Pulseless ventricular tachycardia: Difference between revisions
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==[[Pulseless ventricular tachycardia natural history, complications and prognosis|Natural History, Complications, and Prognosis]]== | ==[[Pulseless ventricular tachycardia natural history, complications and prognosis|Natural History, Complications, and Prognosis]]== | ||
==Diagnosis== | ==Diagnosis== | ||
Revision as of 15:47, 14 June 2020
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| Rythm; Pulseless ventricular tachycardia |
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Pulseless ventricular tachycardia Microchapters |
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Differentiating Pulseless ventricular tachycardia from other Diseases |
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Diagnosis |
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Treatment |
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Case Studies |
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Pulseless ventricular tachycardia On the Web |
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American Roentgen Ray Society Images of Pulseless ventricular tachycardia |
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Risk calculators and risk factors for Pulseless ventricular tachycardia |
For patient information, click here
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aisha Adigun, B.Sc., M.D.[2]
Synonyms and keywords: pVT
Overview
Pulseless ventricular tachycardia(pVT) is an often fatal cardiac dysrhythmia where the regular rhythmic contraction of the heart is replaced by non-rhythmic, faster, yet inadequate contractions. These ineffective contractions do not appropriately perfuse the organ, leading to ischemia as well as heart failure. This condition requires immediate medical attention as it is an emergency and can lead to ventricular fibrillation and sudden death.[1]
Historical Perspective
- There is limited information about the historical perspective of Pulseless ventricular tachycardia.
- Gallavardin in 1906 was responsible for the discovery of the rationale behind cardiac instability leading to ventricular tachycardia. He further put forth the idea that ventricular tachycardia could convert to ventricular fibrillation and lead to cardiac arrest and death.
- The first electrographic description of ventricular tachycardia was given by Thomas Lewis in 1909.
- Coronary occlusion was suggested to be the main cause of ventricular tachycardia in 1921.
- Several advancements have since been made in the diagnosis and management protocols on Ventricular tachycardia.
Classification
Pulseless ventricular tachycardia as a ventricular tachycardia, may be classified based on the morphology of the QRS complexes into two subtypes/groups: monomorphic ventricular tachycardia, and polymorphic ventricular tachycardia.
Pathophysiology
Rapid abnormal automaticity and triggered activity are thought to be the main electrophysiological mechanisms of pulseless ventricular tachycardia. In abnormal automatically, the ventricular myocytes produce strong, voluntary, and recurrent depolarization and subsequent contractions at a rate that is higher than normal. This is due to a due to a decrease (ranging between -70mV and -30mV) in normal resting membrane potential. The higher the reduction in membrane potential, the faster and more rapid the already abnormal automaticity.[3] Triggered activity is used to depict the indication of impulse in cardiac myocytes that is dependent on afterdepolarizations (an oscillation in membrane potential that occurs after repolarization). Two types of afterdepolarizations have been identified: Early afterdepolarizations(EAD) and Delayed afterdepolarizations (DAD). When either of these afterdepolarizations become high enough to reach the membrane threshold, they result in a spontaneous "triggered" action potential. Hence for a triggered activity to occur, at least one action potential must precede it.[4]
In pulseless ventricular tachycardia, the combination of increased automatically and/or triggered activity leads to a rate of contraction that is too rapid to result in adequate ventricular filling during diastole. This results in deficient cardiac output, inadequate perfusion of organs, and hemodynamic collapse.[1]
Causes/Risk Factors
Structural heart disease is the most common cause of pulseless ventricular tachycardia. Other causes include but are not limited to, drugs/medications, congenital heart diseases, not to mention congenital and inherited channelopathies. It is important to note that QT interval lengthening medications, as well as electrolyte disturbances, can also result in pulseless ventricular tachycardia.[5]
Life-threatening Causes
- Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. They are mainly due to acute conditions that promote rapid dysfunction of automaticity and include. but are not limited to;[6][7][8][9][10]
Common Causes
- Acid-base disturbances
- Antiarrhythmics
- Azithromycin
- Cardioversion
- Clarithromycin
- Claritin
- Cocaine
- Congestive heart failure
- Dilated cardiomyopathy
- Erythromycin
- Hypokalemia
- Hypomagnesemia
- Myocarditis
- Obstructive sleep apnea
- Pulmonary artery catheter
- STEMI
- Tricyclic antidepressants
Differentiating Pulseless ventricular tachycardia from other Diseases
Pulseless ventricular tachycardia must be differentiated from other diseases that cause wide complex tachycardia, such as supraventricular tachycardia with aberrant conduction, SVT with pre-excitation and antidromic atrioventricular reentrant tachycardia.[11]
Epidemiology and Demographics
- Ventricular tachycardia and ventricular fibrillation[12] are the causes of most sudden cardiac deaths and account for about 300,000 deaths per year in the united states alone. This figure is most likely underestimated as it doesn't account for deaths due to unwitnessed dysrhythmias.[13]
- The majority of deaths due to ventricular arrhythmias occur In adults over 35 years of age.[1]
Screening
According to the 2017 American Heart Association guidelines screening of first-degree relatives is recommended when a patient presents with any of the symptoms such as QT syndrome, hypertrophic or dilated cardiomyopathy and right ventricular dysplasia.[14][15]
Natural History, Complications, and Prognosis
Diagnosis
Symptoms
- On initial presentation, patients with impending pulseless ventricular tachycardia may present with signs of inadequate cardiac perfusion such as chest pain, shortness of breath, diaphoresis, palpitations, and syncope.
- Physical examination may be positive for hypotension, tachycardia, tachypnea, increased JVD, and an S1.
- Eventually, Pulseless ventricular tachycardia ensues and patients become unconscious and unresponsive with no detectable pulse.[1]
Electrocardiogram[1]
The diagnosis of Pulseless ventricular tachycardia almost completely depends on findings seen on ECG. These findings include;
- Regular R-R intervals
- Absence of p-waves largely due to rapid ventricular rates.
- A wide QRS complex and AV dissociation.
Treatment
Defibrillation[16][1]
- As opposed to other unstable Ventricular tachycardias, PVT should be managed with immediate defibrillation. A high energy defibrillator (150-200 J on biphasic and 360 J on monophasic) should be used for the initial shock dose, followed by an equal or higher shock dose for successive shocks
- 5 CPR cycles each containing 30 chest compressions and 2 breaths should be done after the first shock is delivered. Each subsequent shock should be followed by airway management with Oxygen delivery, and IV access with vasopressors.
Medical Therapy
- Medical therapy with IV vasopressors and antiarrhythmic medications is usually simultaneous with defibrillation.
- Antiarrhythmic drugs can be attempted in pulseless ventricular tachycardia that is resistant to shock. Intravenous amiodarone is the first line in this scenario, lidocaine may be considered as well. 2018 AHA recommendations for use of antiarrhythmic drugs during resuscitation from adult VF/pVT cardiac arrest state that both medications may be especially useful on patients with witnessed arrest, for whom time to drug administration may be shorter.
- 1mg 1V of epinephrine administered every 3-5 minutes or, a single dose of 40 units IV of vasopressin can be used as vasopressors.[17]
ACLS Cardiac Arrest Algorithm
| Adult Cardiac Arrest | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Start CPR Give oxygen Attach monitor/defibrillator | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Rhythm shockable? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| VF/pVT | 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 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
Adapted from Adult Cardiac Arrest Algorithm - 2018 Update[18]
Case Studies
Related Chapters
- Tachycardia
- Ventricular Tachycardia
- Wide complex tachycardia
- Ventricular fibrillation
- Supraventricular tachycardia
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Foglesong A, Mathew D. PMID 32119354 Check
|pmid=value (help). Missing or empty|title=(help) - ↑ "Ventricular tachycardia historical perspective - wikidoc".
- ↑ Armendares S, Pérez Treviño C (1968). "[Congenital heart diseases in chromosome abnormalities. I. In Down's syndrome (mongolism)]". Arch Inst Cardiol Mex (in Spanish; Castilian). 38 (6): 779–91. PMID 4237287.
- ↑ Buchmann A, Ruggeri B, Klein-Szanto AJ, Balmain A (August 1991). "Progression of squamous carcinoma cells to spindle carcinomas of mouse skin is associated with an imbalance of H-ras alleles on chromosome 7". Cancer Res. 51 (15): 4097–101. PMID 1855225.
- ↑ Baldzizhar A, Manuylova E, Marchenko R, Kryvalap Y, Carey MG (September 2016). "Ventricular Tachycardias: Characteristics and Management". Crit Care Nurs Clin North Am. 28 (3): 317–29. doi:10.1016/j.cnc.2016.04.004. PMID 27484660.
- ↑ Ajijola, Olujimi A.; Tung, Roderick; Shivkumar, Kalyanam (2014). "Ventricular tachycardia in ischemic heart disease substrates". Indian Heart Journal. 66: S24–S34. doi:10.1016/j.ihj.2013.12.039. ISSN 0019-4832.
- ↑ Meja Lopez, Eliany; Malhotra, Rohit (2019). "Ventricular Tachycardia in Structural Heart Disease". Journal of Innovations in Cardiac Rhythm Management. 10 (8): 3762–3773. doi:10.19102/icrm.2019.100801. ISSN 2156-3977.
- ↑ Coughtrie, Abigail L; Behr, Elijah R; Layton, Deborah; Marshall, Vanessa; Camm, A John; Shakir, Saad A W (2017). "Drugs and life-threatening ventricular arrhythmia risk: results from the DARE study cohort". BMJ Open. 7 (10): e016627. doi:10.1136/bmjopen-2017-016627. ISSN 2044-6055.
- ↑ El-Sherif, Nabil (2001). "Mechanism of Ventricular Arrhythmias in the Long QT Syndrome: On Hermeneutics". Journal of Cardiovascular Electrophysiology. 12 (8): 973–976. doi:10.1046/j.1540-8167.2001.00973.x. ISSN 1045-3873.
- ↑ "Ventricular tachycardia causes - wikidoc".
- ↑ "Correction". Heart Rhythm. 15 (11): e282. November 2018. doi:10.1016/j.hrthm.2018.09.024. PMID 30267690.
- ↑ Tang PT, Shenasa M, Boyle NG (December 2017). "Ventricular Arrhythmias and Sudden Cardiac Death". Card Electrophysiol Clin. 9 (4): 693–708. doi:10.1016/j.ccep.2017.08.004. PMID 29173411.
- ↑ McNally B, Robb R, Mehta M, Vellano K, Valderrama AL, Yoon PW, Sasson C, Crouch A, Perez AB, Merritt R, Kellermann A (July 2011). "Out-of-hospital cardiac arrest surveillance --- Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005--December 31, 2010". MMWR Surveill Summ. 60 (8): 1–19. PMID 21796098.
- ↑ Shoubkhova TS (July 1968). "[Determination of the particle size of suspensions of dried bacteria by the method of turbidimetric analysis]". Zh. Mikrobiol. Epidemiol. Immunobiol. (in Russian). 45 (7): 108–10. PMID 5731530.
- ↑ Flannery MD, La Gerche A (January 2019). "Sudden Death and Ventricular Arrhythmias in Athletes: Screening, De-Training and the Role of Catheter Ablation". Heart Lung Circ. 28 (1): 155–163. doi:10.1016/j.hlc.2018.10.004. PMID 30554599.
- ↑ "What are the treatment options for pulseless ventricular tachycardia (VT)?".
- ↑ Callaway CW (January 2013). "Epinephrine for cardiac arrest". Curr. Opin. Cardiol. 28 (1): 36–42. doi:10.1097/HCO.0b013e32835b0979. PMID 23196774.
- ↑ "www.ahajournals.org".