From the Guidelines
For non-responsive ventricular fibrillation (V-fib) that has not responded to epinephrine and multiple defibrillation attempts, the next line of drug therapy should be either amiodarone or lidocaine, as they may be considered for VF/pVT that is unresponsive to defibrillation 1. When deciding between these two options, it's crucial to consider the context of the arrest, such as whether it was witnessed, which could influence the timing of drug administration.
- Amiodarone may be administered at a dose of 300 mg IV push, with the possibility of a second dose of 150 mg IV if needed.
- Alternatively, lidocaine can be used, starting with a dose of 1-1.5 mg/kg IV, followed by 0.5-0.75 mg/kg IV for up to two additional doses if V-fib persists. It's also important to continue resuscitation efforts while identifying and treating potential underlying causes such as hypokalemia, hypomagnesemia, acidosis, or drug toxicity.
- Magnesium sulfate 1-2 g IV should be considered, especially if torsades de pointes is suspected, as it can help stabilize cardiac cell membranes. Throughout this process, maintaining high-quality CPR with minimal interruptions and continuing defibrillation attempts at appropriate intervals is vital. The choice between amiodarone and lidocaine should be based on the clinical judgment of the healthcare provider, considering the specific circumstances of the patient and the potential benefits and risks associated with each medication, as suggested by the American Heart Association guidelines update 1.
From the FDA Drug Label
Amiodarone hydrochloride injection is indicated for initiation of treatment and prophylaxis of frequently recurring ventricular fibrillation (VF) and hemodynamically unstable ventricular tachycardia (VT) in patients refractory to other therapy. The next line of drugs for non-responsive v fib with epinephrine and defibrillations is amiodarone (IV), as it is indicated for patients with VF who are refractory to other therapy 2.
From the Research
Next Line of Treatment for Non-Responsive V Fib with Epinephrine and Defibrillations
- The next line of treatment after epinephrine and defibrillations for non-responsive ventricular fibrillation (V Fib) includes the administration of antiarrhythmic drugs.
- According to a study published in The New England Journal of Medicine 4, amiodarone has been shown to be more effective than lidocaine in treating shock-resistant ventricular fibrillation, with a higher rate of survival to hospital admission.
- Another study published in the Journal of the American College of Cardiology 5 found that amiodarone was effective in facilitating defibrillation of ventricular fibrillation refractory to lidocaine and epinephrine plus direct current countershocks in an experimental model of acute myocardial infarction.
Alternative Treatment Options
- Esmolol, a beta-blocker, has also been reported to be effective in treating refractory ventricular fibrillation, as seen in a case report published in BMJ case reports 6.
- Double sequential defibrillation (DSD) and beta-blockade are increasingly recognized in the literature and practice for refractory VF, as mentioned in a study published in The western journal of emergency medicine 7.
- Extracorporeal cardiopulmonary resuscitation (E-CPR) has also been shown to improve clinical outcomes in patients with refractory ventricular fibrillation, as compared to conventional CPR, according to a study published in Resuscitation 8.
Key Findings
- Amiodarone is a recommended next-line treatment for non-responsive V Fib with epinephrine and defibrillations, due to its effectiveness in facilitating defibrillation and improving survival rates 4, 5.
- Esmolol and DSD may also be considered as alternative treatment options for refractory VF, although more research is needed to confirm their efficacy 7, 6.
- E-CPR may be considered for patients with refractory VF who do not respond to conventional CPR, as it has been shown to improve clinical outcomes 8.