What is the treatment for ventricular fibrillation (VFib)?

Treatment of Ventricular Fibrillation

The definitive treatment for ventricular fibrillation is immediate defibrillation with an unsynchronized electric shock, followed by high-quality CPR and advanced life support measures. 1, 2

Immediate Management

• Recognize ventricular fibrillation on cardiac monitor as disorganized electrical activity without discernible QRS complexes 1
• Begin high-quality CPR immediately with minimal interruptions at a rate of at least 100 compressions per minute and a depth of 2/3 of the anteroposterior chest diameter 1, 3
• Attach a monitor/defibrillator as soon as possible 1
• Deliver an immediate unsynchronized shock with an initial energy of 200J (monophasic) or according to manufacturer's recommendations for biphasic defibrillators 4, 2
• If the first shock is unsuccessful, deliver a second shock at 200-300J, and if necessary, a third shock at 360J 4, 1
• Resume CPR immediately after each shock, beginning with chest compressions 1

Medication Administration

• Establish IV/IO access while continuing CPR 1
• Administer epinephrine 1mg IV/IO every 3-5 minutes 1, 3
• For refractory VF (persisting after initial shocks), consider amiodarone 150mg IV infused over 10 minutes 5
• Lidocaine 1.5mg/kg IV/IO may be considered if amiodarone is unavailable 4, 3

Advanced Airway Management

• Consider advanced airway placement after initial shocks if personnel are available 1
• If an advanced airway is 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

Post-Resuscitation Care

• Maintain adequate ventilation and oxygenation after return of spontaneous circulation (ROSC) 1, 3
• Correct electrolyte abnormalities, particularly potassium and magnesium, to prevent recurrent episodes of VF 4, 3
• Search for and treat reversible causes (Hs and Ts): Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade, Toxins, Thrombosis (pulmonary and coronary) 1, 3
• Consider beta-blockers if VF occurred in the context of acute myocardial infarction 4, 3

Special Considerations

• For witnessed VF arrest with immediate access to a defibrillator, deliver shock first then begin CPR 4
• For unwitnessed arrest or prolonged VF, consider 2 minutes of CPR before the first shock 4, 6
• In the context of acute myocardial infarction, primary VF is most common (3-5%) in the first 4 hours 4
• For drug-refractory polymorphic VT, consider aggressive attempts to reduce myocardial ischemia, including beta-blockade, intra-aortic balloon pumping, and emergency revascularization 4

Common Pitfalls to Avoid

• Do not delay defibrillation for witnessed VF arrest 1, 7
• Avoid excessive interruptions in chest compressions, including for rhythm checks 1
• Do not use synchronized cardioversion for VF (always use unsynchronized shocks) 1, 3
• Do not treat isolated ventricular premature beats, couplets, runs of accelerated idioventricular rhythm, and nonsustained VT 4
• Avoid excessive ventilation, which can decrease cardiac output during CPR 1
• Be aware that VF commonly recurs after initial successful defibrillation, with median time of recurrence being 27 seconds after shock 8