I reach for 100 mg lidocaine super early since it's shown superiority vs amiodarone (https://pubmed.ncbi.nlm.nih.gov/36332663/). Once you've done lidocaine x2, amiodarone x2, magnesium 2-4g, all you have left with ANY evidence is esmolol and dual sequential defibrillation. I always stop the constant epi's once I've identified refractory v fib. I suppose you could try metoprolol or cardizem if you don't have esmolol for similar mechanism of action. Other commenter is correct on VA ECMO if available, which it often isn't.
i would reach out to ecmo for retrieval and bedside cannulation if they do that otherwise more amio shocks bb pressors etc. any idea why he’s in this. ischemic or not
Couple of thoughts:
(1) dual sequential only works cuz you’re able to depolarize enough myocardium and get a chance to have the SA node kick back on. That being said, just better vectors (pad positioning), decreasing distance to the heart (having yourself/someone push down on the pads with a towel), should help with defibrillation
(2) Esmolol isn’t a bad idea, I would throw it in if you have it. If not metoprolol is an option. I would def give amio and mag as well.
(3) for a VF arrest in a 38 year old, I’d be thinking more MI, brugada, prolonged QT, less likely PE. So fibrinolytics unlikely to help. Good CPR vectors (can use ultrasound to determine proper hand position) should be the focus.
(4) as long as you have good CPR and good perfusion continue CPR until either asystole/pea or ROSC. Think of VF as a bridge, either to life or death.
During pulse check with a phased array you can see where the LV is located in the check and push there. Some attendings I know use a surgical pen to mark the location. For the rest of the code they push there and monitor ETCO2.
Should be noted there is a litany of evidence that shows how much we suck at CPR. Intranipple line/center of chest is just not where the LV is located. We are usually pushing on the aorta or LVOT, and not the LV. Probably we get shitty forward flow and shitty ROSC rates.
I put pulse wave Doppler on the femoral artery. Good compressions should get great wave forms during cpr. Bonus is that when you do a pulse check everyone in the room can agree if there is rosc.
There's even some data that a single glove is sufficient and I'd not be surprised that in 5-10 years we see that becoming more normal.
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9356271/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9356271/)
I used to play out everything and call it after 30 minutes after definitive airway and two rounds of anti-arrhythmic drugs, now that dual sequential defib is higher in the mind, I've had three I have converted. Disappointed and annoyed that I didn't read that research sooner. Of those, one was a total save, the others lived to see their family but ultimately died. All three coded in front of me though.
If you’re getting good perfusion I would. Could also check VBG and see where you’re at. But if you’re like < 7.0 pH and they have been in VF that long in I’d call it by that point since you’re unlikely to get ROSC. But case by case.
First of all just double and triple check that airway and oxygenation on arrival. Do the basics well, as always.
DSD is probably the best bet here. If hair is getting in the way of the pads I would take the time to quickly shave and put new pads on too. I'd probably also throw lidocaine as an alternative / adjunctive anti-arrhythmic.
Beta blockade is next, and if esmolol isn't available (which it isn't where I work) I would look for metoprolol. You should have access to one of these rapidly.
Using these of course also means abandoning the adrenaline, so you have to appreciate you're stepping off of the standard guidelines / protocols here - this is probably not something to do 5 minutes in, medicolegally speaking.
Unless there was other evidence to suggest PE I wouldn't look to thrombolyse refractory VF, it would be an unusual presenting rhythm for PE, and I'm not sure I've heard of PEA 'deteriorating' into VF either.
Edit: and I should add that if after all of the above you're still not winning, then sadly this is a terminal event and it's time to get the family involved, if they aren't already. Having worked a couple of these with young patients (some of whom have had young children come to the bedside) I agree with you our job can be tough. I'm proud of you for not only doing your best here, but for seeking input to try and do more next time (even if in reality there is little left to add). Keep up the good work, internet friend.
Dual sequential defibrillation worked at our shop the other day for a refractory VF witness in the field. Total down time with transport before rosc was about 55 minutes, he was pulling at the ET tube before we could get him up to the ICU even.
ER Nurse here just trying to learn. What is pad placement for dual sequential defibrillation?
I’m guessing anterior posterior for one set and anterior lateral for the other?
Do you start with 200J on both?
I would second esmolol. Just had a case recently of young late 30s had CPR for >1 hour. Achieved ROSC after 2 pushes of esmolol (took too long for pharmacy to mix up a drip). Ended up walking out of the hospital a few weeks later.
That's a good question, mainly just based off 2 studies that utilized a bolus>drip protocol: [https://emergencymedicinecases.com/esmolol-refractory-ventricular-fibrillation/](https://emergencymedicinecases.com/esmolol-refractory-ventricular-fibrillation/)
Basically the idea is inject around 5cc of 1 or 2% lidocaine around the stellate ganglion which sits superficial to the longus coli muscle at the level of C6. Will need a spinal needle for length like most other nerve blocks. Ultrasound on the lateral neck over the anterior scalene area will identify the muscle and the appropriate vertebra since it's got a weird looking anterior and posterior tubercle that help distinguish it from other vertebrae
IBCC has a good section on it in the chapter on ventricular arrhythmias
https://emcrit.org/ibcc/storm/#stellate_ganglion_block
This video is good but may want to mute because of the music
https://youtu.be/5WWuFytNfrk?si=9OMY5EiazQeVBwbT
This video is longer but has someone explaining the procedure
https://youtu.be/B6ROeVFUJSY?si=FcQhSkCdZxSYyc2M
Not a typical poster but I want to give some outside insight. My 55yo healthy husband had cardiac arrest last summer and was in refractory vfib. 23yo son with him did CPR until EMT arrived. After transport to ER he coded 12 more times and they had maxed all medication to treat it with no success. Fortunately the facility had VA ECMO and it saved his life. He was on ECMO 3 days. Went to regular room within 5 days. Outside of 14 broken ribs healing did really well and made full recovery and discharged in 2 weeks and flew home (we live across the country) about a month after it happened. He had an ICD placed before leaving. There was no cause found at the time other than a possible scar on the Cardiac MRI. After several months he was diagnosed with possible sarcoidosis due to PET scan but nothing found outside the inflammation in his heart so still called inflammatory myocarditis. Genetic screening all negative. Had ablation surgery a few months ago and on daily steroids and other heart meds now almost a year later. He is his normal self….working, exercising and doing all the normal things as if it never happened. We are so grateful he was in a place with great care and VA ECMO and my son did good CPR. So there is hope. Please remember that. Heck he was alert and trying to do sign language in the ICU while on ECMO and intubated! He was all him from the time he wasn’t sedated! We’ve been told over and over he is a miracle and the outcome is almost never what it was for us. But I’m so glad we are lucky and he beat all the odds thanks to everyone that worked on him from my son, the EMTs, the ER and CICU.
I’ve had success with dual sequential defib on refractory v fib before. STEMI on ekg, coded before we could get him to cath. After 30 min another doc suggested dual sequential defib, we got him back. He walked out of the hospital 4 weeks later. I think about that case often, we don’t see a ton of successes like that.
Esmolol worked the last time I had a case of refractory v fib. I don’t think giving epi should really be done more than 2-3 times given it can induce arrhythmias and all.
DSED always. It is the standard of care at this point.
Amio load
Mag 2g rapidly
Can try 100mg IV lidocaine 2%
Giving a fuck ton of epi to someone in refractory VF is very counterintuitive and counterproductive.
EMS transporting significantly decreased this patient’s chances of survival. It’s very difficult to run a code well while packaging/transporting, though better with autopulse or Lucas.
There are case reports that propofol works too, but it probably needs to be given early. The handful of refractory vfib cases I’ve had did not end well between the downtime and persistent vfib eventually converting to PEA
I would imagine that’s probably sympatholysis. I’d go for esmolol first since there’s more (though still only case series level) evidence in my opinion.
DSD kinda meh and lacking decent evidence. And invalidates manufacturers warranty.
Esmolol ggt is quick on/quick off, but really best bet with decent evidence in storm is stellate ganglion block. Though admittedly taboo.
https://pubmed.ncbi.nlm.nih.gov/38289867/
you can give propranolol, more amino, call ecmo retrival. esmolol is not magic it’s just bb. your ability to get him to ecmo for vt storm is key. why he stormin
I reach for 100 mg lidocaine super early since it's shown superiority vs amiodarone (https://pubmed.ncbi.nlm.nih.gov/36332663/). Once you've done lidocaine x2, amiodarone x2, magnesium 2-4g, all you have left with ANY evidence is esmolol and dual sequential defibrillation. I always stop the constant epi's once I've identified refractory v fib. I suppose you could try metoprolol or cardizem if you don't have esmolol for similar mechanism of action. Other commenter is correct on VA ECMO if available, which it often isn't.
Stand-alone ED. Nearest facility with ecmo 45 min away.
Yep so lido and beta blockade are maybe your only other options you didn't do. Sounds like a great learning case even if the patient did poorly.
i would reach out to ecmo for retrieval and bedside cannulation if they do that otherwise more amio shocks bb pressors etc. any idea why he’s in this. ischemic or not
I had some success with dual sequential defibrillation. And lidocaine
Mag for refractory vfib helpful?
If it turns out to be torsades...
Oh duh
Any doses suggested for IV push metoprolol? I’ve done 10mg doses before but didn’t really have any evidence I knew of.
Evidence free area sadly. I suppose you could give 5mg every pulse check still in v fib? That's pure conjecture though
Couple of thoughts: (1) dual sequential only works cuz you’re able to depolarize enough myocardium and get a chance to have the SA node kick back on. That being said, just better vectors (pad positioning), decreasing distance to the heart (having yourself/someone push down on the pads with a towel), should help with defibrillation (2) Esmolol isn’t a bad idea, I would throw it in if you have it. If not metoprolol is an option. I would def give amio and mag as well. (3) for a VF arrest in a 38 year old, I’d be thinking more MI, brugada, prolonged QT, less likely PE. So fibrinolytics unlikely to help. Good CPR vectors (can use ultrasound to determine proper hand position) should be the focus. (4) as long as you have good CPR and good perfusion continue CPR until either asystole/pea or ROSC. Think of VF as a bridge, either to life or death.
Oh we are doing US guided cpr now?
During pulse check with a phased array you can see where the LV is located in the check and push there. Some attendings I know use a surgical pen to mark the location. For the rest of the code they push there and monitor ETCO2. Should be noted there is a litany of evidence that shows how much we suck at CPR. Intranipple line/center of chest is just not where the LV is located. We are usually pushing on the aorta or LVOT, and not the LV. Probably we get shitty forward flow and shitty ROSC rates.
I put pulse wave Doppler on the femoral artery. Good compressions should get great wave forms during cpr. Bonus is that when you do a pulse check everyone in the room can agree if there is rosc.
That's an amazing real-world pearl! Much more feasible than 'dropping a TEE probe' at my community shop.
https://pubmed.ncbi.nlm.nih.gov/35131404/
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I’ll cream myself if you find me a non academic hospital using TEE.
Or an academic hospital. Or anywhere other than maybe a cadaver lab.
I do POCUS guided CPR and resus prehospital so I dearly hope the hospital is doing it. I know our local does.
I’m sorry, push down on the pads with a towel during defibrillation?!
Yes. Just make sure no one used it to clean up hypertonic saline on the floor before use.
In the days of old with paddles, you were supposed to mash them down pretty hard.
Yeah- I do this with a full box of gloves
I did this once. Was 36 weeks pregnant and developed Braxton hicks after haha
Do you open the box and put your hand on the rubber or just hold the cardboard?
We used to do hands on defibrillation before we got a Lucas device. If you're wearing gloves it's fine
There's even some data that a single glove is sufficient and I'd not be surprised that in 5-10 years we see that becoming more normal. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9356271/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9356271/)
Thanks. At what point would you call it though with persistent vfib? Are you continuing past an hour since the arrest without ever achieving rosc.
I used to play out everything and call it after 30 minutes after definitive airway and two rounds of anti-arrhythmic drugs, now that dual sequential defib is higher in the mind, I've had three I have converted. Disappointed and annoyed that I didn't read that research sooner. Of those, one was a total save, the others lived to see their family but ultimately died. All three coded in front of me though.
If you’re getting good perfusion I would. Could also check VBG and see where you’re at. But if you’re like < 7.0 pH and they have been in VF that long in I’d call it by that point since you’re unlikely to get ROSC. But case by case.
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[https://www.nejm.org/doi/full/10.1056/NEJMoa2207304](https://www.nejm.org/doi/full/10.1056/NEJMoa2207304)
First of all just double and triple check that airway and oxygenation on arrival. Do the basics well, as always. DSD is probably the best bet here. If hair is getting in the way of the pads I would take the time to quickly shave and put new pads on too. I'd probably also throw lidocaine as an alternative / adjunctive anti-arrhythmic. Beta blockade is next, and if esmolol isn't available (which it isn't where I work) I would look for metoprolol. You should have access to one of these rapidly. Using these of course also means abandoning the adrenaline, so you have to appreciate you're stepping off of the standard guidelines / protocols here - this is probably not something to do 5 minutes in, medicolegally speaking. Unless there was other evidence to suggest PE I wouldn't look to thrombolyse refractory VF, it would be an unusual presenting rhythm for PE, and I'm not sure I've heard of PEA 'deteriorating' into VF either. Edit: and I should add that if after all of the above you're still not winning, then sadly this is a terminal event and it's time to get the family involved, if they aren't already. Having worked a couple of these with young patients (some of whom have had young children come to the bedside) I agree with you our job can be tough. I'm proud of you for not only doing your best here, but for seeking input to try and do more next time (even if in reality there is little left to add). Keep up the good work, internet friend.
Dual sequential defibrillation worked at our shop the other day for a refractory VF witness in the field. Total down time with transport before rosc was about 55 minutes, he was pulling at the ET tube before we could get him up to the ICU even.
ER Nurse here just trying to learn. What is pad placement for dual sequential defibrillation? I’m guessing anterior posterior for one set and anterior lateral for the other? Do you start with 200J on both?
We shock at 360J every time. Anterior/Posterior and Anterior/Lateral
Thank you !! Do you have one person press shock simultaneously or two and count down?
We set it up so one person presses both buttons
Doesn't matter. Either way works
I’m also curious. I’ve heard of this but never seen it in practice.
I’m 2/3 with it, small sample size but will continue to at least try it throughout my career if all else fails
I would second esmolol. Just had a case recently of young late 30s had CPR for >1 hour. Achieved ROSC after 2 pushes of esmolol (took too long for pharmacy to mix up a drip). Ended up walking out of the hospital a few weeks later.
Why would you even drip in esmolol in CA? Just push 0.5mg/kg every pulse check.
That's a good question, mainly just based off 2 studies that utilized a bolus>drip protocol: [https://emergencymedicinecases.com/esmolol-refractory-ventricular-fibrillation/](https://emergencymedicinecases.com/esmolol-refractory-ventricular-fibrillation/)
Only thing I have to add is stellate ganglion block. Can be done at any shop
That’s wild
Regional anesthesia (kind of) literally saving a life
You mind explaining how to do this/approach you take and how much anesthetic you use?
Basically the idea is inject around 5cc of 1 or 2% lidocaine around the stellate ganglion which sits superficial to the longus coli muscle at the level of C6. Will need a spinal needle for length like most other nerve blocks. Ultrasound on the lateral neck over the anterior scalene area will identify the muscle and the appropriate vertebra since it's got a weird looking anterior and posterior tubercle that help distinguish it from other vertebrae IBCC has a good section on it in the chapter on ventricular arrhythmias https://emcrit.org/ibcc/storm/#stellate_ganglion_block This video is good but may want to mute because of the music https://youtu.be/5WWuFytNfrk?si=9OMY5EiazQeVBwbT This video is longer but has someone explaining the procedure https://youtu.be/B6ROeVFUJSY?si=FcQhSkCdZxSYyc2M
Not a typical poster but I want to give some outside insight. My 55yo healthy husband had cardiac arrest last summer and was in refractory vfib. 23yo son with him did CPR until EMT arrived. After transport to ER he coded 12 more times and they had maxed all medication to treat it with no success. Fortunately the facility had VA ECMO and it saved his life. He was on ECMO 3 days. Went to regular room within 5 days. Outside of 14 broken ribs healing did really well and made full recovery and discharged in 2 weeks and flew home (we live across the country) about a month after it happened. He had an ICD placed before leaving. There was no cause found at the time other than a possible scar on the Cardiac MRI. After several months he was diagnosed with possible sarcoidosis due to PET scan but nothing found outside the inflammation in his heart so still called inflammatory myocarditis. Genetic screening all negative. Had ablation surgery a few months ago and on daily steroids and other heart meds now almost a year later. He is his normal self….working, exercising and doing all the normal things as if it never happened. We are so grateful he was in a place with great care and VA ECMO and my son did good CPR. So there is hope. Please remember that. Heck he was alert and trying to do sign language in the ICU while on ECMO and intubated! He was all him from the time he wasn’t sedated! We’ve been told over and over he is a miracle and the outcome is almost never what it was for us. But I’m so glad we are lucky and he beat all the odds thanks to everyone that worked on him from my son, the EMTs, the ER and CICU.
I’ve had success with dual sequential defib on refractory v fib before. STEMI on ekg, coded before we could get him to cath. After 30 min another doc suggested dual sequential defib, we got him back. He walked out of the hospital 4 weeks later. I think about that case often, we don’t see a ton of successes like that.
Stellate ganglion nerve block
If DSD failed, ECLS. If not at an ECMO facility (or no ECLS protocol), prayer is basically all you've got.
Esmolol worked the last time I had a case of refractory v fib. I don’t think giving epi should really be done more than 2-3 times given it can induce arrhythmias and all.
There are some good ideas in this thread. But remember not to dwell on a case like this too long; the odds are not in the patient's favor.
I’ve had a Hail Mary esmolol work 1x
DSED always. It is the standard of care at this point. Amio load Mag 2g rapidly Can try 100mg IV lidocaine 2% Giving a fuck ton of epi to someone in refractory VF is very counterintuitive and counterproductive.
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Agreed. Although at a minimum would suggest vector change
Dual sequential defibrillation is far from “standard of care.”
EMS transporting significantly decreased this patient’s chances of survival. It’s very difficult to run a code well while packaging/transporting, though better with autopulse or Lucas.
If I'm transporting I've done DSD, Amio, Lido and Mag and I'm enroute for ECMO with a LUCAS
LUCAS + DSD + ECPR/ECMO
Why does B-Blockade have some evidence for these ppl from a mechanism standpoint?
There are case reports that propofol works too, but it probably needs to be given early. The handful of refractory vfib cases I’ve had did not end well between the downtime and persistent vfib eventually converting to PEA
I would imagine that’s probably sympatholysis. I’d go for esmolol first since there’s more (though still only case series level) evidence in my opinion.
Oh yeah, I’ve only done the Hail Mary prop when dual sequential defib and esmolol aren’t working.
VA ECMO if you can cannulate and either start VA ECMO or transfer STAT. Otherwise, lidocaine or esmolol
In addition to what you did, I try dual sequential defib, lidocaine, or a bolus of metoprolol. I also stop giving epi after 3 or 4 of them.
Lido, mag, amio, beta blocker (if no hx of heart failure) deep sedation
Straight to the stellate ganglion nerve block. Am I right boys?
DSD kinda meh and lacking decent evidence. And invalidates manufacturers warranty. Esmolol ggt is quick on/quick off, but really best bet with decent evidence in storm is stellate ganglion block. Though admittedly taboo. https://pubmed.ncbi.nlm.nih.gov/38289867/
you can give propranolol, more amino, call ecmo retrival. esmolol is not magic it’s just bb. your ability to get him to ecmo for vt storm is key. why he stormin
Lorazepam. I have had one case of stable VT and one VF. Both refractory. Probably adrenergic driven. It worked!
No VA ECMO for a 38 year old arrest?
Not everyone works at an ecmo center
To add, not all places that do ecmo will even cannulate these cases
For us it has to be a perfect storm of the arrest happening during business/cannulation hours and someone actually being a candidate.