Emergency Medicine is Hard

What is refractory VFib?

Refractory (or recurrent) VF, defined as VF still present after 5 shocks

What is the most common cause of refractory VFib?

Majority caused by acute coronary occlusion and therefore definitive care is usually PCI

What are my options?

1. Early epinephrine (1mg q3-5min)
   • To improve blood pressure and flow to the coronary and cerebral circulation so as to enhance the likely restoration of circulation and to reduce brain injury
   • Will drive up lactic acid which is associated with worse outcomes
2. Dual sequential external defibrillation
3. Amiodarone (First dose: 300mg; second dose: 150mg)
4. Lidocaine (First dose: 1-1.5 mg/kg; second dose: 0.5-0.75 mg/kg)
5. Esmolol (500 mcg/kg bolus, followed by a continuous infusion of up to 100 mcg/kg/min)
   • A more recent review article looked at two retrospective studies with a combined total of 66 patients who were given esmolol in the treatment of refractory VT or VF. These studies were small but did suggest significantly higher rates of return of spontaneous circulation in the esmolol group compared to standard care.
6. Extracorporeal membrane oxygenation (ECMO)