What are the preparations for Advanced Cardiovascular Life Support (ACLS) ventricular fibrillation (VFib)?

ACLS Ventricular Fibrillation Preparation

The most important preparation for ACLS ventricular fibrillation management is establishing high-quality CPR with minimal interruptions, early defibrillation, and appropriate equipment setup including airway management tools, vascular access, and medications such as amiodarone or lidocaine. 1

Equipment Preparation

• Ensure defibrillator is immediately available and functional with appropriate energy settings (biphasic: manufacturer recommendation 120-200J; monophasic: 360J) 1
• Prepare airway management equipment including:
  • Bag-mask device with HEPA filter (especially for suspected COVID-19 patients) 1
  • Supraglottic airway devices or endotracheal intubation equipment 1
  • Waveform capnography for confirming and monitoring advanced airway placement 1
• Establish suction devices with:
  • Large-bore, non-kinking suction tubing and semi-rigid pharyngeal tips 1
  • Adequate vacuum (>40 L/min airflow, >300 mmHg vacuum when clamped) 1
• Prepare IV/IO access equipment for medication administration 1

Medication Preparation

• Prepare amiodarone for refractory VF/pVT:
  • First dose: 300 mg bolus IV/IO 1, 2
  • Second dose: 150 mg IV/IO 1
  • For maintenance infusion after ROSC: 1000 mg over 24 hours 2
• Alternative: Prepare lidocaine for refractory VF/pVT:
  • First dose: 1-1.5 mg/kg IV/IO 1
  • Second dose: 0.5-0.75 mg/kg IV/IO 1
• Prepare epinephrine 1 mg IV/IO (to be administered every 3-5 minutes) 1

Team Preparation

• Assign clear roles to team members including:
  • Team leader to coordinate resuscitation efforts 3
  • Compressor(s) to perform high-quality chest compressions 1
  • Airway manager to secure and maintain the airway 1
  • Medication administrator 3
  • Defibrillator operator 1
• Plan for compressor rotation every 2 minutes to minimize fatigue and maintain high-quality compressions 1
• Ensure all team members wear appropriate PPE, especially when aerosol-generating procedures are anticipated 1

CPR Quality Monitoring Preparation

• Set up quantitative waveform capnography to monitor CPR quality (PETCO2 <10 mmHg indicates need to improve CPR quality) 1
• Consider intra-arterial pressure monitoring if available (relaxation phase pressure <20 mmHg indicates need to improve CPR quality) 1
• Prepare for continuous assessment of:
  • Compression rate (100-120/min) 1
  • Compression depth (at least 2 inches/5 cm) 1
  • Complete chest recoil 1
  • Minimal interruptions in compressions 1

Algorithm Review

• Review VF/pVT algorithm with team:
  • Immediate recognition of cardiac arrest 1
  • Early CPR with minimal interruptions 1
  • Rhythm check and defibrillation as soon as possible 1
  • Resume CPR immediately after shock without pulse check 1
  • Consider antiarrhythmic drugs after 2-3 shocks 1
  • Address reversible causes (Hs and Ts) 1

Special Considerations

• For pregnant patients, prepare for lateral uterine displacement to relieve aortocaval compression 1
• For suspected COVID-19 patients, ensure appropriate PPE and HEPA filters on ventilation equipment 1
• Consider ECPR (extracorporeal CPR) preparation for select patients when conventional CPR is failing in settings where this can be implemented 1

Common Pitfalls to Avoid

• Avoid excessive ventilation (maintain 8-10 breaths/minute with advanced airway) 1
• Minimize interruptions in chest compressions, including during advanced airway placement 1
• Avoid delays in defibrillation while preparing medications 1
• Don't rely solely on ETCO2 cutoff values for prognostication or termination decisions 1
• Prevent prolonged pulse checks; if pulse is not definitely felt within 10 seconds, resume CPR 1

Effective ACLS VF management requires both proper preparation and execution. The foundation of successful resuscitation is high-quality CPR with minimal interruptions and early defibrillation, with other interventions being supportive but not proven to increase long-term survival 1, 4.