutes 1, 2
   • Procainamide: For patients without severe heart failure or acute MI 1

Special Considerations

• Timing of CPR vs. Defibrillation:

  • For in-hospital cardiac arrest: Immediate defibrillation is recommended 1
  • For out-of-hospital cardiac arrest: If response time >5 minutes, consider 2 minutes of CPR before defibrillation 1, 4, 5

• Post-shock management:

  • Resume chest compressions immediately after shock delivery 1, 6
  • Most patients remain pulseless for over 2 minutes after defibrillation 6
  • Do not waste time checking for pulse immediately after shock 1

• CPR Quality:

  • Rotate compressors every 2 minutes to prevent fatigue 1
  • Maintain compression rate of at least 100/min 1
  • Ensure proper depth (2/3 of chest diameter) 1
  • Minimize interruptions in chest compressions 1

• For LV Fascicular VT (RBBB morphology with left axis deviation):

  • Consider verapamil or beta-blockers 1

Common Pitfalls to Avoid

• Delaying defibrillation for hemodynamically unstable VTach - immediate cardioversion is critical 1
• Prolonged pulse checks after defibrillation - resume CPR immediately after shock 1, 6
• Inadequate CPR quality - ensure proper depth, rate, and minimal interruptions 1
• Multiple stacked shocks - modern defibrillators have high first-shock efficacy; deliver single shock then immediately resume CPR 1
• Delaying medication administration while focusing on defibrillation - establish IV access early but prioritize defibrillation and CPR 1