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
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
- 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.
- Postresuscitative care
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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- 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.
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.