VT and WCT

Differentials for WCT

- first exclude SHIT (STEMI with massive ST, Hyperk, Idioventricular Rhythm accelerated, Tox e.g. [TCLDD = TCA, Lithium, Cocaine, Dig, Diphenhydramine]

- if in doubt, treat as VT

- cardiovert if unstable, SYNCHRONIZED, can start as 50J cuz it's an organized (ACLS says 100J)

Monomorphic vs Polymorphic

Monomorphic: Structural

Polymorphic: DIEC (Drugs, Ischemia, Electrolytes, Chanellopathies)

(Mayo Clin Proc,Vol 83,p. 1392)

Monomorphic VT (may proceed directly to cardioversion)

EF normal:

- IIa (probably helpful) Procainamide, Sotalol

- IIb (possibly helpful) Amiodarone, Lidocaine

EF <40, CHF: Amiodarone 150mg x 2 minutes, Lidocaine 0.5-0.75mg/kg (50-100mg) IVP or 2 minutes; Cardiversion

- stable: Procainamide or Amiodarone or Lidocaine

1. Amiodarone 150mg x 10 minutes, repeat x 1 if didn't convert, cardiovert if still unsuccessful

2. Maintenance: 1mg/min x 6 hours, then 0.5mg/min

Amiodarone protocol

1. Rapid Loading: 150mg x 10 minutes (150mg or 3mL + 100mL D5W x 10 minutes)

2. Slow Loading: 360mg x 6 hours (1mg/min)

3. Maintenance: 540mg x 18 hours (0.5mg/min)

If hypotension/bradycardia in Amiodarone

• slow infusion
• IV fluid challenge
• inotropes
• pacing

Af with WPW

- irregular with rate approaching to 300/min

- Procainamide 1g x 1 hour or cardiovert SYNC

V-tach Storm (Incessant VT)

- usually ischaemic or structural (CMP)

- ERCAST

- failed cardioversion

- lidocaine -> amiodarone -> metoprolol 5mg IV

- amiodarone can give 1g in acute setting?

- benzos

- intubation

- ?overdrive pacing (called ATP: anti-tachycardia pacing)

- ?procainamide ?sotalol

- antitachycardia pacing

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