FDIC International 2024 Preview: Refractory Ventricular Fibrillation: Old and Novel Therapies

Out-of-hospital cardiac arrest (OOHCA) claims the lives of over 350,000 people in the United states alone each year. Many of these, approximately 80,000, are due to sudden cardiac death from ventricular fibrillation (VF) which often remains refractory to standard American Heart Association Advanced Cardiac Life Support (AHA-ACLS) therapies.^{3, 61}

In the last few years, advances have been made in not only making changing to the standard therapies of ACLS (epinephrine dosing and timing as well as use vs non-use of antiarrhythmics such as lidocaine or amiodarone) but also new and novel therapies to try and achieve improved rates of return of spontaneous circulation (ROSC).

At a minimum, as prehospital care professional providers, we need to try to achieve high rates of high-quality CPR as well as providing early defibrillation.³ Decades of research has shown that as time to initiate these therapies is prolonged success of resuscitation is dramatically decreased. Our treatment starts, hopefully, with bystanders at the scene who will start cardiopulmonary Resuscitation (CPR) and find and use an automated external defibrillator (AED) either independently or by trained dispatchers. A potential issue is when the victim persists in VF that is either recurrent or refractory.

Recurrent VF is when defibrillation terminates VF but the VF reoccurs. This is felt to be more of a myocardial issue and not a defibrillation issue. Refractory VF is when defibrillation fails to terminate VF and this is possibly a defibrillation issue.^{13, 14}

Providing high quality care for the victim of out-of-hospital cardiac arrest often depends on a stable environment. For many years, and in my prior field practice, the mantra was often “load and go” to get out patient to the hospital as quickly as possible, despite us having at our disposal the exact tools we needed to achieve ROSC.

Once you have started the field resuscitation it is now considered good care to stay on scene, maintain high-quality CPR (HQ-CPR), initiate defibrillation and other potential therapies and not moving toward the hospital until ROSC is achieved and you have further stabilized the patient before transporting to hopefully avoid re-arrest during transport.⁴⁵

The only caveat to this plan may be in communities where victims of cardiac arrest may be taken directly to the receiving hospital cardiac catheterization lab for extra-corporeal membrane oxygen (ECMO) therapy and intervening to open the culprit coronary artery.^{22, 62}

Research has shown that staying on scene may achieve ROSC 48.3% of the time compared to 15.8% by transport while still in arrest. In addition, 12.6% of those staying on scene were discharged from the hospital alive and 10.2% had good discharge neurological function (modified Rankin Score <3) compared to 3.8% and 2.6% respectively if transported early.^{45, 61}

Another aspect of HQ-CPR that is often overlooked is limiting interruptions in CPR. One method to achieve good CPR fraction time is to limit peri-defibrillation pauses.

The best method seems to be continuing CPR while the defibrillator is charged, pausing only briefly with compressors hands just above the chest while the rhythm is quickly analyzed, delivering the shock if VF and then immediately restart CPR without pausing to look at the rhythm. This can be achieved in less than 10 seconds. Longer pauses decrease cerebral and coronary artery perfusion and may limit successful resuscitation.^{20, 32}

The first drug given in cardiac arrest is epinephrine and has been the standard of care for decades despite dismal rates of ROSC through various dosing and timing iterations. The current AHA-ACLS standard is 1mg of IV or IO epinephrine every 3-5 minutes.³ However, novel dosing is being used in various agencies around the country.

These range from giving a single 1mg dose of epinephrine for VF and no further is given, to other dosing patterns that cap the total dose of epinephrine for VF to 2mg and is only given for VF once certain End Tidal Carbon Dioxide (EtCO2) levels of 20mm Hg or higher.^{2, 5, 53, 54}

The ALPS (Amiodarone, Lidocaine, Placebo Study) showed that the use of antiarrhythmics for VF did not demonstrate increased ROSC vs placebo although a later review seemed to indicate amiodarone may be successful if given within eight minutes of onset of VF arrest.³⁷

Novel therapies to potentially achieve higher rates of ROSC with survival with good neurological function in those with recurrent or refractory VF may include:

• Vector change defibrillation^{14, 20}
  • Changing from antero-lateral to antero-posterior pad position
• Dual-Sequential Defibrillation^{7, 10, 13, 14, 16, 17, 20, 21, 30, 34, 35, 36, 38, 40, 43, 55}
  • Two sequential shocks from an antero-lateral and antero-posterior pads
• Esmolol^{7, 23, 46, 52}
  • Using beta-blocker to reduce sympathetic tone and reducing refractory VF
• Stellate ganglion block⁴⁴
  • Ultrasound guided injection of local anesthetic along the left paracervical ganglion to reduce cardiac sympathetic tone
• Out-of-Hospital ECMO⁶²
  • Bring the ECMO machine to the scene of the victim of cardiac arrest.

Out-of-hospital cardiac arrest tests our skills and our knowledge and the field is changing often. It is important to not only frequently practice those interventions that have proven efficacy (HQ-CPR and proper and timely defibrillation) but also to stay aware of new devices, technologies and interventions that may better achieve ROSC and return the victim of OOHCA to a functional life.

More: https://www.fdic.com/

MORE FDIC 2024 PREVIEWS

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• Improvement and Management of Post-Cardiac Arrest Care
• Autism Awareness for First Responders
• Real Patient Cases: Pediatric Video Visual Diagnosis

References and Further Reading

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