Refractory VF and the post-ROSC bundle

This is refractory ventricular fibrillation — VF that persists despite multiple shocks, adrenaline and amiodarone. The resuscitation continues the shockable loop: high-quality CPR with minimal interruption, a rhythm check every two minutes, a shock at each VF recurrence, the adrenaline every cycle, and the amiodarone completed. The reversible causes are sought at every cycle — in particular an acute coronary occlusion, an electrolyte derangement and a toxin — by the bedside ultrasound during the rhythm check, the early blood gas, and the history.^[3]

For the truly refractory VF in a suitable patient — witnessed, a shockable rhythm throughout, a short downtime, no terminal comorbidity — the escalation is extracorporeal cardiopulmonary resuscitation, with the cannulation begun while the mechanical CPR maintains the perfusion, as a bridge to the definitive treatment (commonly the percutaneous coronary intervention for the occluded artery that underlies most of these arrests). The centre with the capability is mobilised early. Throughout, the team is led and the algorithm is run; the refractory rhythm is not a reason to abandon the structure.^[3]

If return of spontaneous circulation is achieved, the post-ROSC bundle begins immediately. The airway and breathing are managed to a saturation of 94 to 98 per cent and a normocapnia; the circulation is supported to a mean arterial pressure of 65 mmHg or more with fluid and vasopressors; the cause is investigated (a 12-lead electrocardiogram and an urgent coronary angiography for the presumed cardiac cause); the temperature is managed at normothermia, actively avoiding fever, since the TTM2 trial showed no benefit of cooling to 33 degrees over normothermia;^[2] seizures are treated and the glucose is controlled. The patient is transferred to the coronary care or intensive care unit, and the prognostication is deferred for several days.^[1]