Category: Critical Care
Keywords: Resuscitation, ventricular fibrillation, cardiac arrest, emergency, cardiology (PubMed Search)
Recent advances in resuscitation science have enabled emergency physicians to identify factors associated with good neurologic and survival outcomes. Cases of persistent ventricular dysrhythmia (VF or VT) present a particular challenge to the critical care provider. The evidence base for interventions in shock refractory ventricular VF mainly consists of case reports and retrospective trials, but such interventions may be worth considering in these difficult resuscitation situations:
1. Double sequential defibrillation
-For shock-refractory VF, 2 sets of pads are placed (anterior/posterior and on the anterior chest wall). Shocks are delivered as "closely as possible."1,2
2. Sympathetic blockade in prolonged VF arrest
-"Eletrical storm," or incessant v-fib, can complicate some arrests in the setting of VF. An esmolol bolus and infusion may be associated with improved survival.3 Left stellate ganglion blockade has been identified as a potential treatment for medication resistant VF.4
3. Don't forget about magnesium!
-May terminate VF due to a prolonged QT interval
4. Invasive strategies
-Though resource intensive, there is limited experience with intra-arrest PCI and extracorporeal membrane oxygenation. Preestablished protocols are key to selecting patients who may benefit from intra-arrest PCI and/or ECMO. 5
5. Utilization of mechanical CPR devices
-Though mechanical CPR devices were not officially endorsed by the AHA/ECC 2010 guidelines, there's little question that mechanical compression devices address the complication of provider fatigue during ongoing resuscitation.