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DEFINITIVE CARE
DIAGNOSIS
The ECG trace will show shockable rhythms such as VF or pulseless VT, or non-shockable rhythms such as asystole or PEA
VF is asynchronous, chaotic ventricular depolarization and repolarization producing no cardiac output. Pulseless VT is a wide-complex, regular tachy-cardia associated with no clinically detectable cardiac output.
Give a DC shock once VF/VT is confirmed on the monitor:
deliver 150–200 J using a biphasic defibrillator
deliver 360 J if using an older monophasic defibrillator
deliver this shock with less than 5 s delay to cardiac compressions.
Immediately resume CPR, continuing with chest compressions to ventilations at a ratio of 30:2, if the airway has not yet been secured
do not delay CPR by reassessing the rhythm or feeling for a pulse
perform compressions at 100/min and ventilations at 10/min without interruption if the airway has been secured by now.
Consider the following drugs even though there are no data in support of their increasing survival to hospital discharge:
amiodarone – give initial bolus of 300 mg i.v. after the third shock, repeated once at a dose of 150 mg for recurrent or refractory VF/VT. Follow with an infusion of 900 mg over 24 h
lignocaine (lidocaine) – give initial bolus of 1 mg/kg i.v. if amiodarone is unavailable, followed by 0.5 mg/kg if necessary. Omit if amiodarone has been given magnesium – give 2 g (8 mmol or 4 mL) of 49.3% magnesium sulphate i.v., particularly in torsades de pointes, or for suspected hypomagnesaemia such as a patient on a potassium-losing diuretic, and for digoxin toxicity. Repeat the dose after 10–15 min if ineffective. Do not rely on any particular early ECG abnormality, or expect to see ST elevation. Give 1 in 10 000 adrenaline (epinephrine) 50 μg (0.5 mL) i.v. if there is persistent hypotension, and other treatable causes such as hypoxia, hypovolaemia, tension pneumothorax, hyperkalaemia or hypokalaemia have been excluded.
Repeat the adrenaline (epinephrine) to maintain a blood pressure similar to the patient’s usual blood pressure, or a systolic blood pressure greater than 100 mmHg, aiming for an adequate urine output of 1 mL/kg/h
Give the adrenaline (epinephrine) and other vasoactive drugs as soon as possible via a dedicated central venous line, which should be inserted under ultrasound control if not already sited.
Control seizures with midazolam 0.05–0.1 mg/kg up to 10 mg i.v., diazepam 0.1–0.2 mg/kg up to 20 mg i.v. or lorazepam 0.07 mg/kg up to 4 mg i.v.
Follow this with phenytoin 15–18 mg/kg i.v. no faster than 50 mg/min by slow bolus, or preferably as an infusion in
250 mL normal saline (never in dextrose) over 30 min under ECG monitoring.
Maintain blood glucose at ≤10 mmol/L, but avoid hypoglycaemia.
Commence therapeutic hypothermia measures to a temperature range of 32–34°C, according to local policy:
initiate cooling following out-of-hospital VF arrest, as well as in post asystole/PEA patients
infuse 30 mL/kg cold 4°C normal saline or Hartmann’s
Place ice packs to the groin and axillae
Use a cooling blanket if available.
Transfer the patient to the ICU, catheter laboratory or coronary care unit (CCU). Perform the following investigations but do not delay the transfer:
serum sodium, potassium, glucose and ABG, if not already done
12-lead ECG
CXR to look for correct positioning of the endotracheal tube, nasogastric tube and central line – exclude a pneumothorax, pulmonary collapse and pulmonary oedema.
Transfer the patient with a trained nurse and doctor in attendance. A minimum of a portable cardiac monitor, defibrillator, oxygen and suction should be available on the trolley.
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