Ventricular tachycardia electrical cardioversion
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in Chief: Avirup Guha, M.B.B.S.[2]
Overview
Therapy may be directed at either terminating an episode of the arrhythmia or for suppressing a future episode from occurring. The treatment is tailored to the specific patient, with regard to how well the individual tolerates episodes of ventricular tachycardia, how frequently episodes occur, their comorbidities, and their wishes. It is usually possible to terminate a VT episode with a direct current shock across the heart. This is ideally synchronised to the patient's heartbeat. As it is quite uncomfortable, shocks should be delivered only to an unconscious or sedated patient.
Electrical Cardioversion
| 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) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
- Electrical Cardioversion is usually possible to terminate a VT episode with a direct current shock across the heart.
- Electrical Cardioversion is ideally synchronised to the patient's heartbeat. As it is quite uncomfortable, shocks should be delivered only to an unconscious or sedated patient.
- A patient with pulseless VT will be unconscious and treated as an emergency on a cardiac arrest protocol.
- Elective cardioversion is usually performed in controlled circumstances with anaesthetic and airway support.
- The shock may be delivered to the outside of the chest using an external defibrillator, or internally to the heart by an implantable cardioverter-defibrillator (ICD) if one has previously been inserted.
- An ICD may also be set to attempt to overdrive pace the ventricle. Pacing the ventricle at a rate faster than the underlying tachycardia can sometimes be effective in terminating the rhythm.
- If this fails after a short trial, the ICD will usually stop pacing, charge up and deliver a defibrillation grade shock.
ACLS Cardiac Arrest 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 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 2010 AHA guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, part 8.[1]
2011 ESC Guidelines for Electrical Cardioversion in Ventricular Tachycardia (DO NOT EDIT)[2][3]
Recommendations for Patients With Implantable Cardioverter-Defibrillators (DO NOT EDIT)[2][3]
| Class I |
| "1. Patients with implanted ICDs should receive regular follow-up and analysis of the device status. (Level of Evidence: C)" |
| "2. Implanted ICDs should be programmed to obtain optimal sensitivity and specificity. (Level of Evidence: C)" |
| "3. Measures should be undertaken to minimize the risk of inappropriate ICD therapies. (Level of Evidence: C)" |
| "4. Patients with implanted ICDs who present with incessant VT should be hospitalized for management. (Level of Evidence: C)" |
| Class IIa |
| "1. Catheter ablation can be useful for patients with implanted ICDs who experience incessant or frequently recurring VT. (Level of Evidence: B)" |
| "2. In patients experiencing inappropriate ICD therapy, EP evaluation can be useful for diagnostic and therapeutic purposes. (Level of Evidence: C)" |
References
- ↑ Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW; et al. (2010). "Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. 122 (18 Suppl 3): S729–67. doi:10.1161/CIRCULATIONAHA.110.970988. PMID 20956224.
- ↑ 2.0 2.1 Stevenson WG, Soejima K (2007). "Catheter ablation for ventricular tachycardia". Circulation. 115 (21): 2750–60. doi:10.1161/CIRCULATIONAHA.106.655720. PMID 17533195. Retrieved 2013-01-15. Unknown parameter
|month=ignored (help) - ↑ 3.0 3.1 "The AHA Guidelines and Scientific Statements Handbook - Google Books". Retrieved 2013-01-15.