VT Diagnosis and Management!

Take Home Points: VT Diagnosis and Management

Is it VT or SVT w abherrancy?? ASSUME VT UNTIL PROVEN OTHERWISE!

Quick EKG tips to diagnose VT

  • Look for AV dissociation – this can be P waves unrelated to the wide QRS complex, or can be diagnosed with fusion (beats 8-9 below) or capture (beat 7 below) beats
  • photo (2)
  • Look for precordial concordance of the QRS complex – meaning they are all upwards or all downwards from V1-V6 (normally progress from downwards to upwards)
  • Look for a “northwest” axis – meaning the QRS has is upward in aVR
  • For a more formal EKG diagnosis, you can look up the Brugada criteria: http://en.ecgpedia.org/wiki/File:Brugada_algorithm.svg

Resident Level Management of VT – you can go through management in a stepwise fashion

  • STEP 1: Pulse or no pulse à No pulse = ACLS for pulseless VT!
  • STEP 2: Stable or Unstable à If Unstable – synchronized cardioversion
    • Remember to give some fentanyl and versed if safely able to! 50mcg fentanyl and 2mg versed are typical doses, but vary by patient.
  • STEP 3: Antiarrhythmic medications à Most common first line are amiodarone and lidocaine
    • Amiodarone – bolus + gtt for loading dose
      • PROS: we’re more familiar with it, short term toxicity is lower, good in non-ischemic VT
      • CONS: effects last longer making inducing VT for EP study challenging but DON’T LET THIS PREVENT YOU FROM USING IT!
    • Lidocaine
      • PROS: shorter acting, works well in ischemia related VT
      • CONS: neuro toxicity significant so can only use short term, less good in non-ischemic VT
    • STEP 4: Refractory VT or “VT Storm” à key is to stop the sympathetic surge!
      • Beta blockers can be used to reduce sympathetic activity on the heart, caution in heart failure and hypotension
      • If all else fails in VT storm, sedate them with propofol – it’s an excellent sympatholytic but may require intubation 2/2 sedation

For more fun algorithms on diagnosing VT, check out this ECGpedia page: http://en.ecgpedia.org/wiki/Approach_to_the_Wide_Complex_Tachycardia

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