UMEM Educational Pearls

Category: Critical Care

Title: Keeping the Beat: Strategies in Shock Refractory VF

Keywords: Resuscitation, ventricular fibrillation, cardiac arrest, emergency, cardiology (PubMed Search)

Posted: 4/6/2013 by Ben Lawner, DO (Updated: 7/18/2019)
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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. 

 

References

 

1. EMS World Magazine online. "Hold the coroner!" 2011. Available at: 
http://www.emsworld.com/article/10318805/hold-the-coroner
2.  Hoch DH, Batsford WP, Greenberg SM, et al. Double sequential shocks for refractory ventricular fibrillation. J Am Coll Cardiol. 1994;23(5):1141-5
3. de Oliveira FC, Feitosa-Filho GS, Ritt LE. Use of beta blockers for the treatment of cardiac arrest due to ventricular fibrillation/pulseless ventricular tachycardia: a systematic review. Resuscitation. 2012;83(6):674-83
4. Patel RA, Priore DL, Szeto WY, et al, Left stellate ganglion blockade for the management of drug-resistant electrical storm. Pain medicine. 2011;12:1196-1198.
5. Kagawa E, Dote K, Sasaki S, et al. Should we emergently revascularize occluded coronaries for cardiac arrest? rapid response extracorporeal membrane oxygenation and intra-arrest percutaneous coronary intervention. Circulation. 2011;126(13):1605-13.