Synchronized Cardioversion Energy for Ventricular Tachycardia

Critical Distinction: Pulse Status Determines Approach

For monomorphic ventricular tachycardia with a pulse, start with 100 joules using synchronized cardioversion with either biphasic or monophasic waveforms, as recommended by the American College of Cardiology 1, 2
Pulseless VT should be treated identically to ventricular fibrillation with unsynchronized high-energy shocks (≥200J), not synchronized cardioversion, according to the American Heart Association 1

For monomorphic VT, initial energy should be 100J synchronized, applicable to both biphasic and monophasic waveforms, as stated by the American College of Cardiology 1, 2
Polymorphic VT should never be treated with synchronized cardioversion, even if a pulse is present, and should be treated as ventricular fibrillation with unsynchronized high-energy shocks, as recommended by the American Heart Association 1

If the initial 100J shock fails, energy should be increased in a stepwise fashion for subsequent attempts, with equipment immediately available, as recommended by the American Heart Association 1
The American Heart Association recommends allowing at least 1 minute between consecutive shocks to avoid myocardial damage 2, 3

Shock must be delivered synchronized to the peak of the QRS complex, and never on the T wave, under any circumstances, as stated by the Journal of the American College of Cardiology 4
Ideally, synchronize to an R wave preceded by a long R-R interval when using low energies, as recommended by the Journal of the American College of Cardiology 4

Cardioversion should be performed with adequate sedation or anesthesia in hemodynamically stable patients, with short-acting anesthetic agents preferred for rapid recovery, as recommended by the American College of Cardiology 2
Hemodynamically unstable patients require immediate cardioversion without delay for sedation, as stated by the American Heart Association 1
Ensure fasting, postabsorptive state for elective procedures, as recommended by the Journal of the American College of Cardiology 4

Anteroposterior electrode configuration is generally more effective than anterolateral, requiring less energy with higher success rates (87% vs 76%), as stated by the American College of Cardiology 2
For patients with implanted devices, position electrodes as far as possible from the pulse generator, preferably in anteroposterior configuration, as recommended by the American College of Cardiology 2