You are down by five, and there are only three seconds left in the game with 80 yards to go. Do you just take a knee or take a shot down the field with a Hail Mary since there is nothing else to lose? Similar to professional football players, we are professional “resuscitationists.” When it comes to taking care of cardiac arrest patients, we cannot be limited to the playbook of advanced cardiovascular life support (ACLS). Occasionally, we, too, have to take a shot with our own version of a Hail Mary. Do we terminate the refractory ventricular fibrillation (VF) coding patient with an end tidal CO2 of 27 mmHg, or is there a new “play” we can try before we pronounce the patient?
A 43-year-old father of two presents to the ED via advanced life support (ALS) in cardiac arrest with a presenting rhythm of ventricular fibrillation. According to the transporting paramedics, the patient had a witnessed arrest at home, and the family performed CPR until basic life support (BLS) arrived on the scene. An automated external defibrillator (AED) was immediately placed with “shock advised.” Two shocks were given by BLS prior to ALS arrival. The paramedics were able to intubate the patient and initiate ACLS. They report continued ventricular fibrillation, without return of spontaneous circulation (ROSC), from the time of arrival on scene until arrival in the ED. A total of 450 mg amiodarone, 5 mg epinephrine, two ampules of calcium chloride, two ampules of sodium bicarbonate, 100 mg lidocaine, and seven defibrillations were given prior to arrival in the ED. End-tidal CO2 has remained around 25 mmHg with high-quality CPR performed in the prehospital setting. All eyes turn to you upon arrival. “Doc, what else can we do? There are no more steps on the ACLS card but more epinephrine and defibrillations. Should we call it?”
The Opponent: Electrical Storm
Electrical storm (ES) is described in the medical literature as a rapidly clustering ventricular fibrillation that necessitates multiple cardioversions in which conventional antidysrhythmic drug therapy, as recommended by ACLS, fails to convert the patient to a life-sustaining rhythm. ES patients are commonly given antidysrhythmic medications serially while also receiving repeated shocks via an AED. However, despite heroic efforts made by all providers, most ES patients die.1 Refractory arrest secondary to ES is not a new