Ventricular tachycardiaMANAGEMENT

CARDIOVASCULAR PRESENTATIONS · 12 SECTIONS

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482 items

☷ Legend

01Approach to the Critical Patient/attcp51

Immediate priorities

›Stabilization and early decisions

›Hemodynamic stability status

›Unstable features

›Hypotension

›Altered mental status

›Ischemic chest discomfort

›Acute heart failure

›If unstable, synchronized cardioversion without delay (Class I)

›Rhythm and pulse confirmation

›Wide-complex tachycardia as VT until proven otherwise

›If no pulse, treat as cardiac arrest

›Defibrillation and CPR sequence per ACLS (Class I)

›Monitoring and access

›Cardiac monitor with defib pads in place

›Continuous pulse oximetry

›Noninvasive BP every 2-3 minutes

›If shock or vasoactive infusions, arterial line when feasible

›Two large-bore IV or IO access

›Reversible causes search

›4H 4T framework for arrest context

›Hypoxia

›Hypovolemia

›Hydrogen ion excess

›Hypo or hyperkalemia

›Tension pneumothorax

›Tamponade

›Toxins

›Thrombosis coronary

›Thrombosis pulmonary

Rhythm classification

›VT phenotypes guiding management

›Monomorphic VT

›Regular wide-complex tachycardia

›Scar-related VT common with prior MI or cardiomyopathy

›Polymorphic VT

›Irregular varying QRS morphology

›If prolonged QT, torsades de pointes pathway

›VT with a pulse versus pulseless VT

›Pulseless VT treated as VF pathway

›VT with pulse treated by stability and morphology

Hemodynamic targets and escalation

›Resuscitation targets

›Perfusion markers

›MAP goal at least 65 mmHg

›Mental status and capillary refill trends

›Oxygenation and ventilation

›SpO2 goal 94-98%

›Avoid hyperventilation in arrest

›Escalation triggers

›Recurrent VT or electrical storm

›EP and ICU activation

›Suspected acute coronary syndrome

›Cath lab consultation pathway

02History/hx52

Focused symptom and context

›Presenting pattern

›Palpitations

›Onset time

›Duration

›Syncope or presyncope

›Exertional occurrence

›Injury during event

›Chest pain or pressure

›Radiation pattern

›Associated diaphoresis

›Dyspnea

›Orthopnea

›Paroxysmal nocturnal dyspnea

›Neurologic symptoms

›Focal deficits

›Postictal features

Risk factors and triggers

›Cardiac substrate risks

›Prior myocardial infarction

›Known reduced LVEF

›Prior ventricular arrhythmia history

›Cardiomyopathy

›Dilated cardiomyopathy

›Hypertrophic cardiomyopathy

›Inherited arrhythmia syndromes

›Long QT syndrome family history

›Brugada syndrome family history

›Catecholaminergic polymorphic VT family history

›Structural disease

›Arrhythmogenic right ventricular cardiomyopathy suspicion

›Congenital heart disease repair history

›Acute triggers

›Recent ischemic symptoms

›New angina pattern

›Cocaine or stimulant exposure

›Medication and toxin triggers

›QT-prolonging drugs list exposure

›Digoxin exposure

›Antidepressant or antipsychotic exposure

›Electrolyte risk

›Vomiting or diarrhea

›Diuretic escalation

Medication and device history

›Baseline treatments and devices

›Antiarrhythmics

›Amiodarone use

›Sotalol use

›Flecainide or propafenone use

›Beta-blocker adherence

›Missed doses

›Recent dose change

›Cardiac devices

›ICD presence

›Recent shocks count

03Physical Exam/exam41

Initial assessment

›Perfusion and instability signs

›Vital signs

›Hypotension

›Fever

›Mental status

›Confusion

›Agitation

›Skin and extremities

›Diaphoresis

›Cool clammy extremities

›Cardiopulmonary exam

›Heart sounds

›New murmur

›S3 gallop

›Lung findings

›Crackles

›Wheeze

›Volume status

›JVP elevation

›Peripheral edema

Clues to etiology

›Ischemia and heart failure clues

›Chest discomfort during exam

›Ongoing ischemia suspicion

›Diaphoresis with pain

›Shock profile

›Narrow pulse pressure

›Delayed capillary refill

›Toxidrome and metabolic clues

›Hyperthyroid features

›Tremor

›Hyperreflexia

›Stimulant intoxication features

›Mydriasis

›Psychomotor agitation

PITFALLS

›Common traps

›Labeling wide-complex tachycardia as SVT with aberrancy without proof

›Treat as VT by default in adults

›Avoid AV nodal blockers if rhythm uncertain and instability risk

›Missing torsades in polymorphic VT

›QT interval assessment when sinus rhythm available

›Immediate magnesium pathway when suspected

04Differential Diagnosis/ddx33

Life-threatening causes of wide-complex tachycardia

›High-risk diagnoses

›Ventricular tachycardia (ICD-10 I47.2)

›Monomorphic VT

›Polymorphic VT

›Ventricular fibrillation (ICD-10 I49.01)

›Pulseless state

›Requires defibrillation

›Acute coronary syndrome with malignant arrhythmia (ICD-10 I21.x)

›Ongoing ischemia signs

›Troponin rise pattern

›Hyperkalemia with conduction changes (ICD-10 E87.5)

›Sine-wave progression

›Bradycardia to arrest transition

Mimics and related rhythms

›Wide-complex tachycardia mimics

›SVT with aberrancy (ICD-10 I47.1)

›Pre-existing bundle branch block

›Rate-related aberrancy

›Pre-excited tachycardia with WPW (ICD-10 I45.6)

›Irregular wide-complex tachycardia as AF with WPW

›AV nodal blockers hazard in AF with WPW

›Ventricular paced rhythm tachycardia

›Pacemaker-mediated tachycardia

›ICD lead issues

Etiologic drivers of VT

›Substrate and trigger categories

›Scar-related reentry

›Prior MI scar

›Post myocarditis scar

›Idiopathic VT

›RV outflow tract VT

›Fascicular VT

›Channelopathies

›Long QT torsades

›Brugada polymorphic VT

05Laboratory Tests/lt33

Immediate bedside tests

›Rapid evaluation set

›Point-of-care glucose

›Hypoglycemia as altered mental status mimic

›Hyperglycemia stress marker

›Venous or arterial blood gas when critically ill

›pH for acidosis trigger

›Potassium estimate confirmation with serum test

›Lactate when shock or arrest

›Trend for resuscitation response

›Marker of hypoperfusion

Core labs for etiology and complications

›Routine evaluation

›Serum electrolytes

›Potassium target 4.0-4.5 mmol/L in ventricular arrhythmia risk

›Magnesium target at least 1.0 mmol/L in torsades risk

›Renal function

›Drug dosing implications for procainamide and sotalol

›AKI as electrolyte driver

›High-sensitivity troponin

›Ischemic trigger assessment

›Demand ischemia interpretation pitfall

›CBC

›Anemia as supply-demand contributor

›Leukocytosis and infection context

Targeted labs based on suspicion

›Directed testing

›Thyroid function tests

›Thyrotoxicosis triggers

›Amiodarone-associated thyroid disease

›Toxicology testing when indicated

›Cocaine and amphetamines

›Tricyclic antidepressants screen when QRS widening suspected

›Drug levels when relevant

›Digoxin level for suspected toxicity

›Antiarrhythmic levels when available

06Diagnostic Tests/dt53

Scoring Systems

›ECG-based VT versus SVT discrimination tools

›Brugada algorithm

›Absence of RS complexes in precordial leads supports VT

›RS interval more than 100 ms supports VT

›AV dissociation supports VT

›Vereckei aVR algorithm

›Initial R in aVR supports VT

›Initial r or q width criteria support VT

›Limitations

›Not reliable in pre-excitation or paced rhythms

›Clinical stability and response still prioritized

MRI

›Cardiac MRI applications

›Structural substrate identification

›Myocardial scar pattern via late gadolinium enhancement

›Arrhythmogenic right ventricular cardiomyopathy features

›Myocarditis evaluation

›Edema and inflammation assessment

›Scar burden and arrhythmia risk

›Operational considerations

›Not for unstable patients

›Device compatibility assessment for ICD or pacemaker

›CT-based evaluation when indicated

›Coronary CT angiography for selected low to intermediate risk chest pain

›Alternative when invasive angiography not immediately required

›Requires stable rhythm and adequate rate control

›CT pulmonary angiography for suspected pulmonary embolism trigger

›RV strain context

›Hypoxemia with tachyarrhythmia

›Limitations

›Contrast nephropathy risk

›Motion artifact at very high rates

Ultrasound

›Point-of-care ultrasound targets

›Cardiac function

›Global LV systolic function estimate

›Regional wall motion abnormality suspicion in ischemia

›Pericardial assessment

›Effusion presence

›Tamponade physiology clues

›Volume and shock physiology

›IVC size and collapsibility trend

›RV dilation suggesting PE

›12-lead ECG and monitoring

›12-lead ECG features supporting VT

›AV dissociation

›Capture beats

›Fusion beats

›Extreme axis

›QT interval assessment for torsades risk

›QTc prolongation context

›Pause-dependent onset pattern

›Continuous rhythm strip

›Onset and termination pattern

›Couplet and triplet burden

07Disposition/dispo24

Level of care selection

›Admission pathway

›ICU indications

›Hemodynamic instability episode

›Recurrent VT

›VT storm

›Need for continuous antiarrhythmic infusion

›Step-down indications

›Stable monomorphic VT terminated and low recurrence risk

›Correctable trigger addressed with monitoring need

Consultation and definitive management

›Specialty involvement

›Cardiology and electrophysiology

›New VT diagnosis

›Device interrogation need

›Ablation candidacy evaluation

›Interventional cardiology

›Suspected acute coronary occlusion

›Ongoing ischemia despite stabilization

Transfer criteria

›Higher level capability needs

›No EP or ICU capability locally

›Recurrent VT requiring advanced therapies

›Mechanical circulatory support consideration

›Post arrest care needs

›Targeted temperature management protocol access

›Coronary angiography capability

08Treatment/t103

Unstable VT with a pulse

›Immediate cardioversion pathway

›Synchronized cardioversion

›Narrow regular energy selection per device protocol

›Wide regular monomorphic VT initial 100-200 J biphasic

›Escalation stepwise to higher energies if unsuccessful

›Sedation when time allows

›Etomidate IV 0.1-0.2 mg/kg

›Ketamine IV 0.5-1 mg/kg if hypotension risk

›Post cardioversion stabilization

›Trigger treatment

›Electrolyte correction targets

›Ischemia evaluation and management

Stable monomorphic VT with a pulse

›Antiarrhythmic selection

›Amiodarone IV

›150 mg over 10 minutes

›Repeat 150 mg over 10 minutes for recurrence

›Avoid rapid bolus hypotension

›Continuous infusion

›1 mg/min for 6 hours

›Then 0.5 mg/min for 18 hours

›Maximum 2.2 g in 24 hours

›Procainamide IV

›20-50 mg/min infusion

›Stop if hypotension

›Stop if QRS increases more than 50%

›Total dose maximum 17 mg/kg

›Maintenance 1-4 mg/min

›Avoid in severe heart failure or prolonged QT

›Lidocaine IV

›1-1.5 mg/kg bolus

›Additional 0.5-0.75 mg/kg every 5-10 minutes

›Maximum 3 mg/kg

›Maintenance 1-4 mg/min

›Reduce dose in hepatic dysfunction

›CNS toxicity monitoring

›Evidence framing

›ACLS supports synchronized cardioversion for unstable tachycardia (Class I)

›Antiarrhythmic use for stable monomorphic VT with pulse supported in ACLS algorithms (Class IIa)

Polymorphic VT and torsades de pointes

›QT-driven polymorphic VT pathway

›Magnesium sulfate IV

›2 g over 10-15 minutes

›Repeat 2 g for recurrence

›Continuous infusion 1-2 g/hour for ongoing torsades risk

›Potassium repletion

›Target potassium 4.5-5.0 mmol/L

›Continuous ECG during rapid replacement

›Heart rate acceleration options when recurrent

›Isoproterenol infusion

›2-10 mcg/min titrated to suppress torsades

›Avoid in congenital long QT with ischemia concern

›Overdrive pacing

›Target 90-110 bpm

›Temporary transvenous pacing in refractory cases

›QT-prolonging drug cessation

›Offending agent list review

›Interaction checks with antiarrhythmics

Pulseless VT and VF

›Cardiac arrest pathway

›Defibrillation

›Biphasic 200 J initial or manufacturer recommended

›Escalate energy for subsequent shocks

›CPR and rhythm checks

›High-quality CPR with minimal pauses

›Rhythm check every 2 minutes

›Epinephrine

›1 mg IV or IO every 3-5 minutes

›Start after second shock in shockable rhythm sequence

›Flush and resume CPR immediately

›Amiodarone for refractory VF or pulseless VT

›300 mg IV or IO bolus

›Additional 150 mg bolus for persistent shockable rhythm

›Post ROSC infusion per local protocol

›Lidocaine alternative

›1-1.5 mg/kg IV or IO bolus

›0.5-0.75 mg/kg additional dosing

›Maintenance infusion after ROSC

VT storm and recurrent ICD shocks

›Electrical storm pathway

›Definition and urgency

›Three or more sustained VT or VF episodes in 24 hours

›High short-term mortality risk

›Sympathetic suppression

›Beta-blockade

›Propranolol IV 0.1 mg/kg divided doses or oral when stable

›Esmolol IV 500 mcg/kg bolus then 50-200 mcg/kg/min titrated

›Deep sedation

›Analgesia and anxiolysis to reduce catecholamines

›Intubation consideration for refractory storm

›Antiarrhythmic escalation

›Amiodarone infusion continuation

›Add beta-blocker synergy

›Monitor QT and bradycardia after conversion

›Lidocaine addition in ischemia-driven storm

›Combine with amiodarone with monitoring

›Avoid toxicity with hepatic impairment

›Device management

›ICD interrogation and reprogramming

›Over-sensing evaluation

›Antitachycardia pacing optimization

›Magnet use when inappropriate shocks suspected

›Continuous monitoring for true VT

›Cardiology guidance recommended

›Definitive therapies

›Emergent catheter ablation consideration

›Stellate ganglion block as bridge therapy in refractory storm (Class IIb)

09Special Populations/sp30

Pregnancy

›Maternal and fetal considerations

›Hemodynamic priorities

›Maternal stabilization as primary fetal resuscitation

›Left uterine displacement in late pregnancy when supine

›Medication considerations

›Magnesium for torsades preferred when indicated

›Amiodarone reserved for refractory life-threatening arrhythmia due to fetal thyroid risk

›Cardioversion and defibrillation safety

›Synchronized cardioversion acceptable when indicated

›Fetal monitoring when feasible after stabilization

Geriatric

›Age-related risk and management

›Ischemic substrate prevalence

›Lower threshold for ACS evaluation

›Higher likelihood of structural heart disease

›Medication adverse effects

›Hypotension risk with procainamide and amiodarone solvents

›Renal dosing considerations for procainamide metabolites

›Disposition bias

›Lower threshold for ICU monitoring

›Polypharmacy review for QT prolongation

Pediatrics

›Pediatric-specific approach

›Rhythm differentials

›SVT with aberrancy more common than in adults

›Congenital heart disease repair as VT risk

›Weight-based dosing

›Amiodarone 5 mg/kg IV over 20-60 minutes for stable VT with pulse

›Lidocaine 1 mg/kg IV bolus for stable VT with pulse

›Defibrillation energies

›Initial 2 J/kg for VF or pulseless VT

›Subsequent 4 J/kg with escalation per protocol

10Background/b32

Epidemiology

›Occurrence patterns

›Association with structural heart disease

›Prior MI and reduced LVEF as major risk group

›Cardiomyopathy and myocarditis as common substrates

›Idiopathic VT subset

›Outflow tract VT often in structurally normal hearts

›Fascicular VT in younger patients

Pathophysiology

›Mechanisms

›Reentry circuits

›Scar-related slow conduction pathway

›Monomorphic VT typical

›Triggered activity

›Early afterdepolarizations in prolonged QT

›Torsades de pointes typical

›Enhanced automaticity

›Catecholamine-driven VT

›Ischemia and stimulant effects

Therapeutic Considerations

›Why treatments work

›Cardioversion and defibrillation

›Electrical interruption of reentry circuits

›Highest efficacy for unstable VT and arrest rhythms

›Antiarrhythmics

›Amiodarone multichannel blockade reducing reentry and ectopy

›Procainamide sodium channel blockade slowing conduction

›Lidocaine ischemia-selective sodium channel blockade

›Electrolyte optimization

›Magnesium suppresses torsades via calcium current modulation

›Potassium optimization reduces early afterdepolarization risk

›Guideline framing

›Urgent cardioversion for unstable tachycardia (Class I)

›Catheter ablation for recurrent monomorphic VT despite drugs (Class I)

›Sympathetic blockade and neuromodulation in refractory storm (Class IIa to IIb depending on modality)

11Patient Discharge Instructions/pdi19

Copy discharge instructions

›Discharge guidance for selected low-risk cases

›Eligibility reminders

›Only if VT excluded or clearly benign idiopathic VT with cardiology plan

›No syncope

›No chest pain or heart failure signs

›Medications and avoidance

›Medication list adherence exactly as prescribed

›Avoid stimulant use

›Avoid QT-prolonging over-the-counter products without clinician check

›Follow-up

›Cardiology follow-up within 7 days or sooner if arranged

›Device clinic follow-up if ICD present

›Return to ED immediately

›Syncope or near-syncope

›Chest pain

›Shortness of breath at rest

›Palpitations lasting more than 10 minutes with lightheadedness

›New weakness or trouble speaking

›ICD shocks

12References/r11

Guidelines and primary sources

›Evidence sources

›American Heart Association ACLS adult tachycardia and cardiac arrest algorithms

›Unstable tachycardia synchronized cardioversion recommendation (Class I)

›Shockable arrest defibrillation and CPR sequence (Class I)

›ACC and AHA and HRS guideline for management of ventricular arrhythmias and prevention of sudden cardiac death

›Catheter ablation for recurrent monomorphic VT despite drugs (Class I)

›ICD therapy for secondary prevention in sustained VT with appropriate indications (Class I)

›European Society of Cardiology guideline on ventricular arrhythmias and sudden cardiac death

›Evaluation for structural heart disease in new VT (Class I)

›Beta-blockade and sedation strategies in VT storm (Class IIa)

›Source file citation

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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