The pulseless ventricular tachycardia rhythm is primarily identified by several criteria. First, the rate is usually greater than 180 beats per minute, and the rhythm generally has a very wide QRS complex.
Second, the patient will be pulseless. And third, the rhythm originates in the ventricles. This is in contrast to other types of tachycardias which have origination above the ventricular tissue (in the atria).
Not all ventricular tachycardias are pulseless, and therefore, pulselessness must be established prior to beginning an algorithm. This is accomplished simply by checking a carotid or femoral pulse.
Pulselessness with a tachyarrhythmia occurs because the ventricles are not effectively moving blood out of the heart and there is, therefore, no cardiac output. Many tachyarrhythmias of a rate >150 will deteriorate into pulselessness if timely treatment is not given.
Pulseless ventricular tachycardia is treated using the left branch of the cardiac arrest algorithm. Click below to view the cardiac arrest algorithm diagram. When finished click again to close the diagram.
Cardiac Arrest Diagram
Click to view, and click again to close the diagram.
PALS Cardiac Arrest Diagram
Play the video below to see what a Pulseless Ventricular Tachycardia will generally look like on a defibrillator monitor. Allow several seconds for video to load. (4.03 mb)
Click for next Rhythm Review: Ventricular Fibrillation
Top Questions Asked on This Page
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Q: What happens after the 2nd dose of Amiodarone is given and the patient is still in the same rhythm? Do we give a 3rd dose immediately or rhythm usually changes after 2nd dose?
A: A 3rd and even a 4th dose of 150 mg amiodarone may be administered. The only thing that needs to be taken into consideration is the 2.2-gram maximum dosage for 24 hours. Also, it is unlikely that the rhythm will remain VF or pVT long enough for you to get to the 3rd or 4th dose.
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Q: What does refractory VT or VF mean?
A: Refractory pVT or VF means that the VF or pVT does not convert to a perfusing rhythm and continues to persist in spite of multiple attempts at conversion with defibrilation, acls drugs, and high quality CPR.
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Q: After initiating CPR and assessing the rhythm, the patient is in VF/ pVT and the first shock is given, and CPR for 2 mins. Then rhythm check and in VT, should the pulse be checked to confirm pVT?
A: If there is no rhythm change and the same waveform of VT continues, you would not need to perform a pulse check. Performing the pulse check would delay the continuation of chest compressions. Once VT is pulseless it is very unlikely that any VT will be able to produce life-sustaining cardiac contractions.
Kamyar Maghazehe says
I have a question, what happens after 2nd dose of Amiodarone is given and still in the same rhythm? Do we give a 3rd dose ultimately or rhythm usually changes after 2nd dose? Thanks for you help.
Jeff with admin. says
A 3rd and even a 4th dose of 150 mg amiodarone can be administered. The only thing that needs to be taken into consideration is the 2.2-gram maximum dosage for 24 hours. Also, it is unlikely that the rhythm will remain VF or pVT long enough for you to get to the 3rd or 4th dose. Kind regards, Jeff
David Jenkins says
Hi, just to be clear, we will flush with 20ml NS immediately after the med is pushed. Then shock, then 5 cycles CPR?
Jeff with admin. says
Here is the sequence from the very beginning of the algorithm. This would be for unwitnessed cardiac arrest.
CPR five cycles > rhythm check > shock > CPR five cycles > rhythm check > shock > CPR five cycles (give epinephrine during CPR and flush with 20 mL normal saline) > rhythm check > shock > CPR five cycles (give amiodarone during CPR) > rhythm check > shock > CPR five cycles……
(once the first dose of epinephrine is given, it is on it’s own timetable and is given every 3 to 5 minutes.)
Please let me know if you have any other questions.
Kind regards,
Jeff
Dan says
Hi Jeff,
Many thanks for a very good article, I was just wondering about shocking VT; if it’s pulseless we do not synchronise but if pulse is present we do (with adverse signs)? Is it not the same rhythm and should be treated the same?
Jeff with admin. says
Pulseless ventricular tachycardia is treated with high energy unynchronized shocks. The research shows that there is a high degree of success with high-energy unsynchronized shocks when treating pulseless ventricular tachycardia. This is the reason why high energy unsynchronize shocks are used or pulseless ventricular tachycardia.
Kind regards,
Jeff
Ellen says
Hi Jeff
Please could you point me in the direction for citied research regarding vt/vf and high energy shocks as I’m currently researching for a dissertation for university. Thanks
Jeff with admin. says
Here is one piece of research. Also within this paper you will find more references at the end in the work cited.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3276405/
Kind regards,
Jeff
Deborah Phillips says
I’m confused. This seems to contradict itself or am I reading it wrong? It says to treat pulseless with synchronized, then says treat with unsynchronized? All in the same paragraph?
Jeff with admin. says
Pulseless ventricular tachycardia is treated with unsynchronized shocks. I did notice in the comments that there was a miss spelling and I stated “on synchronized” instead of unsynchronized.
This was a mistake that was made because I use a voice to text translation software. From time to time I do not catch the errors. My apologies for the confusion. I have corrected the error that was in the comments.
Kind Regards, Jeff
Nancy says
Jeff
What does refractory VT or VF mean?
Thanks
Nancy
Jeff with admin. says
Refractory pVT or VF means that the VF OR pVT does not convert to a perfusing rhythm when defibrillation is performed.
Kind regards,
Jeff
bob says
After initiating CPR and assessing rhythm patient is in VF/ pVT and first shock is given, and CPR for 2mins. Then rhythm check and in VT, should the pulse be checked to confirm pVT?
Jeff with admin. says
If there is no rhythm change and the same waveform of VT continues you would not need to perform a pulse check. Performing the pulse check would delay the continuation of chest compressions. Once VT is pulseless it is very unlikely that any VT will be able to produce life sustaining cardiac contractions.
Kind regards,
Jeff
Jennifer says
It seems like epinephrine is given regardless of PEA or pVT or VF, or asystole. Given regardless there is bradycardia or tachycardia. It seems like it’s always that go to med and first action that is drawn up and administered prior to any vasopressors, antihypertensive, antiarrhymtmias, or vasodilation medications, So is it fair to say that there is no way to definitively define or put into a category of to increase or decrease the P?
Jeff with admin. says
Epinephrine has several effects that are helpful in different situations and it is dose dependent. Epinephrine can be given to increase the heart rate, it is given to improve blood pressure, and it is given to circulation to the vital organs. It can also be given to cause mucosal vasoconstriction with serious cases of asthma.
Each of these effects is basically dependent upon how much is given. It is a very versatile medication and is considered very important in emergency medicine.
Kind regards,
Jeff
DanitaK says
is there supposed to be sound to the videos? If so, I don’t have any sound and how do I fix this. Thank you.
Jeff with admin. says
There are a couple videos that do you have audio narration. All of the mega code series videos have background music with text on screen to read. The volume control should be in the lower right-hand corner of the video player for a PC, and you can control the volume on an iPhone or android with your volume control just as with any audio play.
If you do need some technical assistance, you can call the technical support line 316-243-7096
Kind regards,
Jeff
Kit says
I am unable to see the short videos. How do I correct this? Thanks
Jeff with admin. says
Thank you for letting me know that you were having some difficulty viewing the videos. There can be a number of technical issues that can cause this problem.
The most common problem can be resolved by updating your Adobe flash player. You can find instructions to do this on the help page listed below.
Help Page
If you continue to have problems, please call the technical support line for assistance 316-243-7096.
Kind regards,
Jeff
Mohammad Akhtar says
No option to get registered for Pakistani doctors .Very disappointing.Please update your countries option and include Pakistan as well.Regards.Dr Mohammad Akhtar.
Jeff with admin. says
I do have some providers from Pakistan that use a prepaid credit card to make the purchase for the membership.
Kind regards,
Jeff
Ajc92289 says
After the 3rd shock you give 300 mg of amiodarone. So after the 4th shock you’d give the 2nd dose of amiodarone the 150 mg?
Thanks!
Jeff with admin. says
It can be given anytime after the fourth shock. It is not a requirement that is given directly after the 4th shock, but it may be given after the first dose of amiodarone has had sufficient time to circulate.
Kind regards,
Jeff
John says
Usually you would give Epinephrine 1mg after the 2nd defibrillayion. Then give Amiodarone 300mg and defibrillate again. Then you would give Epinephrine 1mg and Fefibrillate again. After that you would give 150mg of Amiodarone
Jeff with admin. says
Shock → CPR → Shock → CPR + 1mg Epi → Shock → CPR + 300mg amiodarone → Shock → CPR (Amiodarone 150mg may be given any time after the 4th shock)
Jennifer says
The pretest on AHA has amiodarone being given after the 2nd shock (it sounds like). “A patient is in pVT. Two shocks and 1 dose of epinephrine have been given. Which drug should be given next?”
I chose epinephrine and it stated that amiodarone 300mg was the correct answer. So that’s not actually correct. At least not for this scenario in which the other options are epinephrine 3mg, adenosine 6mg, and lidocaine 0.5mg/kg.
Jeff with admin. says
The sequence cardiac arrest with pVT is as follows:
Shock → 5 cycles CPR → Shock → 5 cycles CPR/Epi 1mg → Shock → 5 cycles CPR/Amiodarone 300mg → Shock → 5 cycles CPR (After the first dose of epi, it is on a time table of give every 3-5 minutes and a second dose of amiodarone can be given any time after the next shock as long as the first dose has had time to adequately circulate.)
Amiodarone is given after the 3rd shock. You must have been mistaken about the AHA pretest. Here is a diagram and you can see that amiodarone is listed as being given after the 3rd shock.
Kind regards,
Jeff
lullrich says
Hi Jeff:
Can you please tell me if on an ECG their is a difference in the tracing if the rhythm is generated in the atria or ventricle? On a couple of the tracings I see the QRS complex is downward instead of upward. I’m not really sure why the complex is “inverted” Thanks. Linda
Jeff with admin. says
Whether or not the QRS complex is inverted depends upon what lead you are looking at. For the purposes of ACLS and rhythm recognition, you will not need to interpret what positively or negatively deflected QRS complexes mean. Positive and negative deflection of QRS complexes is a subject for understanding 12-lead ECG interpretation and is beyond the scope of ACLS.
Does that make sense?
Kind regards,
Jeff
Joyce nelson says
Can cardiac shock resuscitation injury the mitral and/or aorta valve?
Also would anyone know if complete failure of blood flow (6ltrs of blood) bleed out could result in any pulmonary dysfunction? I.e. Hypertension?
Jeff with admin. says
Thanks for the questions. I’ll take them one at a time.
Can cardiac shock resuscitation injury the mitral and/or aorta valve?
This depends on a lot of factors. But I would say that it is possible that any part of the heart can be injured during cardiac resuscitation, not necessarily from a defibrillation, if that is what you are meaning when say “shock,” a dying heart is being revived and that heart muscle is “dying” from a lack of oxygen. When you take away the oxygen, the tissues get damaged. It is only after resuscitation when the full extent of the damage can be evaluated.
“would anyone know if complete failure of blood flow (6ltrs of blood) bleed out could result in any pulmonary dysfunction? I.e. Hypertension?”
Complete failure of blood flow most often times results in total death. If you take away the blood flow, you have taken away the oxygen. No oxygen, no life. There is a progression from a lack of oxygen in the tissues, to tissue hypoxia, to tissue injury, to tissue death and this can be any tissue involved including pulmonary tissue, cardiac tissue, any organ tissue. If not corrected the organism dies.
So yes, complete failure of blood flow could result in pulmonary dysfunction.
Kind regards,
Jeff
Irene says
Sorry, I can’t help myself… You refer above to “total death”. If there is a “total death”, it follows that there is such a thing as a “partial death”? What would that be?
You made my day, and I just could not stop laughing!
Was there a Torsades de Points there, as an example or was I just imaging that?
Thanks
Jeff with admin. says
LOL. I agree. I just re-read that, and I had to laugh too. Reminded me of a movie called the “Princess Bride.” A magician was trying to revive a princess who he said was “mostly dead.”
Kind regards,
Jeff
Kjkamk says
Where have you been the last 9 times I’ve taken ACLS? Granted, it’s been simplified somewhat but this is so much better than just turning pages in a book!
Helentina Garstang says
I agree.
This is so simple to follow and remember
icecakes@aol.com says
I am confused, it says to give Epi 1 mg and repeat in 3 to 5 min, when do u have time to give the second dose? it seems to me there is no time for the second dose of epi because after the next shock amiodarone will be given ?
Jeff with admin. says
Once the first dose of epinephrine is given after the 2nd shock, it is on it’s own time table and is not dependent on any other action in the flow of care. It is given on its own time table of every 3-5 minutes. When the recorder states “3 minutes has passed since the last dose of epinephrine”, you would give the epinephrine as soon as the next cycle of CPR begins. Kind regards, Jeff
Sharain says
The video states to shock ASAP. The reading states CPR then shock. I would want to shock right away. Which is correct?
Jeff with admin. says
This means that defibrillation should just take place as soon as possible. If a collapse is witnessed you can shock immediately. If the collapse is unwitnessed, you would complete 2 minutes of high quality CPR then perform defibrillation.
Kind regards,
Jeff