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Ventricular Fibrillation

Pulseless Ventricular Tachycardia

Clinical Operating Guidelines AC-8This protocol has been altered from the original NCCEP Protocol by the Durham County EMS Medical Director4/2020

Revised

Reversible Causes

HypovolemiaHypoxiaHydrogen ion (acidosis)HypothermiaHypo / Hyperkalemia

Tension pneumothoraxTamponade; cardiacToxinsThrombosis; pulmonary (PE)Thrombosis; coronary (MI)

AT ANY TIME

Return ofSpontaneous

Circulation

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Resuscitation Protocol AC 9

Cardiac Arrest Protocol AC 3

Notify Destination or Contact Medical Control

Continue CPR CompressionsPush Hard ( 2 inches) Push Fast (100 - 120 / min)

Change Compressors every 2 minutes(sooner if fatigued)

(Limit changes / pulse checks 10 seconds)

If Rhythm RefractoryContinue CPR

and give Agency specific Anti-arrhythmics and EpinephrineContinue CPR up to point

where you are ready to defibrillate with device charged.Repeat pattern during resuscitation.

Immediate Defibrillation at 200JBegin Continuous CPR Compressions

Push Hard ( 2 inches), Push Fast (100 - 120 / min)Change Compressors every 2 minutes

(sooner if fatigued)(Limit changes / pulse checks 10 seconds)

Place iGel or ETT ASAPVentilate at 1 breath every 6 seconds

Place viral filter when availableMonitor EtCO2

if availableAt the end of each 2 minute cycle

Check AED / ECG Monitor If shockable rhythm, deliver shock and immediately continue chest

compressions

Amiodarone 300 mg IV / IOMay repeat if refractory

Amiodarone 150 mg IV / IO

RefractoryConsider Lidocaine 1.0 – 1.5 mg/kg IV / IO

May repeat if refractoryLidocaine 0.75 mg/kg IV / IO

Maximum dose 3 mg/kg

Refractory or Torsades de PointesMagnesium 2 gm IV / IO

IV / IO Procedure

Epinephrine (1:10,000) 1 mg IV / IORepeat every 3 to 5 minutes

Refractory after 5 Defibrillations AttemptsConsider Dual Sequential Defibrillation Procedure

if available

Search for Reversible Causes

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ALL RESCUERS DON FULL PPE: N95, GOGGLES,

GOWN, GLOVES

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Ventricular Fibrillation

Pulseless Ventricular Tachycardia

Clinical Operating Guidelines AC-8This protocol has been altered from the original NCCEP Protocol by the Durham County EMS Medical Director4/2020

Revised

Pearls FIRST ARRIVING UNIT PLACE AN iGEL AS SOON AS POSSIBLE. PAUSE CPR TO PLACE iGEL.

IF THE iGEL DOES NOT SEAL WELL, THE MOST EXPERIENCED PROVIDER SHOULD PERFORM ENDOTRACHEAL INTUBATION VIA VIDEO LARYGOSCOPY. IF THE PATIENT REQUIRES INTUBATION, PAUSE CPR FOR THE ATTEMPT.

BVM should be attempted only if iGel and ETI fail. Ensure a good mask seal by using two rescuers (one for mask seal, one for ventilation) as well as an appropriate sized airway adjunct.

Team Focused Approach / Pit-Crew Approach – assign responders to predetermined tasks.

Efforts should be directed at high quality and continuous compressions with limited interruptions and early defibrillation when indicated.

Consider early IO placement if available and / or difficult IV access anticipated.

DO NOT HYPERVENTILATE: If no advanced airway (BIAD, ETT) compression to ventilation ratio is 30:2. If advanced airway in place, ventilate 10 breaths per minute with continuous, uninterrupted compressions.

Reassess and document BIAD and / or endotracheal tube placement and EtCO2 frequently, after every move, and at transfer of care.

IV / IO access and drug delivery is secondary to high-quality chest compressions and early defibrillation.

Refractory ventricular fibrillation/tachycardia: ventricular fibrillation/tachycardia that remains after 5 or more consecutive defibrillations.

Recurrent ventricular fibrillation/tachycardia: ventricular fibrillation/tachycardia that converted to another rhythm but then returns during another pulse check.

End Tidal CO2 (EtCO2)

o If EtCO2 is < 10 mmHg, improve chest compressions.

o If EtCO2 spikes, typically > 40 mmHg, consider Return of Spontaneous Circulation (ROSC)

Magnesium Sulfate is not routinely recommended during cardiac arrest, but may help with Torsades de pointes, Low Magnesium States (Malnourished / alcoholic), and Suspected Digitalis Toxicity.

If no IV / IO, with drugs that can be given down ET tube, double dose and then flush with 5 ml of Normal Saline followed by 5 quick ventilations. IV / IO is the preferred route when available.

Return of spontaneous circulation: Heart rate should be > 60 when initiating anti-arrhythmic infusions.