Definition
- VF which persiste ≥3 shocks
- Recurrent VF (recurs during following PCR cycle) [1]
Epidemiology
- 5.6/100,000 population
- 42.6% of OOHCA with initial shockable rhythm [2]
- 63% of OOHCA with VF [3]
Causes [4]
- Myocardial infarction
- Cardiomyopathy
- Congenital QT abnormalities
- Brugada syndrome
- Severe metabolic acidosis
- Electrolyte abnormalities (↓K+, ↑K+, ↓Mg2+)
- Hypothermia
- Hypoxia
Factors affecting survival
Lower rates of refractory VF and higher survival to hospital discharge if:
- Witnessed arrest by EMS
- Defibrillation with AED pre-EMS arrival
- Bystander CPR
Management of refractory VF
- Initial management as per ACLS
- High quality CPR
- Adequate ventilation
- Early defibrillation
- Adrenaline 1mg IV after 2nd shock & @ 3-5 min
- Amiodarone 300mg IV after 3rd shock &
- Amiodarone 150mg IV after 5th shock
- Consider Esmolol to ↓sympathetic drive [5]:
- Bolus 500mcg/kg then infusion of 50-100mcg/kg/min
- Consider US guided stellate ganglion block [6]
No ROSC after 3 shocks
Consider alt. defib. strategies:
- Vector change:
- Single defibrillator
- Move pads to AP position
- Double Sequential External Defib. (DSED):
- 2 defibrillators delivering sequential high-energy shocks
- Pads placed in both antero-lateral (AL) and AP positions
- Single operator activating the defibrillators in sequence
- Aim to overcome high defibrillation thresholds
DOSE-VF trial [7] (2022): Supported DSED: Survival to discharge: DSED 30% vs 22% in vector change group, neurological outcome significantly higher in DSED group.
Links
References
- Bas J Verkaik, Robert G Walker, Tyson G Taylor, Mette M Ekkel, Rob Marx, Remy Stieglis, Vera G M van Eeden, Lotte C Doeleman, Michiel Hulleman, Fred W Chapman, Hans van Schuppen, Christian van der Werf, Defibrillation and refractory ventricular fibrillation, European Heart Journal, Volume 46, Issue 6, 7 February 2025, Pages 582–584
- Alhenaki A, Alqudah Z, Williams B, Nehme E, Nehme Z. Temporal trends in the incidence and outcomes of shock-refractory ventricular fibrillation out-of-hospital cardiac arrest. Resusc Plus. 2024 Mar 8;18:100597
- Coult J, Yang BY, Kwok H, Kutz JN, Boyle PM, Blackwood J, Rea TD, Kudenchuk PJ. Prediction of Shock-Refractory Ventricular Fibrillation During Resuscitation of Out-of-Hospital Cardiac Arrest. Circulation. 2023 Jul 25;148(4):327-335
- Ludhwani D, Goyal A, Jagtap M. Ventricular Fibrillation. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan
- Driver BE, Debaty G, Plummer DW, Smith SW. Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with refractory ventricular fibrillation. Resuscitation. 2014 Oct;85(10):1337-41
- Wittwer ED, Radosevich MA, Ritter M, Cha YM. Stellate Ganglion Blockade for Refractory Ventricular Arrhythmias: Implications of Ultrasound-Guided Technique and Review of the Evidence. J Cardiothorac Vasc Anesth. 2020 Aug;34(8):2245-2252
- Cheskes S, Verbeek PR, Drennan IR, McLeod SL, Turner L, Pinto R, Feldman M, Davis M, Vaillancourt C, Morrison LJ, Dorian P, Scales DC. Defibrillation Strategies for Refractory Ventricular Fibrillation. N Engl J Med. 2022 Nov 24;387(21):1947-1956