What method would YOU use to discern V-Tach from SVT with abbarency?

[d_miracle36]

Amio and lido are both pretty poor at VT/VF in general.

Lido is very efficacious when the action potential threshold is messed up due to ischemia. So your ischemic VT's should respond very well to lidocaine. It also has the benefit of having little cardiac effects if the patient has normal myocardium and you "guessed wrong" and it was SVT-A.

Amiodarone is a sledgehammer and has a multitude of antiarrhythmic effects. It has a nasty half-life, is packaged with a cardioactive solvent, and can cause lung fibrosis in higher doses. It also is not really that much better than lidocaine overall, and certainly does not beat lido in ischemic VT. The one upside to amiodarone is it is a sledgehammer and will "work" to some degree on most types of arrhythmias.

I recently read that Lido is not a good diagnostic agent, and that it can cause v-tach to not be treated as such because it did not respond to lidocaine. What about in a patient who has no response to lidocaine, and you still don't know if it was SVT-A or V-tach? When do you just decide to sedate and cardiovert? Sorry if I got off topic.

 

[unleashedfury]

if Amio and Lido are poor at acting on VF/VT why aren't we just jumping right to cardioversion instead?

I can understand that it could be a little overwhelming to the patient as you say hey buddy this is gonna hurt as your going after him with paddles.. But if its stable enough to play with antidysrthymics a little analgesic or sedative isn't going to take much longer.

 

[Christopher]

I recently read that Lido is not a good diagnostic agent, and that it can cause v-tach to not be treated as such because it did not respond to lidocaine. What about in a patient who has no response to lidocaine, and you still don't know if it was SVT-A or V-tach? When do you just decide to sedate and cardiovert? Sorry if I got off topic.

Adenosine isn't a great diagnostic agent either if you're looking for 100% certainty

I'm comfortable with sedation and cardioversion, and would choose simple cardioversion without sedation for myself if/when I have an arrhythmia. As for when on a patient? Anything reaaally ugly that I'm not comfortable with antiarrhythmics I will cardiovert.

 

[Christopher]

if Amio and Lido are poor at acting on VF/VT why aren't we just jumping right to cardioversion instead?

Sedation is deemed riskier than antiarrhythmics perhaps? Also I would imagine a bolus of lidocaine is more "humane" than cardioverting simple VT. I dunno, I've decided to choose cardioversion alone for myself.

I can understand that it could be a little overwhelming to the patient as you say hey buddy this is gonna hurt as your going after him with paddles.. But if its stable enough to play with antidysrthymics a little analgesic or sedative isn't going to take much longer.

Agreed. The ED is much quicker to cardiovert than we are.

 

[rlcpr]

Quickest and easiest way would be concordance in the precordial leads (usually favors V Tach in that case). Also, I would look for Josephson's/Brugada's if time permitted (for v tach).

But honestly, the pads would be on anyway so it would most likely be a synchronized cardioversion either way. Probably around 100J to start and see if that brings them out.