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
- CPR is the hallmark of cardiac arrest management.
- Chest compression should be done to a depth of at least 2 inches, or 5 cm, for an average adult while avoiding excessive chest compression depths (greater than 2.4 inches, or 6 cm) (Class 1, LOE B), with the rate of 100 to 120/min (Class 2a, LOE B).
- Early defibrillation is critical for survival of cardiac arrest presented with VF or pulseless VT. However, there was not established benefit of double sequential defibrillation—shock delivery by 2 defibrillators nearly simultaneously for refractory shockable rhythm.[1]
- There are some uncertainty evidence about the IO rout. IV access is preferred rout and if attempts for IV access are unsuccessful or not feasible, IO route is recommended.[2]
- Epinephrine is recommended as soon as feasible for cardiac arrest with a non-shockable rhythm.
- In shockable rhythm with the failed first attempt to defibrillation, epinephrine should be administrated.
- Early administration of epinephrine for non-shockable rhythm is emphasized in the new guideline.
- In pulseless VT or VF, emergency tachycardia rhythm should be treated under the ACLS cardiac arrest algorithm.
- In stable wide complex tachycardia, antiarrhythmic medications can be used.
- For treatment of unstable tachyarrhythmia (with chest pain, dyspnea, pulmonary edema, altered mental status), other than VF or pulselessVT, synchronized cardioversion may be warranted under sedation or anesthesia.
- 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.
Cardiac arrest algorithm
CPR quality
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Medication
| Advanced Airway
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Shock energy
| Cardiac arrest algorithm | Return of Spontaneous Circulation(ROSC)
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| Correction of reversible causes | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| The above adopted from 2020 AHA/ECC Guideline for CPR |
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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 |
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| 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 |
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References
- ↑ 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.
- ↑ 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.
- ↑ 3.0 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.
- ↑ 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.