II. Management: Approach

  1. ABC Management
  2. CPR until Defibrillator available
    1. Good quality Cardiac Compressions are critical for survival (ROSC)
    2. Consider 5 cycles CPR (2 min) before defibrillating
  3. Defibrillation options (single shock)
    1. Manual Defibrillator
      1. First: 2-4 J/kg
      2. Subsequent: 4 J/kg
      3. Maximum: 10 J/kg or up to adult dose
    2. AED (age 1 year or older)
      1. Child system is preferred if available ages 1-8
  4. Secure cardiopulmonary access
    1. See Cardiopulmonary Resuscitation
    2. Ventilate with 100% oxygen
    3. Endotracheal Intubation
    4. Obtain Intravenous Access
  5. Cycles
    1. Perform 5 cycles of CPR (15:2 if two providers) for total of 2 minutes
      1. Once Advanced Airway in place, give 8-10 breaths per minute (every 6-8 min) and compressions >100/minute asynchronously
    2. Re-evaluate rhythm with minimum interruption of Cardiac Compressions (<10 seconds)
      1. Organized Electrical activity: Check for pulse
      2. Non-shockable rhythm: See Other protocols
        1. Asystole
        2. Pulseless Electrical Activity (PEA)
      3. Shockable rhythm: Defibrillate
        1. Ventricular Fibrillation
        2. Pulseless Ventricular Tachycardia (V. fib or V. Tach)
    3. Repeat Defibrillation as above after each cycle
      1. Call clear
      2. Compressions need not be interrupted if mechanical CPR device is in place
    4. Administer medications once IV or IO access obtained (see below)
      1. Administer during Cardiac Compressions (between Defibrillations)
      2. Epinephrine (every 3-5 minutes)
        1. First dose after second Defibrillation
        2. IV/IO: 0.01 mg/kg (0.1 ml/kg of 1:10,000) up to 1 mg IV
        3. ET: 0.1 mg/kg (0.1 ml/kg of 1:10,000) up to 2.5 mg via ET
      3. Amiodarone (up to 3 doses)
        1. Dose: 5 mg/kg up to a maximum of 300 mg for a single dose
        2. First dose after the third Defibrillation
        3. May repeat up to 2 additional doses
    5. Adjunctive medications
      1. Magnesium Sulfate
        1. Dose: 25 to 50 mg/kg IV or IO
        2. Indications
          1. Polymorphic VT (Torsades de Pointes)
          2. Suspected Hypomagnesemia

III. Management: Post Return of Spontaneous Circulation (ROSC)

  1. Assess Vital Signs
  2. Support Airway and breathing
  3. Consider maintaining Antiarrhythmic medications
    1. Infusion of Antiarrhythmic that converted rhythm
    2. Discuss with pediatric cardiology
  4. Pursue definititive management of underlying cause
    1. Reversible Causes of Cardiopulmonary Arrest (5H5T)
  5. Initiate Hypothermia protocol
    1. Improves longterm CNS recovery post-hypoxic event

IV. Management: Example

  1. Cycle 1
    1. Perform 5 cycles of CPR (15:2) for total of 2 minutes
    2. Obtain IV Access concurrent with CPR
    3. Rhythm check and Defibrillate 2 J/kg (Call 'clear' and <10 second cardiac compression interruption)
  2. Cycle 2
    1. Perform 5 cycles of CPR (15:2) for total of 2 minutes
    2. Place Advanced Airway concurrent with CPR
    3. Rhythm check and Defibrillate 4 J/kg (Call 'clear' and <10 second cardiac compression interruption)
  3. Cycle 3
    1. Perform CPR for 2 minutes (If Advanced Airway, give asynchronously 8-10 breaths per minute and >100 compressions/min)
    2. Administer Epinephrine 0.01 mg/kg IV up to 1 mg IV maximum
    3. Treat reversible cause (e.g. contact catheterization lab if Acute Coronary Syndrome suspected)
      1. With mechanical CPR device in place, inter-hospital transport is viable despite lack of ROSC
    4. Rhythm check and Defibrillate 4 J/kg (Call 'clear' and <10 second cardiac compression interruption)
  4. Cycle 4
    1. Perform CPR for 2 minutes
    2. Administer Amiodarone 5 mg/kg IV up to 300 mg IV maximum
    3. Rhythm check and Defibrillate 4 J/kg (Call 'clear' and <10 second cardiac compression interruption)
  5. Cycle 5
    1. Perform CPR for 2 minutes
    2. Administer Epinephrine 0.01 mg/kg IV up to 1 mg IV maximum
    3. Rhythm check and Defibrillate 4 J/kg (Call 'clear' and <10 second cardiac compression interruption)
  6. Cycle 6
    1. Perform CPR for 2 minutes
    2. Administer Amiodarone 5 mg/kg IV up to 300 mg IV maximum
    3. Rhythm check and Defibrillate 4 J/kg (Call 'clear' and <10 second cardiac compression interruption)
  7. Cycle 7: Perfusing rhythm obtained
    1. Check for pulse (confirm not Pulseless Electrical Activity)
    2. Amiodarone maintenance to prevent recurrent arrhythmia
      1. Discuss indication and dosing with pediatric cardiology
    3. Initiate Induced Therapeutic Hypothermia protocol
      1. Discuss specific protocols with local experts
      2. Requires paralysis, Sedation and opioid Analgesics to prevent shivering

Images: Related links to external sites (from Google)

Ontology: Ventricular Fibrillation (C0042510)

Definition (NCI) An arrhythmia characterized by an irregular pattern of high or low-amplitude waves that cannot be differentiated into QRS complexes or T waves. These electrocardiographic waves occur as a result of fibrillary contractions of the ventricular muscle due to rapid repetitive excitation of myocardial fibers without coordinated contraction of the ventricle. (NCI)
Definition (NCI) A disorder characterized by a dysrhythmia without discernible QRS complexes due to rapid repetitive excitation of myocardial fibers without coordinated contraction of the ventricles.
Definition (NCI) Arrhythmia characterized by fibrillary contractions of the ventricular muscle due to rapid repetitive excitation of myocardial fibers without coordinated contraction of the ventricle.
Definition (CSP) arrhythmia characterized by fibrillary contractions of the ventricular muscle due to rapid repetitive excitation of myocardial fibers without coordinated contraction of the ventricle.
Definition (NCI) Arrhythmia characterized by fibrillary contractions of the ventricular muscle due to rapid repetitive excitation of myocardial fibers without coordinated contraction of the ventricle.
Definition (MSH) A potentially lethal cardiac arrhythmia that is characterized by uncoordinated extremely rapid firing of electrical impulses (400-600/min) in HEART VENTRICLES. Such asynchronous ventricular quivering or fibrillation prevents any effective cardiac output and results in unconsciousness (SYNCOPE). It is one of the major electrocardiographic patterns seen with CARDIAC ARREST.
Concepts Disease or Syndrome (T047)
MSH D014693
ICD9 427.41
ICD10 I49.01
SnomedCT 155371004, 71908006
English Fibrillations, Ventricular, Ventricular Fibrillations, FIBRILLATION PAROXYSMAL VENT, FIBRILLATION VENTRICULAR, Fibrillation, Ventricular, VENTRICULAR FIBRILLATION, VENTRICULAR FIBRILLATION PAROXYSM, Cardiac arrest-ventric fibrill, VF, VFib, Ventricular Fibrillation, ventricular fibrillation (diagnosis), ventricular fibrillation, Ventricular fibrillation paroxysm, Fibrillation paroxysmal vent, Paroxysmal ventricular fibrillation, Ventricular fibrillation paroxysmal, Fibrillation ventricular, Cardiac arrest and ventricular fibrillation, FIBRILLATION, VENTRICULAR, Ventricular Fibrillation [Disease/Finding], fibrillation ventricular, Fibrillation;ventricular, vf, Ventricular fibrillation, Cardiac arrest - ventricular fibrillation, VF - Ventricular fibrillation, Ventricular fibrillation (disorder), fibrillation; ventricular, ventricular; fibrillation
French FIBRILLATION VENTRICULAIRE, FV, Fibrillation ventriculaire paroxystique, Fibrillation paroxystique ventr, FIBRILLATION VENTRIC PAROXYSTIQUE, Fibrillation ventriculaire
Portuguese FIBRILACAO VENTRICULAR, Fibrilhação ventricular paroxística, FIBRILACAO VENTRICULAR PAROXISTIC, Fibrilhação ventricular, Fibrilação Ventricular
Spanish FIBRILACION VENTRICULAR, Fibrilación ventricular paroxística, FV, Ventricular fibrillation, FIBRILACION VENTRICULAR PAROXIST, fibrilación ventricular (trastorno), fibrilación ventricular, Fibrilación ventricular, Fibrilación Ventricular, Fibrilacion Ventricular
German KAMMERFLIMMERN, Kammerflimmern paroxysmal, VF, paroxysmales Kammerflimmern, KAMMERFLIMMERN PAROXYSMAL, Kammerflimmern
Dutch paroxysmale ventrikelfibrillatie, VF, ventrikelfibrilleren paroxysmaal, ventrikelfibrillatie, ventrikelfibrillatie-paroxysme, fibrilleren; ventrikel, ventrikel; fibrilleren, ventrikelfibrilleren, Fibrilleren, ventrikel-, Ventrikelfibrilleren
Italian Fibrillazione ventricolare parossistica, Fibrillazione ventricolare
Japanese 心室細動, 発作性心室細動, シンシツサイドウ, ホッサセイシンシツサイドウ
Swedish Kammarflimmer
Finnish Kammiovärinä
Russian ZHELUDOCHKOV FIBRILLIATSIIA, ЖЕЛУДОЧКОВ ФИБРИЛЛЯЦИЯ
Czech Fibrilace komor, Paroxysmální komorová fibrilace, Paroxysmální fibrilace komor, Komorová fibrilace, komorová fibrilace, FiK, fibrilace komor
Croatian FIBRILACIJA VENTRIKULA
Polish Migotanie komór
Hungarian Fibrillatio, ventricularis, Ventricularis fibrillatio, Paroxysmalis ventricularis fibrillatio, Paroxysmalis kamrai fibrillatio, VF, Paroxysmalis kamrafibrillatio, Ventricularis paroxysmalis fibrillatio