Pulseless Ventricular Tachycardia (VT): Treatment Overview

Introduction

Pulseless ventricular tachycardia (VT) is a life-threatening cardiac arrhythmia characterized by a rapid and ineffective heart rhythm originating in the ventricles. Since this condition leads to an absence of effective cardiac output, it results in cardiac arrest.

Causes and Risk Factors

Pulseless VT can be triggered by several conditions, including: - Coronary artery disease (CAD) - Prior myocardial infarction (heart attack) - Electrophysiological abnormalities - Electrolyte imbalances (e.g., hyperkalemia, hypokalemia) - Drug toxicity (e.g., from antiarrhythmic drugs, stimulants) - Congenital heart conditions

Immediate Treatment Approach

Pulseless VT should be managed as a cardiac arrest emergency using the Advanced Cardiac Life Support (ACLS) protocol:

1. Immediate Recognition and Activation of Emergency Response

• Confirm that the patient has no pulse and is unresponsive.
• Call for emergency medical assistance (e.g., 911 or local emergency services).

2. High-Quality Cardiopulmonary Resuscitation (CPR)

• Begin chest compressions at a rate of 100-120 compressions per minute with a depth of at least 2 inches (5 cm).
• Perform 30 compressions followed by 2 rescue breaths if trained in CPR.
• Minimize interruptions to chest compressions.

3. Early Defibrillation

• Use an automated external defibrillator (AED) or manual defibrillator if available.
• If VT is confirmed and still pulseless, deliver an immediate unsynchronized shock (defibrillation) .
• If no response after the first shock, continue CPR for 2 minutes before reassessing.

4. Advanced Cardiac Life Support (ACLS) Algorithm

• Administer epinephrine (1 mg IV/IO every 3-5 minutes) to improve perfusion and increase chances of return of spontaneous circulation (ROSC).
• Consider antiarrhythmic drugs such as:
  • Amiodarone: 300 mg IV bolus, followed by a 150 mg IV dose if needed.
  • Lidocaine as an alternative to amiodarone.
• Identify and treat reversible causes (known as the H’s and T’s ):
  • Hypoxia, Hypovolemia, Hydrogen ion (acidosis), Hypo-/Hyperkalemia, Hypothermia
  • Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (coronary/pulmonary)

5. Post-Resuscitation Care

Once spontaneous circulation is restored, the patient requires: - Continuous hemodynamic monitoring. - Targeted temperature management (TTM) if unresponsive. - Coronary angiography if an acute coronary syndrome is suspected.

Summary

Pulseless VT is a medical emergency that requires immediate CPR, defibrillation, and adherence to ACLS guidelines. Rapid intervention significantly improves survival chances and neurological outcomes.

Source recommendations

1. American Heart Association (AHA) Guidelines on Advanced Cardiac Life Support

1. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithms
2. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001194
3. https://cpr.heart.org/en/cpr-courses-and-kits/healthcare-professional/acls
4. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000916
5. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-and-advanced-life-support

2. European Resuscitation Council (ERC) Guidelines on Cardiac Arrest

1. https://www.sciencedirect.com/science/article/pii/S0300957221000642
2. https://cprguidelines.eu/guidelines-2021
3. https://www.resuscitationjournal.com/article/S0300-9572(21)00064-2/fulltext
4. https://www.erc.edu/
5. https://cprguidelines.eu/assets/guidelines/European-Resuscitation-Council-and-European-Societ.pdf

3. International Liaison Committee on Resuscitation (ILCOR) Guidelines

1. https://www.ilcor.org/
2. https://cpr.heart.org/en/resuscitation-science/ilcor
3. https://www.ilcor.org/publications
4. https://www.resuscitationjournal.com/article/S0300-9572(23)00306-4/fulltext
5. https://www.ilcor.org/about