Ventricular tachycardia electrical cardioversion

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in Chief: Sara Zand, M.D.[2] Avirup Guha, M.B.B.S.[3]

Overview

For treatment of unstable tachyarrhythmia (with chest pain, dyspnea, pulmonary edema, altered mental status), other than VF or pulselessVT, synchronized cardioversion should be warranted.In Synchronized cardioversion the amount of energy delivered is less than defibrillation and also the shock is delivered in different parts of the cardiac cycle. R-on -T phenomena may happen if the electrical defibrillated shock is delivered during the refractory period (on the latter part of T wave) which is vulnerable to induce VF. For prevention of this phenomena and monitoring R wave for each QRS complex for delivery of shock in cardiac cycle, the defibrillator is placed on synchronize mode. The recommendation energy for synchronized cardioversion is 50-200 jouls.

Electrical Cardioversion

Cardiac arrest algorithm

 
 
 
 
 
 
 
 
 
 
 
 
 
CPR quality
 
 
 
 
 
 
 
 
 
 
 
Medication
 
 
 
 
 
 
 
 
Advanced Airway
  • Supraglottic advanced airway or endotracheal intubation
  • 10 breaths per minute with maintaining chest compressions
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Shock energy
    • Biphasic: Manufacturer recommendation ( initial dose of 120–200 J): if unknown, use maximum available
    • Second and subsequent doses should be equivalent
    • Higher doses may be considered
     
     
     
     
     
    Cardiac arrest algorithm
     
     
     
     
     
    Return of Spontaneous Circulation(ROSC)
  • Pulse and blood pressure
  • Checking perfusion status when exhaled CO2 > 25 mm Hg, the amount > 40 mm Hg is equal to ROSC
  • Spontaneous arterial pressure waves with intra-arterial monitoring
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Correction of reversible causes
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    The above adopted from 2020 AHA/ECC Guideline for CPR

    [3]

    Advanced Cardiovascular Life Support (ACLS) Algorithm

     
     
     
     
     
     
     
     
     
     
     
     
    Adult Cardiac Arrest
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Start CPR
    Give oxygen
    Attach monitor/defibrillator
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Rhythm shockable?
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    No
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    VF/VT
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Asystole/PEA
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Shock
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Box A:

    CPR 2 min
    IV/IO access
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Rhythm shockable?
     
    No
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Shock
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Box B:

    CPR 2 min
    Epinephrine every 3-5 min
    Consider advanced airway
    and capnography
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Box C:

    CPR 2 min
    IV/IO access
    Epinephrine every 3-5 min
    Consider advanced airway
    and capnography
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Rhythm shockable?
     
    No
     
     
     
     
     
     
     
     
     
     
     
    Rhythm shockable?
     
    Yes
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    No
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Shock
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    CPR 2 min
    Amiodarone or lidocaine
    Treat reversible causes
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Box D:

    CPR 2 min
    Treat reversible causes
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Go back to box A
     
     
     
     
     
     
     
     
     
     
     
    No
     
    Rhythm shockable?
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Shock
    Then, go to box A or box B
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    If no signs of return of spontaneous circulation:
    Go to box C or box D

    If return of spontaneous circulation:
    Start post cardiac arrest care
     
     
     
     
     
     
     
     
     
     
    The above adopted from 2020 AHA/ECC Guideline for CPR

    [3]




     
     
     
     
     
     
     
    ICD with recurrent VT, VF
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Polymorphic VT/VF
     
     
     
     
     
     
     
    Sustained monomorphic VT
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Correction of reversible causes
     
     
     
     
     
     
    Catheter ablation as first line therapy (class2b)
     
    Amiodarone, sotalol (class1)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Ischemia= revascularization (class1)
     
    Drug, electrolytes: Treating QT prolongation, discontinuation offending drugs, correction electrolytes abnormality (class1)
     
    NO reversible causes
     
     
     
     
    Arrhythmia not controlled
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Amiodarone (class1)
     
    Betablocker (class2a)
     
    Non ischemic cardiomyopathy
     
    IHD with frequent VT or VT storm
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Arrhythmia not controlled
     
     
     
     
    Catheter ablation (class2a)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Considering PVC triggers
     
     
     
     
     
    Yes: Catheter ablation (class1)
     
    NO: Catheter ablation (class2a)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes: Catheter ablation
     
    NO: Autotomic modulation (class2b)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    The above algorithm adopted from 2017 AHA/ACC/HRS Guideline

    [4]

    References

    1. Beck, Lauren R.; Ostermayer, Daniel G.; Ponce, Joseph N.; Srinivasan, Saranya; Wang, Henry E. (2019). "Effectiveness of Prehospital Dual Sequential Defibrillation for Refractory Ventricular Fibrillation and Ventricular Tachycardia Cardiac Arrest". Prehospital Emergency Care. 23 (5): 597–602. doi:10.1080/10903127.2019.1584256. ISSN 1090-3127.
    2. Granfeldt, Asger; Avis, Suzanne R.; Lind, Peter Carøe; Holmberg, Mathias J.; Kleinman, Monica; Maconochie, Ian; Hsu, Cindy H.; Fernanda de Almeida, Maria; Wang, Tzong-Luen; Neumar, Robert W.; Andersen, Lars W. (2020). "Intravenous vs. intraosseous administration of drugs during cardiac arrest: A systematic review". Resuscitation. 149: 150–157. doi:10.1016/j.resuscitation.2020.02.025. ISSN 0300-9572.
    3. 3.0 3.1 Merchant, Raina M.; Topjian, Alexis A.; Panchal, Ashish R.; Cheng, Adam; Aziz, Khalid; Berg, Katherine M.; Lavonas, Eric J.; Magid, David J. (2020). "Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. 142 (16_suppl_2). doi:10.1161/CIR.0000000000000918. ISSN 0009-7322.
    4. Al-Khatib, Sana M.; Stevenson, William G.; Ackerman, Michael J.; Bryant, William J.; Callans, David J.; Curtis, Anne B.; Deal, Barbara J.; Dickfeld, Timm; Field, Michael E.; Fonarow, Gregg C.; Gillis, Anne M.; Granger, Christopher B.; Hammill, Stephen C.; Hlatky, Mark A.; Joglar, José A.; Kay, G. Neal; Matlock, Daniel D.; Myerburg, Robert J.; Page, Richard L. (2018). "2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death". Circulation. 138 (13). doi:10.1161/CIR.0000000000000549. ISSN 0009-7322.


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