• Use the same model of defibrillator.
• Pads need to be as close together as possible but not touching to avoid capacitor overload.
• Do not use synchronization.

2. Medications: think about using esmolol

Amiodarone has been traditionally used in the management of VT or VF as an adjunct to defibrillation. More recent literature and guidelines support the use of lidocaine as an alternative agent, and currently both are included in standard advanced cardiovascular life support .^12,13

Prior systematic reviews have looked at the use of beta blockade in the management of refractory VT or VF.¹⁴ A more recent review article looked at two retrospective studies with a combined total of 66 patients who were given esmolol in the treatment of refractory VT or VF.^6,15,16 These studies were small but did suggest significantly higher rates of return of spontaneous circulation in the esmolol group compared to standard care. There was insufficient data to suggest improvement in survival to discharge or degree of neurologic recovery. Proposed dosing for esmolol in the management of refractory VT or VF is 500 mcg/kg bolus, followed by a continuous infusion of up to 100 mcg/kg/min.

3. Extracorporeal membrane oxygenation

Of patients with out-of-hospital cardiac arrest presenting to the ED in refractory VF, a majority have significant coronary artery disease, much of which is amenable to percutaneous coronary intervention.^17,18 Given this, the advent of extracorporeal membrane oxygenation (ECMO) presents an opportunity to bridge care between traditional resuscitation of refractory VF patients in the ED and more definitive management in the catheterization lab. Post-resuscitation ECGs demonstrating ST segment elevation are significant in delineating which patients might benefit most from advanced reperfusion techniques.¹⁷ While previous evidence for the use of ECMO in refractory VF arrest has come from observational studies, the ARREST trial in 2020 represented the first open-label randomized trial evaluating the use of ECMO in the management of patients presenting to the ED in refractory VF arrest.¹⁸ This trial showed significant improvement in performance of patients treated with ECMO compared to standard care with regard to survival to hospital discharge, survival at six months, and overall functional outcome.¹⁹ Some aspects of the study, including rapid EMS response times and training as well as rapid time to cannulation, limit the generalizability of the data, but overall this study suggests significant promise in the use of ECMO for the management of this patient cohort.

Dr. Toomey (@DAVIDTOOMEYMD) is a senior instructor of Emergency Medicine at the University of Rochester Medical Center in Rochester, NY.