image by: Tabitha Hartman
He has no pulse, so you start chest compressions. Initial rhythm is PEA so you give epinephrine and continue compressions as the patient is successfully intubated. The second rhythm shows ventricular fibrillation (VF). You think to yourself, “Great this guy might actually have a chance!” You’re feeling pretty good as you administer a shock and then resume compressions. It’s time for the next rhythm and pulse check, and the rhythm is still VF. You shock again, resume CPR, give epinephrine, and ask the nurse to pull up amiodarone 300mg as you anxiously await the next check. Rhythm is still VF.
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The use of a second defibrillator with separate pairs of electrodes allows 400 J of biphasic energy to be applied to depolarize a critical amount of myocardium. First described by in animal models by Geddes (4) in 1976, and then by Hoch (1) in 1994. He found that patients who developed refractory ventricular fibrillation during electrophysiology procedures had restoration of regular rhythm.
Given the difficulty in converting RVF to a perfusing rhythm, here are a few strategies beyond the standard therapy to add to your toolbox.
The evidence for esmolol in refractory Ventricular Fibrillation isn’t the greatest – no big RCTs to be certain. 500mcg/kg IV bolus followed by a drip of a maximum of 100mcg/kg/minunte
A small proportion of these patients will have refractory VF/VT OHCA not treatable by standard ACLS guidelines. One possible modality for these patients is extracorporeal membrane oxygenation (ECMO, followed by immediate coronary angiography and percutaneous coronary intervention (PCI). How would this ECMO-facilitated resuscitation strategy fair when applied in a US metropolitan community?
Dosing esmolol for refractory VF: 500mcg/kg bolus, followed by drip (max typically 1000 mcg/kg/min).
These refractory VF patients likely need a cardiac catheterization more than anything else. The more you can do in the ER to stabilize them to revascularization of the vessel that precipitated their refractory VF electrical storm, the better. Esmolol should be a strong consideration in these rare situations.
Electrical storm is frequently associated with a catecholamine surge, either as the cause of the arrythmias, or as a result of the frequent shocks and underlying etiology. Treatment is aimed at counteracting that sympathetic tone, which includes analgesia, sedation, and beta-blockers.
Esmolol is the only drug in the management of cardiac arrest that has shown an increased rate of survival to hospital discharge with favorable neurologic outcomes. Albeit in a small study, patients who received esmolol after three defibrillations and 3 mg of epinephrine had a 50 percent survival to hospital discharge with a favorable neurologic outcome compared to 11 percent of patients who did not receive esmolol.4
Stellate ganglion blockade has been used for over a century to decrease sympathetic tone to the heart.
You’ve shocked this guy 4-5 times and he still has VF and occasionally what looks like pulseless VT. Do you just keep shocking this guy?! Answer: = Yes.. and maybe even give a double shock. DOUBLE SHOCK????
For those of us in the trenches of the emergency department, we have to think beyond ACLS at times. Although VF typically responds very well to the standard energies of defibrillation, maybe in patients with higher body mass index or morbid obesity we need higher energies to achieve successful defibrillation.