Refractory VF

As we all know, rapid and effective resuscitation makes a huge difference to the chance of survival from a cardiac arrest.

If you’re going to pick a rhythm to have as the patient or as the Resuscitationist, then it’s going to be a shockable rhythm, so VF or pulseless VT as they hold the greatest chance of survival. You’ll find an initial shockable rhythm in around 20% of cases & defibrillation alone may lead to a ROSC. So it’s absolutely imperative to get the immediate management spot on!

Whilst current practice is good, there are some aspects of care that we can improve on and make a real difference to outcomes in these patients, with those first on scene or at the bedside in a phenomenally important position to deliver life saving care.

In this episode we’ll be talking predominantly about refractory VF but the strategy will transfer to how we can also deal with refractory VT cardiac arrests. 

We’ll be running through all of the following;

• VF incidence
• Mechanisms behind VF
• Refractory and recurrent VF
• Defibrillation strategies
• Pharmacological strategies
• PCI in arrest
• ECMO

Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon, Rob & James

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References

Epidemiology and genetics of ventricular fibrillation during acute myocardial infarction. Glinge. J Geriatr Cardiol. 2016

Mechanisms of VF maintenance: Wandering wavelets, mother rotors, or foci. Tableaux. Heart Rhythm. 2009

Ventricular Arrhythmias in First Acute Myocardial Infarction: Epidemiology, Mechanisms, and Interventions in Large Animal Models. Sattler. Front Cardiovasc Med. 2019

Epidemiology and outcomes from out-of-hospital cardiac arrests in England. Hawkes. Resuscitation. 2016

Ventricular Fibrillation. Ludhwani. StatPearls. 2023

Incidence and outcome of in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit. Nolan. Resuscitation. 2016

Cardiac Arrest Annual Report: 2018/19; London Ambulance Service. 2019

Resuscitation after cardiac arrest: a 3-phase time-sensitive model. Weisfeldt. JAMA. 2002

Abstract 419: Incidence of True Refractory Ventricular Fibrillation in Patients Meeting a Pragmatic Definition of Refractory Ventricular Fibrillation. Verkaik. Criculation. 2023

Comparing Drugs for Out-of-hospital, Shock-refractory Cardiac Arrest: Systematic Review and Network Meta-analysis of Randomized Controlled Trials. Srisurapanont. West J Emerg Med. 2021

2018 American Heart Association Focused Update on Advanced Cardiovascular Life Support Use of Antiarrhythmic Drugs During and Immediately After Cardiac Arrest: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Panchal. AHA. 2018

Defibrillation Strategies for Refractory Ventricular Fibrillation. Cheskes. NEJM. 2023

RCUK; Defibrillation strategies for refractory ventricular fibrillation including double sequential external defibrillation (DSED)

Beta-blockade for the treatment of cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia: A systematic review and meta-analysis. Gottlieb. Resuscitation. 2020

Thrombolysis during resuscitation for out-of-hospital cardiac arrest. Bottinger. NEJM. 2008

Successful percutaneous coronary intervention during cardiac arrest with use of an automated chest compression device: a case report. Libungan. There Clin Risk Manag. 2014

Cardiopulmonary Resuscitation With Mechanical Chest Compression Device During Percutaneous Coronary Intervention. A Case Report. Ujvarosy. Front Cardiovasc Med. 2021

Intra-arrest percutaneous coronary intervention: a case series. Balevski. Wein Kin Wochenschr. 2015 

Early Extracorporeal CPR for Refractory Out-of-Hospital Cardiac Arrest. Sovereign. NEJM. 2023

Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Immediate Invasive Assessment and Treatment on Functional Neurologic Outcome in Refractory Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. Belohlavek. JAMA. 2022

Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. Yannopolous. Lancet. 2020

Early extracorporeal CPR for refractory out-of-hospital cardiac arrest – A pre-planned per-protocol analysis of the INCEPTION-trial. Ubben. Resuscitation. 2023

Supraglottic airway devices are associated with asphyxial physiology after prolonged CPR in patients with refractory Out-of-Hospital cardiac arrest presenting for extracorporeal cardiopulmonary resuscitation. Bartos. Resuscitation. 2023

A randomized trial of expedited intra-arrest transfer versus more extended on-scene resuscitation for refractory out of hospital cardiac arrest: Rationale and design of the EVIDENCE trial. Burns. Am Heart J. 2024

LITFL; Ventricular Fibrillation

Mononmorphic VT Storm; IBCC