What do I do as a nurse if my patient is going into ventricular tachycardia (V-tach)?

Immediate Management of Ventricular Tachycardia

If your patient is hemodynamically unstable (hypotensive with systolic BP ≤90 mmHg, altered mental status, chest pain, acute heart failure, or shock), perform immediate synchronized cardioversion without delay—do not wait for a 12-lead ECG or IV access if the patient is extremely unstable. 1, 2, 3

Rapid Assessment Algorithm

Step 1: Check for pulse and assess hemodynamic stability immediately 1

• If pulseless VT: Treat as ventricular fibrillation with immediate unsynchronized defibrillation at 200J, then 200-300J, then 360J if unsuccessful 1
• If pulse present: Proceed to Step 2 1

Step 2: Determine hemodynamic stability 2, 4

Signs of instability include:

• Systolic blood pressure ≤90 mmHg 2
• Acute altered mental status 1
• Ischemic chest pain 1
• Acute heart failure 1
• Heart rate ≥150 beats/min increases likelihood that symptoms are rhythm-related 1

Management of Hemodynamically Unstable VT (With Pulse)

Perform immediate synchronized cardioversion starting at 100J for monomorphic VT 2, 3

• If the patient is conscious but unstable, give immediate sedation before cardioversion—but do not delay if the patient is extremely unstable 1, 2
• Escalate energy: 100J → 200J → 360J if initial shocks unsuccessful 2
• For polymorphic VT that resembles VF, use unsynchronized 200J shock instead 3
• Call for physician assistance immediately while preparing for cardioversion 1

Critical pitfall: Do not delay cardioversion to obtain a 12-lead ECG in unstable patients 1, 4

Management of Hemodynamically Stable VT

If the patient is stable (alert, adequate blood pressure, no chest pain), you have time for a more measured approach 1, 2

Immediate nursing actions for stable VT:

• Attach continuous cardiac monitoring 2
• Establish IV access 1
• Obtain 12-lead ECG to confirm diagnosis and determine VT type 1
• Assess oxygen saturation and provide supplemental oxygen if needed 1
• Notify physician immediately for medication orders 2
• Have crash cart and defibrillator at bedside 2

Anticipated physician orders for stable monomorphic VT:

Procainamide is the preferred first-line medication (10 mg/kg IV at 50-100 mg/min over 10-20 minutes, maximum 10-20 mg/kg) 2, 3

• Monitor continuously for hypotension and QRS widening during administration 2
• Do not use procainamide if the patient has severe heart failure or acute MI—amiodarone should be used instead 1, 2

Amiodarone is preferred if heart failure or ischemia present: 150 mg IV over 10 minutes, then 1 mg/min infusion for 6 hours, then 0.5 mg/min 1, 2, 5

For polymorphic VT (continuously changing QRS morphology):

• If normal QT interval: likely ischemia-related, anticipate IV beta-blockers and aggressive ischemia treatment 2
• If prolonged QT (Torsades de Pointes): anticipate IV magnesium sulfate 8 mmol bolus followed by 2.5 mmol/h infusion 2

Critical Nursing Considerations

Always presume wide-complex tachycardia is ventricular tachycardia when in doubt—never assume it is supraventricular 2, 4, 3

Never administer calcium channel blockers (verapamil, diltiazem) for wide-complex tachycardia unless you are absolutely certain it is fascicular VT—these can cause hemodynamic collapse in structural VT 2, 3

If VT recurs after successful cardioversion, anticipate antiarrhythmic drug orders to prevent reinitiation 3

Monitoring Requirements During Treatment

• Continuous ECG monitoring is mandatory 2
• Measure and correct serum potassium and magnesium before antiarrhythmics if time permits 2
• Monitor QTc interval—notify physician if QTc prolongs to ≥500 ms 2
• Ensure cardiac resuscitation capabilities are immediately available 2

When to Escalate

Call for immediate physician assistance if: 1, 2

• Patient becomes hemodynamically unstable at any point
• VT is incessant or recurrent despite treatment
• You are uncertain about rhythm diagnosis
• Patient develops cardiac arrest

In-hospital cardiac arrests from VT should receive immediate defibrillation because the likelihood of sustained ventricular tachyarrhythmia is greater than in out-of-hospital arrests 1