Immediate Management Of Ventricular Tachyarrhythmias

Initial management of the patient who presents with a sustained VTA is guided by advanced cardiac life support (ACLS) recommendations. National guidelines vary, and specific aspects—particularly adjunctive pharmacological therapy—are controversial. This is largely because of the lack of controlled trials, which are difficult to perform in victims of VTA (20). The International Liaison Committee on Resuscitation (ILCOR) was formed to create a consensus guideline from the diverse guidelines established in different countries (21). The American Heart Association (AHA) has recently published recommendations entitled "Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care." These recommendations represent an international consensus, and include a comprehensive discussion of the rationale of treatments, as well as alternative treatments and their indications classified according to the confidence of scientific data supporting the recommendation (22).

Defibrillation is performed as soon as possible in patients who present with pulseless VTA or VF. If the initial three attempts at defibrillation fail, they are repeated after intravenous (iv) administration of epinephrine 1 mg every 3-5 min, or a single dose of vasopressin (40 units iv). Reversible causes of the VTA should be found and corrected. Sodium bicarbonate administration should be considered in refractory VTA, or in situations such as tricyclic overdose, hyperkalemia, and prolonged resuscitative efforts. Special situations may require alterations in management that deviate from the basic algorithm (23). Some authorities have recommended higher doses of epinephrine (up to 0.1 mg/kg), although clinical trials have not shown a significant improvement in survival until hospital discharge.

Although arbitrary, an arrhythmia may be considered intractable if there is failure to convert the rhythm after several attempts of defibrillation, epinephrine, or vasopressin,

Table 1

Dosages of Antiarrhythmic Drugs for VF/Pulseless VT

Table 1

Dosages of Antiarrhythmic Drugs for VF/Pulseless VT

Drug

Bolus

Rebolus

Infusion

Comments

Amiodarone

300 mg iv push

150 mg iv push if needed

1 mg/min for 6 h

Maximum cumulative dose 2.2 mg/ kg/24 h

Lidocaine

1.0-1.5 mg/kg iv

Consider 1.0-1.5

1-4 mg/min

Maximum

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