ACLS review: Wide Complex Tachycardia (WCT) Part 6

Procainamide

·         20-50mg/min until rhythm is suppressed                                

·         Max dose 17mg/kg.

·         Observe for > 50% widening of QRS complex

·         Observe for hypotension

·         Maintenance dose 1-4mg/min.

Note:  Procainamide and sotalol should be avoided in patients with prolonged QT. If one of these antiarrhythmic agents is given, a second agent should not be given without expert consultation.

Amiodarone

·         Give 150mg IV bolus over 10 minutes                                            

·         Repeat as needed

·         Followed bolus by a continuous infusion at 1mg/min for 6 hours then 0.5mg/min for 18 hours.

·         Observe for hypotension and bradycardia

Note:   Amiodarone is also effective in preventing recurrent monomorphic VT or treating refractory ventricular arrhythmias in patients with coronary artery disease and poor ventricular function. It is given 150 mg IV over 10 minutes; dosing should be repeated as needed to a maximum dose of 2.2 g IV per 24 hours

Sotalol

·         In clinical studies 1.5 mg/kg.                                                                

·         Avoid in patients with poor perfusion

·         Observe for hypotension and arrhythmias

·         Avoid if prolonged QT

Note:  In a separate study of 109 patients with a history of spontaneous and inducible sustained ventricular tachyarrhythmias, infusing 1.5 mg/kg of sotalol over ≤5 minutes was found to be relatively safe and effective, causing hypotension in only 2 patients, both of whom responded to IV fluid.421 Package insert recommends slow infusion, but the literature supports more rapid infusion of 1.5 mg/kg over 5 minutes or less. Sotalol should be avoided in patients with a prolonged QT interval.

(US package labeling recommends any dose of the drug should be infused slowly over a period of 5 hours)

Lidocaine

·         an initial bolus of 1.0 to 1.5 mg/kg IV

·         additional bolus of 0.5 to 0.75 mg/kg can be given over 3 to 5 minutes               

·         Total dose should not exceed 3 mg/kg

·         A continuous infusion of initiated at 1 to 4 mg/min.

Note:  By comparison, lidocaine is less effective in terminating VT than

procainamide, sotalol, and amiodarone, and when given to patients with or

without a history of MI with spontaneous sustained stable VT in the hospital setting.

Thus, while occasionally effective, lidocaine should be considered second-line antiarrhythmic therapy for monomorphic VT. Lidocaine can be administered at a dose of 1 to 1.5 mg/kg IV bolus. Maintenance infusion is 1 to 4 mg/min (30 to 50 mcg/kg per minute).



Reviewed 2/28/16