QuestionSBA
QuestionChoice
Amiodarone is not yet indicated. This may be administered after the third shock.
10017353
c
Administer amiodarone
QuestionChoice
As cardiac arrest was witnessed and monitored with a defibrillator immediately available, up to 3 consecutive (stacked) shocks should be delivered.
10017351
a
Administer up to 3 (stacked) shocks
QuestionChoice
This will not be possible as the patient does not have a pulse. Vagal manoeuvres should be attempted in cases of supraventricular tachycardia with no adverse features. This patient is in pulselsess ventricular tachycardia.
10017355
e
Initially, attempt vagal manoeuvres
QuestionChoice
There is no indication for adrenaline at present. This is administered immediately in cardiac arrest with a non-shockable rhythm, or after the 3rd shock (and then every 3-5 minutes) in a cardiac arrest with a shockable rhythm.
10017352
b
Administer adrenaline
QuestionChoice
Adenosine is indicated in supraventricular tachycardia with no adverse features. This patient is in pulseless ventricular tachycardia.
10017354
d
Administer adenosine
Concept
Chapter
# Summary 

Ventricular Tachycardia (VT) is a regular broad complex tachycardia that originates from the ventricles of the heart. The patient may have a pulse or not - if VT is pulseless it is one of the shockable cardiac arrest rhythms. Emergency management involves identification of VT on an ECG or heart monitor, then treating patients with a pulse and no adverse features with IV amiodarone. Patients who do not respond to this or have adverse features should be treated with synchronised DC cardioversion. Patients in cardiac arrest with VT should be treated as per the Advanced Life Support (ALS) algorithm with cardiopulmonary resuscitation (CPR), adrenaline and amiodarone as well as unsynchronised shocks. 

# Definition
 
Ventricular Tachycardia (VT) is a type of broad complex tachycardia characterised by a heart rate of more than 100 bpm and a QRS width of more than 120ms. Other types of broad complex tachycardias include Torsades de Pointes (which is a type of ventricular tachycardia described as polymorphic, where there are multiple ventricular foci) and Supraventricular Tachycardia with aberrant conduction.
 
[lightgallery]
 

# Aetiology
 
Factors that increase the risk of VT include:
 
- Electrolyte abnormalities such as hypokalaemia and hypomagnesaemia
- Structural heart disease including previous myocardial infarction and cardiomyopathies
- Drugs that cause QT prolongation e.g. clarithromycin, erythromycin (for Torsades de Pointes) 
- Inherited channelopathies e.g. Romano-Ward syndrome (for Torsades de Pointes)

# Management
 
**Pulseless VT:**

Pulseless VT is one of the four cardiac arrest rhythms, as so is managed as per Advanced Life Support guidelines:

- CPR will be in progress
- 120-360 J unsynchronised shock should be administered as early as possible, then every 2 minutes
- IV adrenaline (1mg of 10ml 1:10,000 solution) and IV amiodarone (300mg) should be administered after delivery of the 3rd shock
- Adrenaline should be administered every 3-5 minutes thereafter
- A further dose of amiodarone 150 mg IV should be given after 5 shocks

**Pulsed VT with adverse features:**

If a patient has a pulse, management is determined by whether they have any of the following adverse features:

 - Heart failure
 - Myocardial ischaemia (chest pain)
 - Shock
 - Syncope

If one or more of these are present, attempt to cardiovert the patient using synchronised DC shocks (up to 3 attempts). If the patient is conscious this will require sedation or anaesthesia.

If this is not effective, an amiodarone infusion would be the next step under expert guidance (300mg IV over 10-20 minutes followed by 900mg infusion over 24 hours).

**Pulsed VT with no adverse features:**

First line treatment is amiodarone 300mg IV over 10-60 minutes.

If this is ineffective then attempt to cardiovert using synchronised DC shocks (up to 3 attempts) with sedation or anaesthesia.

**Torsades de Pointes:**

This is a special situation which is managed differently to monomorphic VT - Torsades de Pointes often self-terminates but the risk is that it deteriorates into ventricular fibrillation (causing cardiac arrest).

IV Magnesium is the mainstay of treatment, along with treatment of any underlying cause identified (e.g. correcting electrolyte imbalance, stopping QT-prolonging medications).

# References
 
[Resuscitation Council UK - Adult advanced life support Guidelines](https://www.resus.org.uk/library/2021-resuscitation-guidelines/adult-advanced-life-support-guidelines)

[Resuscitation Council UK - Adult Tachycardia Algorithm](https://www.resus.org.uk/sites/default/files/2021-04/Tachycardia%20Algorithm%202021.pdf)

[Patient UK - Torsades de Pointes](https://patient.info/doctor/torsades-de-pointes)
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Ventricular tachycardia seen on an ECG.
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VT.png
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Emergency Management of Ventricular Tachycardia
Topic
39
Emergency Medicine
Video
Concept
694
Emergency Management of Ventricular Tachycardia
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Quesmed Tutorial: Arrhythmias
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In witnessed cardiac arrest with ventricular tachycardia and no pulse, resuscitation involves immediate administration of up to three stacked shocks.
A patient admitted to the resuscitation room of the emergency department is being examined when the cardiac monitor alarms. The trace monitor shows new ventricular tachycardia (previously sinus rhythm). There is no pulse present.

What is the most appropriate action to take?
a