Ventricular Fibrillation Management in the Adult

Aka: Ventricular Fibrillation Management in the Adult, Pulseless Ventricular Tachycardia Management in the Adult, Refractory Ventricular Fibrillation Management

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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. Mechanical CPR devices (Lucas, Vest-CPR, Auto-pulse) are preferred if available
  3. Defibrillation options (single shock)
    1. Manual biphasic: Device specific dose (120-200 J) or
    2. Automated External Defibrillator (AED) or
    3. Monophasic 360 joules
  4. Secure cardiopulmonary access
    1. See Cardiopulmonary Resuscitation
    2. Hyperventilate with 100% oxygen
    3. Endotracheal Intubation
    4. Obtain Intravenous Access
  5. Cycles
    1. Perform 5 cycles of CPR (30:2) 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. Rotate compressors every 2 minutes
    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
        1. First dose after the second Defibrillation
        2. Repeat every 3-5 minutes
        3. May substitute all Epinephrine doses (for at least 20 minutes) with a single Vasopressin dose once
      3. Amiodarone
        1. First dose after the third Defibrillation
        2. Repeat once after the fifth Defibrillation
        3. May substitute with Lidocaine only if Amiodarone unavailable
  6. Refractory Ventricular Fibrillation (failed response to 3 or more Defibrillation attempts)
    1. Move pads
      1. Move anteroposterior Defibrillation pads to anterolateral placement (or vice versa)
    2. Dual Simultaneous Defibrillation
      1. Place Defibrillation pads in anteroposterior position and anterolateral position
      2. Discharge both Defibrillators simultaneously
      3. Cheskes (2020) Resuscitation 150:178-84 [PubMed]
    3. Sympathetic overdrive suppression
      1. Esmolol infusion
      2. Left Stellate Ganglion Block
        1. Linear Ultrasound probe in transverse position left lateral neck over carotid/internal jugular
        2. Landmarks: Longus coli Muscle, C6-7 transverse process
        3. Spinal needle (22 gauge) inserted from lateral to medial
          1. Needle directed through the anterior scalene Muscle and deep to the Carotid Artery
          2. Inject 5 cc Lidocaine just superficial to the longus coli Muscle
        4. Video: Ultrasound guided stellate Ganglion block
          1. https://www.youtube.com/watch?v=B6ROeVFUJSY
      3. References
        1. Swaminathan and She (2024) Stellate Ganglion Block in Ventricular Fibrillation, EM:Rap, 7/31/2024

III. Management: Medications (after IV or IO Access obtained)

  1. Adrenergic Medication
    1. Vasopressin 40 Units IV for single, one time dose, replacing either the first or second Epinephrine dose OR
    2. Epinephrine 1 mg IV push (repeat every 3-5 min) or
      1. Do not use Epinephrine for 20 minutes after Vasopressin
      2. Avoid Escalating or high dose Epinephrine (e.g. 3 or 5 mg)
  2. Antiarrhythmic medication (choose one)
    1. Amiodarone (preferred)
      1. Dose 1: 300 mg IV push
      2. Dose 2: 150 mg IV push
      3. Maximum cumulative dose: 2.2 grams in 24 hours
      4. Requires pressure support after use
    2. Lidocaine (only use if Amiodarone is unavailable)
      1. Contrasted with Amiodarone, not shown to improve survival
      2. Dose 1: 1.0 to 1.5 mg/kg IV push
      3. Dose 2: 0.5 to 0.75 mg/kg IV push
      4. Maximum cumulative dose: 3 mg/kg
  3. Consider adjunctive medications (specific indications)
    1. Avoid Sodium Bicarbonate as does not improve survival (out of ECC guidelines as of 2010)
    2. Magnesium Sulfate
      1. Dose: 1-2 g IV
      2. Indications
        1. Irregular, Polymorphic VT (Torsades de Pointes)
        2. Suspected Hypomagnesemia

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

  1. Assess Vital Signs
  2. Support Airway and breathing
  3. Consider medications
    1. Infusion of Antiarrhythmic that converted rhythm
  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

V. Management: Example

  1. Cycle 1
    1. Perform 5 cycles of CPR (30:2) for total of 2 minutes
    2. Obtain IV Access concurrent with CPR
    3. Rhythm check and Defibrillate (Call 'clear' and <10 second cardiac compression interruption)
    4. Rotate compressor
  2. Cycle 2
    1. Perform 5 cycles of CPR (30:2) for total of 2 minutes
    2. Place Advanced Airway concurrent with CPR
    3. Apply mechanical CPR device (e.g. Lucas, Vest-CPR, Auto-pulse) if available (<10 second CPR interruption)
    4. Rhythm check and Defibrillate (Mechanical CPR device, such as Lucas, need not be stopped for Defibrillation)
  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 1 mg IV
    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. Cycle 4
    1. Perform CPR for 2 minutes
    2. Administer Amiodarone 300 mg IV
    3. Rhythm check and Defibrillate
  5. Cycle 5
    1. Perform CPR for 2 minutes
    2. Administer Vasopressin 40 U IV
    3. Rhythm check and Defibrillate
  6. Cycle 6
    1. Perform CPR for 2 minutes
    2. Administer Amiodarone 150 mg IV
    3. Rhythm check demonstrates organized rhythm (e.g. Sinus Bradycardia)
  7. Cycle 7
    1. Check for pulse (confirm not Pulseless Electrical Activity)
    2. Amiodarone maintenance to prevent recurrent Arrhythmia
      1. Initial: 1 mg/min for 6 hours
      2. Next: 0.5 mg/min up to total cummulative dose not more than 2.2 grams
    3. Post-Resuscitation
      1. See Induced Therapeutic Hypothermia
      2. See Post-Cardiac Arrest Care

VI. References

  1. Cardiopulmonary Resuscitation Guidelines
    1. http://www.circulationaha.org
    2. (2010) Guidelines for CPR and ECC [PubMed]
    3. (2005) Circulation 112(Suppl 112):IV [PubMed]
    4. (2000) Circulation, 102(Suppl I):86-9 [PubMed]

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