## Clinical Diagnosis **Key Point:** This patient has ventricular tachycardia (VT) with hemodynamic instability (syncope, hypotension, altered perfusion). The ECG findings of wide complex tachycardia with AV dissociation and fusion beats are pathognomonic for VT. The clinical context (prior MI, reduced EF, cardiomegaly) confirms structural heart disease as the substrate. ## Hemodynamic Stability Assessment **High-Yield:** In any wide complex tachycardia with hemodynamic compromise (SBP <90 mmHg, syncope, altered consciousness), the first-line treatment is **synchronized DC cardioversion**, NOT pharmacotherapy. | Finding | Implication | |---------|-------------| | SBP 85/50 mmHg | Severe hypotension | | Syncope | Loss of cerebral perfusion | | HR 180 bpm | Inadequate diastolic filling | | Reduced EF (28%) | Severely compromised cardiac output | ## Management Algorithm ```mermaid flowchart TD A[Wide Complex Tachycardia]:::outcome --> B{Hemodynamically Stable?}:::decision B -->|No: SBP <90, syncope, altered mental status| C[Synchronized DC Cardioversion]:::action B -->|Yes: Stable BP, conscious| D[IV Amiodarone or Procainamide]:::action C --> E[Restore sinus rhythm]:::outcome D --> F[Pharmacological conversion]:::outcome ``` **Clinical Pearl:** Verapamil is contraindicated in VT with hemodynamic instability and should never be used as first-line in wide complex tachycardia—it can precipitate cardiovascular collapse. **Warning:** Do NOT delay cardioversion to obtain IV access or administer drugs when the patient is hemodynamically unstable. Time is myocardium. ## Post-Cardioversion Management After successful cardioversion: - Initiate IV amiodarone infusion (150 mg over 10 min, then 1 mg/min × 6 hrs, then 0.5 mg/min) - Correct electrolytes (K^+^, Mg^2+^) - Evaluate for ICD candidacy given EF <35% [cite:Harrison 21e Ch 226]
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