History:  A patient in their mid-60’s with no known medical history is brought to the ER for collapse 40 minutes ago.  The wife heard him fall.  He has been shocked 7 times for VF, given epi x4 and amio 300mg, but is still in V-fib.

.Exam:  GCS 3 but clenching teeth and breathing spontaneously at a reasonable rate, CPR by Lucas device.  US shows no free fluid in the abdomen and at pulse check no pericardial effusion and a heart in VF with no peripheral pulses.

After 5mg of IV metoprolol and dual sequential defibrillation he gets ROSC.  His ECG is shown below

An ECG is done

What are potentially life-saving treatment options for refractory VF?

  • A) Dual sequential defibrillation
  • B) Beta-blockers
  • C) Stellate ganglion nerve block
  • D) Vector change defibrillation
  • E) All of the above

<<<<<<<<<<<<<<<<<<<<< ADVERTISEMENT & SPACER >>>>>>>>>>>>>>>>>>>>>

THE EMERGENCY MEDICINE POCKETBOOK TRIFECTA

Emergency Medicine 1-Minute Consult, 5th edition

A-to-Z EM Pharmacopoeia & Antibiotic Guide, NEW 5th edition

8-in-1 Emergency Department Quick Reference, NEW 5th edition 

******************************************************************************

Check out our weekly Wednesday EM Case Challenge

We are currently posting on Facebook (ERpocketbooks.com) & Twitter (@EM1MinuteGuru) twice a month

 

<<<<<<<<<<<<<<<<<<<<<<<<< END SPACER >>>>>>>>>>>>>>>>>>>>>>>>>

QUIZ ANSWER: What are potentially life-saving treatment options for refractory VF?

  • A) Dual sequential defibrillation
  • B) Beta-blockers
  • C) Stellate ganglion nerve block
  • D) Vector change defibrillation
  • E) All of the above – CORRECT

1-Minute Consult on this topic: Click HERE and scroll to proper page

 

Resistant VF: Either refractory (3 rounds of defib) or recurrent VF

  • Beta blocker: May mitigate myocardial oxygen consumption from Epi.  May raise K+.  Metoprolol 5mg fast.  Esmolol 500mcg/kg load + 50-100mcg/kg/m.
    • No good RCT, but multiple studies w/ 2-3 x rate of ROSC & survival w/ good CNS outcome
  • Potassium: Often low, epi &/or bicarb drop it further.  No known studies (do one please!)
  • DSD: dual sequential defibrillation: useful as is vector change.
    • Make sure pad position not too low, which is a common mistake
  • SGB:  Stellate ganglion block: anesthetize the left stellate ganglion w/ bupivicaine
    • risks:        Horner’s, hoarseness, vascular puncture, CPR delay…
    • how:         Stop CPR, use US, aim for left C6 transverse process below prevertebral fascia
        •  22-25g needle on 10mL syringe, 6mL Marcaine, approach lateral to carotid/jugular
        •  Feel for L C6 process lateral to cricoid cartilage, aim under longus colli muscle

Case Outcome: K 2.6, trop 110, proximal LAD and 90% RCA occlusions, post cath trop 4,000, not rechecked after that.  EF 27% (stunned).  At 48 hours following commands, extubated.  At 4 weeks remembering all passwords and no exertional limitations.