In unstable tachycardia with wide complex VT that is monomorphic, what is the recommended initial management?

• A. Amiodarone 150 mg in 50 mL NS over 10 min
• B. Repeat synchronized cardioversion
• C. Defibrillate
• D. Synchronized Cardioversion & Analgesia

Answer: (D)

When a patient has unstable tachycardia with a wide complex VT that is monomorphic, the priority is to rapidly restore perfusion by delivering a synchronized cardioversion. The synchronization is crucial because it times the shock with the QRS complex to avoid delivering during the vulnerable T wave, which could trigger worse rhythms. Since there is a pulse, defibrillation (unsynchronized shock) is not the initial step; defibrillation is reserved for pulseless VT or VF.

Providing analgesia or sedation during synchronized cardioversion helps keep the patient comfortable and can blunt a dangerous sympathetic surge, but it should not delay the shock. Antiarrhythmics like amiodarone are not the first move in an unstable VT with a pulse; they’re more appropriate for stable VT or as a subsequent measure if cardioversion doesn’t promptly terminate the rhythm.

So the best initial management is synchronized cardioversion with analgesia to safely and promptly restore a stable rhythm.