II. Management: Approach
- ABC Management
- CPR until Defibrillator available
- Good quality Cardiac Compressions are critical for survival (ROSC)
- Consider 5 cycles CPR (2 min) before defibrillating
-
Defibrillation options (single shock)
- Manual Defibrillator
- First: 2-4 J/kg
- Subsequent: 4 J/kg
- Maximum: 10 J/kg or up to adult dose
- AED (age 1 year or older)
- Child system is preferred if available ages 1-8
- Manual Defibrillator
- Secure cardiopulmonary access
- See Cardiopulmonary Resuscitation
- Ventilate with 100% oxygen
- Endotracheal Intubation
- Obtain Intravenous Access
- Cycles
- Perform 5 cycles of CPR (15:2 if two providers) for total of 2 minutes
- Once Advanced Airway in place, give 8-10 breaths per minute (every 6-8 min) and compressions >100/minute asynchronously
- Re-evaluate rhythm with minimum interruption of Cardiac Compressions (<10 seconds)
- Organized Electrical activity: Check for pulse
- Non-shockable rhythm: See Other protocols
- Shockable rhythm: Defibrillate
- Ventricular Fibrillation
- Pulseless Ventricular Tachycardia (V. fib or V. Tach)
- Repeat Defibrillation as above after each cycle
- Call clear
- Compressions need not be interrupted if mechanical CPR device is in place
- Administer medications once IV or IO Access obtained (see below)
- Administer during Cardiac Compressions (between Defibrillations)
- Epinephrine (every 3-5 minutes)
- First dose after second Defibrillation
- IV/IO: 0.01 mg/kg (0.1 ml/kg of 1:10,000) up to 1 mg IV
- ET: 0.1 mg/kg (0.1 ml/kg of 1:10,000) up to 2.5 mg via ET
- Amiodarone (up to 3 doses)
- Dose: 5 mg/kg up to a maximum of 300 mg for a single dose
- First dose after the third Defibrillation
- May repeat up to 2 additional doses
- Adjunctive medications
- Magnesium Sulfate
- Dose: 25 to 50 mg/kg IV or IO
- Indications
- Polymorphic VT (Torsades de Pointes)
- Suspected Hypomagnesemia
- Magnesium Sulfate
- Perform 5 cycles of CPR (15:2 if two providers) for total of 2 minutes
III. Management: Post Return of Spontaneous Circulation (ROSC)
- Assess Vital Signs
- Support Airway and breathing
- Consider maintaining Antiarrhythmic medications
- Infusion of Antiarrhythmic that converted rhythm
- Discuss with pediatric cardiology
- Pursue definititive management of underlying cause
- Initiate Hypothermia protocol
- Improves longterm CNS recovery post-hypoxic event
IV. Management: Example
- Cycle 1
- Perform 5 cycles of CPR (15:2) for total of 2 minutes
- Obtain IV Access concurrent with CPR
- Rhythm check and Defibrillate 2 J/kg (Call 'clear' and <10 second cardiac compression interruption)
- Cycle 2
- Perform 5 cycles of CPR (15:2) for total of 2 minutes
- Place Advanced Airway concurrent with CPR
- Rhythm check and Defibrillate 4 J/kg (Call 'clear' and <10 second cardiac compression interruption)
- Cycle 3
- Perform CPR for 2 minutes (If Advanced Airway, give asynchronously 8-10 breaths per minute and >100 compressions/min)
- Administer Epinephrine 0.01 mg/kg IV up to 1 mg IV maximum
- Treat reversible cause (e.g. contact catheterization lab if Acute Coronary Syndrome suspected)
- With mechanical CPR device in place, inter-hospital transport is viable despite lack of ROSC
- Rhythm check and Defibrillate 4 J/kg (Call 'clear' and <10 second cardiac compression interruption)
- Cycle 4
- Perform CPR for 2 minutes
- Administer Amiodarone 5 mg/kg IV up to 300 mg IV maximum
- Rhythm check and Defibrillate 4 J/kg (Call 'clear' and <10 second cardiac compression interruption)
- Cycle 5
- Perform CPR for 2 minutes
- Administer Epinephrine 0.01 mg/kg IV up to 1 mg IV maximum
- Rhythm check and Defibrillate 4 J/kg (Call 'clear' and <10 second cardiac compression interruption)
- Cycle 6
- Perform CPR for 2 minutes
- Administer Amiodarone 5 mg/kg IV up to 300 mg IV maximum
- Rhythm check and Defibrillate 4 J/kg (Call 'clear' and <10 second cardiac compression interruption)
- Cycle 7: Perfusing rhythm obtained
- Check for pulse (confirm not Pulseless Electrical Activity)
- Amiodarone maintenance to prevent recurrent Arrhythmia
- Discuss indication and dosing with pediatric cardiology
- Initiate Induced Therapeutic Hypothermia protocol
- Discuss specific protocols with local experts
- Requires paralysis, sedation and Opioid Analgesics to prevent shivering
V. References
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Related Studies
| Definition (NCI_FDA) | 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) | A disorder characterized by an electrocardiographic finding of a rapid grossly irregular ventricular rhythm with marked variability in QRS cycle length, morphology, and amplitude. The rate is typically greater than 300 bpm. (CDISC) |
| Definition (NCI_CTCAE) | 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_CDISC) | Ventricular Fibrillation is characterized by rapid, usually more than 300 bpm (cycle length: 180 ms or less), grossly irregular ventricular rhythm with marked variability in QRS cycle length, morphology, and amplitude. |
| 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 (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 |
| LNC | LA17073-0 |
| English | Fibrillations, Ventricular, Ventricular Fibrillations, FIBRILLATION VENTRICULAR, Fibrillation, Ventricular, 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, Ventricular Fibrillation [Disease/Finding], fibrillation ventricular, Fibrillation;ventricular, vf, VENTRICULAR FIBRILLATION, FIBRILLATION, VENTRICULAR, 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, FIBRILACION VENTRICULAR PAROXIST, fibrilación ventricular (trastorno), fibrilación ventricular, Fibrilación ventricular, Fibrilación 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, ｼﾝｼﾂｻｲﾄﾞｳ, ﾎｯｻｾｲｼﾝｼﾂｻｲﾄﾞｳ |
| 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 |
| Norwegian | Ventrikkelflimmer, Fibrillatio ventriculorum |
