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.

Exam:  GCS 3 but clenching teeth and breathing 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.

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

An ECG is done

What are treatment options for refractory VF?

  • A) Dual sequential defibrillation
  • B) Beta-blockers
  • C) Cervical sympathetic nerve block
  • D) Pericarditis
  • E) All of the above

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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 4000, not rechecked after that.  EF 27% (stunned).  At 48 hours following commands, extubated