Ventricular Fibrillation Pulseless Ventricular Tachycardia

Section 4 - CARDIAC

4.08 CARDIAC ARREST - VENTRICULAR FIBRILLATION /PULSELESS VENTRICULAR TACHYCARDIA

Ventricular Fibrillation (VF) and Pulseless V-Tach (VT) focuses in the correction of the dysrhythmia into a pulse producing rhythm. Consider all possible reversible causes for cardiac arrest utilizing a national recommended mnemonic of “H’s and T’s”:

H’s	T’s
Hypovolemia	Tension Pneumothorax
Hypoxia	Tamponade, cardiac
Hydrogen Ion (acidosis)	Toxins or Tablets (overdose)
Hypo/hyperkalemia	Thrombosis, pulmonary
Hypothermia	Thrombosis, cardiac

In addition, also consider the following:

Hypoglycemia

Trauma

When the Patient found in cardiac arrest:

• Initiate BLS algorhythm with 5 cycles of high quality CPR (push hard/push fast)
  • Minimum of 100 compressions per minute, minimize interruptions
  • Compression rate of 30:2 for approximately 2 minutes
  • Depth of compression of at least 2 inches
  • Initiate the use of a mechanical compression device if available
• Assist ventilations with OXYGEN @ 100% via BVM - DO NOT HYPERVENTILATE
• Attach cardiac monitor – Evaluate the cardiac rhythm
  • VF/VT Present – deliver a DEFIBRILLATION 120-200j biphasic
• Continue high quality CPR/Ventilations for 2 minutes
• Establish intravenous access via IV or IO
• Consider advanced airway procedure using supraglottic airway (king tube) or endotracheal intubation
  • Do not interrupt compressions to place an advanced airway
  • Confirm tube placement with capnography (a range 5-20 mmHg is indicative of low cardiac output)
• Administer EPINEPHRINE 1:10,000 1 mg IV / IO – repeat every 3-5 minutes of arrest

OR

• Administer VASOPRESSIN 40 units IV / IO – replaces the first or second dose of epinephrine
  • Vasopressin is a one-time dose
  • Do not stop CPR to administer medications
• Reassess for circulation every two minutes
  • VF/VT Present – deliver a DEFIBRILLATION 300-360j biphasic
  • Subsequent shocks should be at the higher dose selected

If after 3 attempts at defibrillation and patient is still presenting VF, each subsequent shock should be delivered at 720j biphasic(using double sequential defibrillation)

• Administer antidysrhythmic medication:
  • AMIODARONE 300 mg IVP, IO.
  • May repeat second dose AMIODARONE (if needed) 150 mg IV, IO in 3-5 minutes.
    • Maximum dose 450 mg.

OR

• Administer LIDOCAINE 1 to 1.5 mg/kg IVP, IO. May repeat every 5-10 minutes to a maximum of 3 mg/Kg.
  • In patients over age 70 or in those with known hepatic disease, administer LIDOCAINE gradually up to a full initial loading dose or until a maximum of 1.5 mg/kg administered.
  • If VF/VT converts to a pulse-producing non-heart block supraventricular rhythm, administer a LIDOCAINE DRIP 1-4 mg/min.
  • In patients over age 70 or in those with known hepatic disease, administer LIDOCAINE DRIP at the lower 1-2 mg/min. MONITOR FOR SIGNS OF TOXICITY including seizure activity.
• Administer MAGNESIUM SULFATE 2 gm IVP only if suspected Polymorphic VT (Torsades de pointes) or hypomagnesemic state (chronic alcohol, diuretic use)
• Administer SODIUM BICARBONATE 1 mEq/kg IVP if suspected, HYPERKALEMIA (e.g. dialysis patient), or Tricyclic antidepressant OD

If patient combative post resuscitation, refer to ANALGESIA / SEDATION PARAMETER (2.04)

Deliver all Defibrillations at 360 Joules in any patient who has had an Automatic Implanted Cardioverter Defibrillator (AICD) shock. (Use Anterior/Posterior position if possible for Defibrillator Pads - Do not place pads over device).

• Consider sedation in patient experiencing cardioversion or defibrillation by their own AICD.
• Leave copy of ECG at ER on any patient with implanted device.