You get a call that a 50-year-old woman collapsed while running a marathon. Bystanders started CPR immediately. Nearby paramedics found her to be in ventricular fibrillation (VF). She was shocked three times and given 3 amps of epinephrine. She is still in VF when she arrives at your emergency department.
Advanced cardiac life support (ACLS) was originally designed to give us a common language and help us avoid paralysis in a crisis situation. However, with each year that passes, it seems like ACLS has become more and more simplified to appeal to a broader scope of rescuers, including those who rarely run codes. Yet cardiac arrest physiology just isn’t that simple. Managing these patients requires a lot more finesse. Practitioners working in settings where they manage codes regularly (eg, the emergency department) should be expected to have a more sophisticated approach when standard ACLS algorithms aren’t effective. In this month’s column, I’ll suggest four strategies to improve the chances of return of spontaneous circulation (ROSC) in shock-resistant VF and, perhaps, survival to hospital discharge. Shock-resistant VF, or electrical storm, is defined as three or more sustained episodes of VF in a 24-hour period.