Ventricular Fibrillation (VF) (And Pulseless Ventricular Tachycardia)

Inclusion Criteria: Apneic, pulseless patients with ventricular fibrillation or pulseless ventricular tachycardia treated by advanced level personnel. Basic- level personnel will use Cardiac Arrest Guidelines.

1. Follow the Cardiac Arrest Guidelines for patients in cardiac arrest with attention to maintaining high quality chest compressions at all times without interruptions.
2. At the end of EACH two-minute period of CPR, check the ECG rhythm and pulse.
     a.    In the event of return of spontaneous circulation (ROSC), refer to Post Cardiac Arrest Management guidelines.
     b.   If asystole or PEA develops, resume CPR and refer to the appropriate treatment guideline
     c.   If the patient is in VF or pVT, resume chest compressions while charging the defibrillator to the appropriate energy level and deliver the FIRST, SINGLE SHOCK.
        i.    Immediately after the shock, resume CPR for 2 full minutes.
        ii.   During this 2-minute period, apply ETCO2 monitors and establish vascular access (if not already done) without interrupting chest compressions. Administer 1:10,000 epinephrine
   
   
3. If the patient remains in VF or pVT, resume chest compressions while charging the defibrillator to the appropriate energy level and deliver the SECOND SINGLE SHOCK. Immediately after the shock, resume CPR for 2 full minutes. During this 2-minute period, administer epinephrine 1:10,000 IVP or IO with a flush as soon as possible after shock delivery.

   Adult Epinephrine 1:10,000: 1 mg IVP or IO, may repeat every 3 to 5 minutes Amiodarone 300 mg IVP or IO; flush If the etiology of the arrest is trauma, administer lidocaine 1 mg/kg - 1.5 mg/kg IV/IO push	Pediatric Epinephrine 1:10,000: 0.01 mg/kg IVP/IO, may repeat every 3 to 5 minutes Amiodarone 5 mg/kg IVP or IO, followed by immediate flush with 10 mL of normal saline    Maximum single dose = 300 mg
   If the rhythm changes following the countershock, continue chest compressions but do not administer epinephrine

   
   
4. If the patient remains in VF or pVT, resume chest compressions while charging the defibrillator to the appropriate energy level and deliver the THIRD SINGLE SHOCK. Immediately after the shock, resume CPR for 2 full minutes. During this 2-minute period, administer epinephrine 1:10,000 IVP or IO with a flush and then an antiarrhythmic drug with a flush, as soon as possible after shock delivery.

   Adult	Pediatric
   Epinephrine 1:10,000: 1 mg IVP or IO; may repeat every 3 to 5 minutes Amiodarone 150 mg IV/IO push; flush If the rhythm could be Torsades de Pointes, add 2 grams magnesium sulfate to 250 ml normal saline bag and infuse IV piggyback over 6 - 10 minutes BioTel authorization required if dialysis patient If the etiology of the arrest is trauma, administer lidocaine 1 mg/kg - 1.5 mg/kg IVP	Epinephrine 1:10,000: 0.01 mg/kg IVP or IO, may repeat every 3 to 5 minutes Amiodarone 5 mg/kg IVP, followed by immediate flush with 10 ml of normal saline Maximum single dose is 150 mg Maximum total, cumulative dose = 10 mg/kg Repeat dosing: Contact BioTel

   
   
5. At the end of the two-minute period of CPR, check a pulse and the ECG rhythm.
   a.    In the event of return of spontaneous circulation (ROSC), refer to Post Cardiac Arrest Management Guidelines.
   
   b.   If asystole or PEA develops, resume CPR and refer to the appropriate treatment guideline.
   
   c.   If  the patient remains in ventricular fibrillation or pulseless ventricular tachycardia, attempt defibrillation again with a SINGLE shock at the highest energy level recommended for that device, and immediately resume CPR for two minutes. Repeat this cycle if the patient either remains in VF/pVT or at any time returns to these rhythms.
   
   d.   Consider placement of an advanced airway.
6. If medics suspect any of these possible causes of V-Fib/pVT, initiate standing order treatment ASAP:
   
   Hyperkalemia (renal failure or dialysis) or pre-existing acidosis (renal failure, dialysis, methanol ingestion, aspirin overdose) or tricyclic antidepressant overdose

   Adult and Pediatric

   sodium bicarbonate 1 mEq/kg IVP

   
   
   If mechanism of injury AND symptoms AND physical exam suggest a tension pneumothorax
   

   Adult perform needle thoracostomy

   Pediatric Contact BioTel

   
   
   If beta blocker toxicity, administer

   Adult Glucagon 1 mg – 5 mg IVP, may repeat

   Pediatric Contact BioTel

   
   
   If calcium channel blocker toxicity, administer

   Adult Calcium chloride (10% solution) 10 - 15 mg/kg IV (optional medication)

   Pediatric Contact BioTel

   
   
   
7. If resuscitation attempt prolonged (greater than 15 minutes), consider [not required]

   Adult Sodium bicarbonate 1 mEq/kg IVP Calcium chloride (10% solution) 10 - 15 mg/kg IV (optional medication)

   Pediatric sodium bicarbonate 1 mEq/kg IVP

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