A patient with a BP of 80/40, P 180 c/o shortness of breath, is diaphoretic, pale and cool. The monitor shows a VTACH rhythm. Which of the following is the best treatment for this patient?

• A. Synchronized cardioversion at 100 joules
• B. Synchronized cardioversion at 50 joules
• C. Defibrillation at 200 joules
• D. Defibrillation at 100 joules

Answer: (A)

Unstable VT with a pulse requires synchronized cardioversion to quickly restore a perfusing rhythm. Because there is a pulse, you synchronize the shock with the QRS to avoid shocking on the vulnerable T wave, which can precipitate degeneration to ventricular fibrillation. The preferred first move is a synchronized cardioversion using the standard initial energy for adults; if the rhythm does not convert, you escalate per protocol. Defibrillation wouldn’t be appropriate here since there is a pulse—defibrillation is reserved for pulseless VT or VF. A small, unsynchronized shock or a shock given without synchronization would not be suitable for a patient with a pulse, and would carry greater risk. After stabilization, consider antiarrhythmic therapy and continued monitoring.