Refractory ventricular fibrillation management

Current ALS Guidelines recommends an intravenous injection of Amiodarone 300mg after 3 defibrillation attempts with Lidocaine 1mg kg-1 to be considered as an alternative.6

A systematic review by Ong et al. compared lidocaine, procainamide, amiodarone, bretylium and magnesium in refractory VF7. There is no conclusive evidence that anti-arrhythmic agents improve survival in cardiac arrest victims. While some agents have shown an improved survival to hospital admission, none have shown an improved survival to discharge or to an improved neurological survival.

A meta-analysis by Khan et al. investigated the relative efficacies of amiodarone, lidocaine, magnesium and placebo as treatments for pulseless VT or VF.8 Eleven studies of 5200 patients including 7 randomized trials (4,611 patients) and 4 non-randomized studies (589 patients) were included in this meta-analysis. This demonstrated that lidocaine had superior effects on survival to hospital discharge, compared to amiodarone (OR, 2.18, 95% CI 1.26–3.13), magnesium (OR, 2.03, 95% CI 0.74–4.82) and placebo (OR, 2.42, 95% CI 1.39–3.54).

Esmolol: a meta-analysis by Miraglia et al. found low grade evidence that esmolol increased survival to discharge, but concluded its effectiveness remained unclear.9

Double sequential external defibrillation: The DOSE-VF randomised pilot study by Cheskes et al. compared vector change defibrillation (VC) or double sequential defibrillation (DSED) to standard defibrillation in refractory VF. The results of this study will be used to inform a larger study but suggested rates of ROSC were higher in the VC and DSED group.10