Algorithm for initial treatment of SMVT in responsive patients with a pulse

SMVT: sustained monomorphic ventricular tachycardia; CV: cardioversion.
* Hemodynamically unstable patients have evidence of hemodynamic compromise, such as hypotension, altered mental status, chest pain, or heart failure. Hemodynamically stable patients should have none of these findings.
¶ Initial choice of pharmacologic agents includes:

• Intravenous lidocaine (1 to 1.5 mg/kg [typically 75 to 100 mg] at a rate of 25 to 50 mg/minute; lower doses of 0.5 to 0.75 mg/kg can be repeated every 5 to 10 minutes as needed), which may be more effective in the setting of acute myocardial ischemia or infarction
• Intravenous procainamide (20 to 50 mg/minute until arrhythmia terminates or a maximum dose of 17 mg/kg is administered)
• Intravenous amiodarone (150 mg IV over 10 minutes, followed by 1 mg/minute for the next six hours; bolus can be repeated if VT recurs)

Δ Electrical cardioversion should be synchronized if possible, using 100-joule biphasic shock or 200-joule monophasic shock. If first shock is unsuccessful, energy level should be escalated on subsequent shocks.
◊ Conditions associated with SMVT include myocardial ischemia, electrolyte disturbances (eg, hypokalemia, hypomagnesemia), drug-related proarrhythmia, and heart failure.