Triage: Cardiac Arrest

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 amiodarone 300mg, but is still in V-fib.

Vital Signs: BVM at 16, CPR with palpable pulse

Exam:  GCS 3 but clenching teeth and breathing spontaneously at a reasonable rate, CPR by Lucas device. 

POCUS: Bedside US shows no free fluid in the abdomen.  At pulse check the heart is viewed and there is no pericardial effusion and a heart in VF with no peripheral pulses.

Treatment: 5mg of IV metoprolol and dual sequential defibrillation done in ER resuscitation bay.  After that he achieves ROSC.

An ECG is done (post ROSC)

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

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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+, which is low in 20% of ED patients, 5% severe low K.  Epi &/or bicarb drop it further.
    • Dosing: 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
  • Dual sequential defibrillation:
    • Make sure pad position not too low, which is a common mistake
    • 200J twice <1 second apart
  • 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 bupivicaine, approach lateral to carotid/jugular
        •  Feel for L C6 process lateral to cricoid cartilage, aim under longus colli muscle

Case Outcome: K+ was 2.6, troponin was 110.  Cath showed both 90% proximal LAD and 90% RCA occlusions.  Post cath troponin was 4,000, and was not rechecked after that.  EF on echo was 27% (stunned).  At 48 hours he was following commands, and was extubated.  At 4 weeks he felt normal including remembering all his passwords and having no exertional limitations.