Treatment of Pulseless Ventricular Tachycardia (pVT)

Introduction

Pulseless ventricular tachycardia (pVT) is a life-threatening cardiac arrhythmia that requires immediate medical intervention. It is a type of shockable rhythm that can lead to cardiac arrest.

Initial Assessment

1. Confirm the Diagnosis:

   • Check for absent pulse.
   • Assess the patient for unresponsiveness and lack of normal breathing.
   • Initiate emergency response and call for help.

2. Start Cardiopulmonary Resuscitation (CPR):

   • Begin high-quality chest compressions at a rate of 100–120 per minute.
   • Provide ventilations at a ratio of 30:2 if no advanced airway is in place.

Defibrillation

1. Immediate Defibrillation:

   • Attach and analyze with an automated external defibrillator (AED) or manual defibrillator.
   • If pVT is confirmed, deliver an immediate shock:
     • Biphasic: 120–200 J (manufacturer-specific)
     • Monophasic: 360 J
   • Resume CPR immediately after shock.

2. Reassess Rhythm and Continue CPR:

   • Perform 2-minute CPR cycles and reanalyze rhythm.
   • If VT persists, administer additional shocks as needed.

Medication Therapy

1. Epinephrine (1 mg IV/IO every 3–5 minutes)

   • Enhances coronary perfusion pressure and improves resuscitation success.

2. Antiarrhythmic Drugs (Administer if VT persists after defibrillation):

   • Amiodarone: 300 mg IV bolus, followed by 150 mg IV if needed.
   • Lidocaine: 1-1.5 mg/kg IV bolus (alternative to amiodarone).

Identifying and Treating Reversible Causes (H’s and T’s)

1. H’s:
   • Hypoxia, Hypovolemia, Hydrogen ion (acidosis), Hypokalemia/Hyperkalemia, Hypothermia.
2. T’s:
   • Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary or coronary).

Post-Resuscitation Care

• If Return of Spontaneous Circulation (ROSC) is achieved:
  • Optimize oxygenation and ventilation.
  • Consider targeted temperature management (32–36°C for 24 hours).
  • Monitor and treat underlying causes to prevent recurrence.

Summary

Pulseless ventricular tachycardia is a medical emergency requiring rapid defibrillation, high-quality CPR, and appropriate pharmacologic therapy. Identifying and treating underlying causes improves survival.

Source recommendations

1. 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

1. https://professional.heart.org/en/science-news/2020-aha-guidelines-for-cpr-and-ecc
2. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000918
3. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines
4. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001194
5. https://pubmed.ncbi.nlm.nih.gov/33081530/

2. 2021 European Resuscitation Council Guidelines for Resuscitation

1. https://cprguidelines.eu/guidelines-2021
2. https://pubmed.ncbi.nlm.nih.gov/33765189/
3. https://pmc.ncbi.nlm.nih.gov/articles/PMC7993077/
4. https://pubmed.ncbi.nlm.nih.gov/33773825/
5. https://www.sciencedirect.com/science/article/pii/S0300957221000551