In this discussion, we will be looking at using synchronized cardioversion on pulseless ventricle tachycardia. Defibrillation and electrical cardioversion are interchangeable and mean the same thing, a transthoracic electrical current to the cardiac cells. I have been looking at the ACLS cardiac arrest and tachycardia protocols and was wondering why we defibrillate (unsynchronized) pulseless ventricle tachycardia (V-Tach), but synchronize cardiovert unstable V-Tach? Isn’t pulseless V-Tach virtually unstable V-Tach? It’s the same mechanism, but one is just too fast to push blood effectively through the heart.
There are two types of V-Tach: focal V-Tach and re-entrant V-Tach. Focal V-Tach happens when a group of cells in the ventricle are irritated (abnormal automaticity) and fires over the SA and AV node. It is widely accepted that the most lethal ventricular tachycardia is re-entrant ventricular tachycardia. In reentrant V-Tach, there is an area of dead heart cells that are usually caused by an old myocardial infarction (MI). This group of dead cells do not conduct electricity. The electrical signals travel around the dead cells on both sides. Depending on the length of the refractory period of the live cardiac cells around the dead cells, the electrical signal can be caught in a loop around the dead cells causing ventricular tachycardia.
The exact mechanism of how electrical cardioversion works to stop tachycardic arrhythmias and ventricular fibrillation (V-Fib) is unclear, but there are two theories: The first by Zipe et al suggests that after depolarization of a critical mass of cardiac muscles by electrical defibrillation, the cardiac tissues are unable to maintain the re-entrant tachycardia. The other theory is that the shock waves of electrical cardioversion or defibrillation cause a prolonged refractory period, terminating the arrhythmia. We use synchronized electrical cardioversion during V-Tach with a pulse for a very specific reason: When we synchronize cardiovert, the defibrillator times out the R wave of the QRS complex. When we press the shock button, the defibrillator waits for the next R wave and delivers the shock on the R wave before the T wave. During the T wave, there is a relative refractory period known as the “vulnerable period”. If a shock is given during this vulnerable period, it can produce what is known as the R-on-T phenomenon and lead to resistant V-Fib. Without synchronized cardioversion for V-Tach with a pulse, you risk making a patient with a pulse, pulseless. The success rate of converting V-Tach with a pulse using synchronized electrical cardioversion is around 95%. That number is huge. If the there is a high success of converting V-Tach with a pulse, can this carry over to a pulseless V-Tach? Do we want to risk shocking on the T wave of pulseless V-Tach and possibly put them into a resistant V-Fib? Is this what we are doing now?
I was only able to find one research article on the subject: Turner, Turner, and Grace, the authors of the study, suggest the current guidelines recommend unsynchronized cardioversion due to the delay in shocks by hooking up the ECG leads. Some monitors, however, such as the Phillips Heartstart MRX, can sense the R wave using only the defib pads. It was a small study, and only 42 V-Tach pulseless/severely hemodynamic compromised patients were included. Thirty patients were shocked within a 100ms window of the peak of the QRS. Of those 30, 28 were converted into a perfusing rhythm; the other two went into V-Fib. The other 12 were shocked outside of the 100ms window, 7 went into V-Fib m, and 5 converted into a perfusing rhythm. It is a small study, and more studies will need to be done, but it makes me think: Should we be trying synchronized cardioversion on pulseless V-Tach? What do you think? Please let me know, as I am interested in your thoughts.
Osmosis. (2016, April 11). Ventricular tachycardia (VT) – causes, symptoms, diagnosis, treatment & pathology. Retrieved from https://www.youtube.com/watch?v=xAfj5AHxC2I
Samie, F.,H., & Jalife, J. (2001). Mechanisms underlying ventricular tachycardia and its transition to ventricular fibrillation in the structurally normal heart. Cardiovascular Research, 20(2). Retrieved from https://owl.purdue.edu/owl/research_and_citation/apa_style/apa_formatting_and_style_guide/reference_list_electronic_sources.html
Sciammarella, J., C., & Bhimji, S.,S. (2017). Cardioversion, Synchronized Electrical. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482173/
Sucu, M., Davutoglu, V., Ozer, O. (2009). Electrical Cardioversion. Annals Saudi Medicine, 29(3), 201-206. Doi:10.4103/0256-4947.51775
Turner, I., Turner, S., Grace. A.,A. (2009). Timing of Defibriltation Shocks for Resuscitation of Rapid Ventricular Tachycardia: Does it Make a Difference? [Abstract]. Resuscitation, 80(2), 133-138. doi: 10.1016/j.resuscitation.2008.09.014
Zoll. (2018). Cardioversion. Retrieved from https://www.zoll.com/medical-technology/cardioversion/
Hi Andy,
Thanks for the post. I really enjoyed this one. I have in the past wondered and questioned the exact same thing. Over 20yrs in EMS/HEMS and years as an ALS (UK/Au) instructor yet I never managed to uncover clear opinion or explanation and hence eventually let it go. The Turner/Turner/Grace reference as to why it perhaps isn’t in as a strategy for ACLS makes sense
I did not know (in all this time) about the two types of VT and their respective pathophys’…. thanks for educating me.
Personally, I think it is a valid approach to consider in a “resuscitationist” setting where unnecessary delays won’t be incurred to shock (and the stats are really interesting). I also think it is beyond the scope and intent (too complicated to get right or use appropriately) on ALS/ACLS short-courses to teach this specific concept in the small-timeframes available, to participants from a variety of disciplines who in the majority may only be occasionally presented with formal resuscitation situations.
Paul
Paul thanks for reading the Blog.
There will need to be more studies to prove the effectiveness of synchronized cardioversion in pulseless Vtach, before this would widely accepted. It might be too complicated to set up, but once the pads are on all you do is hit the sync button before you hit the defib button. In ACLS they teach synchronized cardioversion for Vtach with a pulse, it would be the same thing but pulseless. I do see your point though, I have seen several times nursed trying to synchronize cardiovert but couldn’t because they didn’t have the leads on, but with some monitors you don’t need the leads on.
Thanks for the reply
Andy Hall
I always thought it was the higher defib dosing that “counteracted” the potential R on T by producing a more global depolarization… Your thoughts?
Scott,
Thanks for reading the blog.
If that is the case then why not just do that with all Vtach pulsless and with a pulse. High doses of energy delivered during the vulnerable period, the relative and supranormal period can still cause R-on-T phenomenon. In Vtach you still have an organized rhythm and most of the cells with be in the relative and supranormal period relatively at the same time. During this time the cell can still depolarize depending on the strength of the stimuli. I stimuli provided by us or even by a PVC during the vulnerable period this can cause ventricle fibrillation. So providing more global depolarization during the vulnerable period will still cause R-on-T phenomenon.
I believe that global depolarization works more for ventricle fibrillation. One theory is that if enough of the cells are depolarize by a shock that the cells are that got depolarized together will take over. The exact mechanism is still unclear.
Thanks,
Andy Hall