ECG Analysis

• Regular wide-complex tachycardia at ~160-190 bpm
• QRS duration markedly prolonged (>120 ms), bizarre morphology
• Uniform QRS shape across leads (aVF, V1-V4) - monomorphic
• No discernible P waves = AV dissociation

Is Shock Indicated?

Scenario A: Patient IS Pulseless (Cardiac Arrest)

• Diagnosis = Pulseless VT - a shockable cardiac arrest rhythm
• Immediate unsynchronized defibrillation (same energy as VF):
  • Biphasic: 120-200 J (manufacturer recommendation; 200 J if unknown)
  • Monophasic: 360 J
• Follow AHA/BLS-ACLS algorithm: shock → CPR 2 min → reassess → repeat
• Do NOT delay shock to establish IV access
• Epinephrine 1 mg IV every 3-5 min after 1st or 2nd shock
• Amiodarone 300 mg IV (or lidocaine as alternative) after 2nd shock if refractory

Scenario B: Patient HAS a Pulse (Hemodynamically Unstable)

• Diagnosis = Sustained VT with hemodynamic compromise (hypotension, chest pain, altered consciousness, pulmonary edema)
• Synchronized cardioversion is indicated:
  • Start at 100 J (biphasic), escalate if needed
  • Sedate the patient first if conscious
• If stable: IV antiarrhythmics (amiodarone, procainamide) can be used first

Scenario C: Patient HAS a Pulse (Hemodynamically Stable)

• Antiarrhythmic drugs first (amiodarone 150 mg IV over 10 min, then infusion)
• Synchronized cardioversion remains available if drugs fail

Bottom Line

Per the 2019 AHA/ACC guidelines on ventricular arrhythmias, pulseless VT is a Class I indication for immediate defibrillation.