What is the immediate management for a patient with ventricular tachycardia (Vtach) without a pulse?

Immediate Management of Pulseless Ventricular Tachycardia

Pulseless ventricular tachycardia is cardiac arrest and must be treated immediately with unsynchronized defibrillation and high-quality CPR—never use synchronized cardioversion for pulseless rhythms. 1, 2

Initial Response Algorithm

Upon recognition of pulseless VTach:

• Immediately begin high-quality chest compressions at a rate of at least 100-120/min, pushing hard (at least 2 inches/5 cm depth) with complete chest recoil between compressions 1
• Activate the emergency response system and call for a defibrillator 1
• Minimize interruptions in chest compressions—CPR quality is the most critical determinant of survival 1

Defibrillation Protocol

As soon as the defibrillator arrives:

• Deliver immediate unsynchronized shock (defibrillation, not cardioversion) 1, 2
• Energy dosing:
  • Biphasic: 120-200 J (manufacturer's recommended dose) 1, 2
  • Monophasic: 360 J 1
  • Subsequent shocks: at least equivalent energy, consider higher doses 1, 2
• Resume CPR immediately after shock delivery without pausing to check rhythm or pulse—begin with chest compressions 1
• Continue CPR for 2 minutes before the next rhythm check 1

Critical Pitfall to Avoid

Never use synchronized cardioversion for pulseless VTach. 2, 3 Synchronization requires the device to sense a QRS complex and may fail to deliver a shock or cause dangerous delays in a cardiac arrest situation. 2 Pulseless VTach is treated identically to ventricular fibrillation with unsynchronized high-energy shocks. 1, 2, 3

Advanced Life Support Interventions

During CPR cycles:

• Establish IV or IO access 1
• Administer epinephrine 1 mg IV/IO every 3-5 minutes 1
• Secure advanced airway (endotracheal intubation or supraglottic device) 1
• After airway placement: provide 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions 1
• Consider amiodarone 300 mg IV/IO for refractory VF/pulseless VT, may repeat 150 mg once 1

Rhythm Assessment Cycle

Every 2 minutes:

• Briefly pause compressions to check rhythm 1
• If VF/pulseless VT persists: deliver another shock and immediately resume CPR 1
• If rhythm changes to organized: check for pulse (≤10 seconds) 1
• If pulse present: begin post-cardiac arrest care 1
• If no pulse with organized rhythm: continue CPR and treat as PEA 1, 3

Search for Reversible Causes

While continuing resuscitation, address the H's and T's: 1

• Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/hyperkalemia, Hypothermia
• Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary), Thrombosis (coronary)

In-Hospital vs Out-of-Hospital Considerations

In-hospital cardiac arrest: immediate defibrillation should be attempted because sustained ventricular tachyarrhythmia is more likely 1

Out-of-hospital cardiac arrest: perform CPR with chest compressions immediately until defibrillation is available 1 The debate about CPR-before-defibrillation has not shown definitive survival benefit, so minimize time to first shock while maintaining high-quality CPR 4, 5, 6

Key Performance Metrics

Monitor CPR quality continuously: 1

• Compression depth ≥2 inches (5 cm)
• Compression rate 100-120/min
• Complete chest recoil
• Minimize interruptions (hands-off time <10 seconds)
• Rotate compressors every 2 minutes to prevent fatigue 1

Continue resuscitation efforts as long as VF/pulseless VT persists—there is no maximum limit on the number of shocks. 2