What is the treatment protocol for Ventricular Fibrillation (VFib)?

Treatment Protocol for Ventricular Fibrillation (VFib)

Immediate defibrillation with high-quality CPR is the definitive treatment for ventricular fibrillation, with initial shock energy of 200J for adults, followed by escalating energy if needed, and administration of epinephrine and amiodarone for shock-resistant VFib. 1

Initial Response and Assessment

• Recognize VFib on cardiac monitor (disorganized electrical activity without discernible QRS complexes) 1
• Immediately begin high-quality CPR with minimal interruptions (at least 100 compressions/min, 2/3 anterior-posterior chest diameter) 1
• Attach monitor/defibrillator as soon as possible 1
• Minimize interruptions in chest compressions, including during rhythm analysis 1

Defibrillation Protocol

• For witnessed VFib arrest, deliver immediate unsynchronized shock 1
  • Initial shock: 200J (monophasic) or manufacturer's recommended dose (biphasic) 1
  • If unsuccessful, deliver second shock at 200-300J 1
  • If still unsuccessful, deliver third shock at 360J 1
• For unwitnessed arrest or prolonged VFib, consider 2 minutes of CPR before first shock 1
• Resume CPR immediately after each shock, beginning with chest compressions 1
• Rotate compressor every 2 minutes to maintain high-quality compressions 1

Medication Administration

• Establish IV/IO access while continuing CPR 1
• Administer epinephrine 1mg IV/IO every 3-5 minutes 1
• For shock-resistant VFib (persisting after 3 shocks), administer amiodarone 300mg IV/IO bolus 2, 3
  • May repeat amiodarone at 150mg IV/IO after 3-5 minutes if VFib persists 2
  • Continue amiodarone infusion at 1mg/min for the first 6 hours, then 0.5mg/min if ROSC achieved 2
• Consider lidocaine 1.5mg/kg IV/IO if amiodarone unavailable 1

Advanced Airway Management

• Consider advanced airway placement after initial shocks if personnel available 1
• If advanced airway placed, deliver 1 breath every 6 seconds (10 breaths/min) with continuous compressions 1
• Use waveform capnography to confirm and monitor endotracheal tube placement 1

Special Considerations

• For pediatric patients, use 2 J/kg for first shock, 4 J/kg for second shock, and 4-10 J/kg for subsequent shocks 1
• If using automated external defibrillator (AED), apply pads and follow device prompts with minimal interruption to CPR 1
• For biphasic defibrillators, follow manufacturer's recommended energy settings 1
• Consider reversible causes (Hs and Ts): Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade, Toxins, Thrombosis (pulmonary and coronary) 1

Post-Resuscitation Care

• After ROSC, maintain adequate ventilation and oxygenation 1
• Monitor for recurrent VFib, which is common and associated with worse outcomes 4
• Correct electrolyte abnormalities, particularly potassium and magnesium 1, 5
• Consider beta-blockers if VFib occurred in setting of acute myocardial infarction 1

Common Pitfalls to Avoid

• Don't delay defibrillation for witnessed VFib arrest 1, 5
• Avoid excessive interruptions in chest compressions, including for rhythm checks 1
• Don't use synchronized cardioversion for VFib (always use unsynchronized shocks) 1
• Avoid excessive ventilation which can decrease cardiac output during CPR 1
• Don't delay epinephrine administration while waiting for defibrillation to be successful 3