Refractory VF, traditionally defined as VF that persists despite three defibrillation attempts, is thought to be the result of excessive endogenous catecholamines released during severe stress and is further augmented by exogenous epinephrine administration. 2–8 Despite its apparent benefit in cardiac arrest, epinephrine has several significant deleterious effects thought to be related to its β-adrenergic properties, which lower the threshold for lethal dysrhythmias. 1–3 Epinephrine’s mechanism of action in cardiac arrest has been attributed to its α-adrenergic effects, which preferentially redirect systemic blood flow towards the heart, thereby increasing myocardial blood flow and achieving the minimum coronary perfusion pressure (CPP) necessary for successful defibrillation. However, to the best of our knowledge, this is the first case of refractory VF that responded to low-dose esmolol β-blockade.Ĭurrent advanced cardiac life support (ACLS) algorithms for the management of ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) consist of high-quality cardiopulmonary resuscitation (CPR), defibrillation and the sequential administration of epinephrine/vasopressin and antiarrhythmic agents. DSD and β-blockade are increasingly recognised in the literature and practice for refractory VF. After administration of low-dose esmolol, he immediately achieved ROSC. Double sequential defibrillation (DSD) was attempted multiple times unsuccessfully. Despite standard ACLS management consisting of high-quality cardiopulmonary resuscitation, serial epinephrine and serial defibrillation, the return of spontaneous circulation (ROSC) was unable to be achieved. We report on a 51-year-old man who presented to the emergency department with chest pain and subsequently went into witnessed VF cardiac arrest. However, refractory VF, which is defined as VF that persists despite three defibrillation attempts, is challenging for all ACLS providers the best resuscitation strategy for patients that persist in refractory VF remains unclear. Current advanced cardiac life support (ACLS) guidelines for the management of ventricular fibrillation (VF) and pulseless ventricular tachycardia is defibrillation.
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