eMedicine Specialties > Emergency Medicine > Cardiovascular

Ventricular Fibrillation: Follow-up

Author: Keith A Marill, MD, Faculty, Department of Emergency Medicine, Massachusetts General Hospital
Coauthor(s): A Antoine Kazzi, MD, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon; Mazen K Khalil, MD, Post Doctoral Research Fellow, Department of Cell Biology, Lerner Research Institute, Cleveland Clinic Foundation; Aaron Bright, MD, Staff Physician, Department of Emergency Medicine, University of Southern California Keck School of Medicine
Contributor Information and Disclosures

Updated: Jul 28, 2008

Follow-up

Further Inpatient Care

  • Resuscitated patients must be admitted to an intensive care unit and monitored because of high risk of a recurrence.
    • They require stabilization and monitoring for possibility of a coexistent emergency or complication.
    • Evaluation of ischemic injury to the CNS, myocardium, and other organs is essential.
    • Patients typically have an underlying etiology that must be investigated and treated.
  • Up to approximately half of cardiac arrest survivors have evidence of an acute MI. Both emergent thrombolytic therapy and percutaneous transluminal coronary angioplasty (PTCA) have been used to treat these patients; however, CPR for greater than 10 minutes is considered a relative contraindication to thrombolysis. Emergent cardiology consultation is warranted for all survivors of cardiac arrest, and efforts at revascularization should be attempted, if indicated.
  • Patients who remain comatose post resuscitation benefit from 12-24 hours of controlled hypothermia therapy at 32-34 degrees Centigrade (89.6-93.2 degrees Fahrenheit). This can be accomplished with chemical sedation and paralysis to prevent shivering and an external cooling blanket or ice. Hypothermia therapy improves both neurologic outcome and mortality.
  • Automated implantable defibrillators (AICDs) are recommended for patients at risk for recurrent VF because they effectively provide early defibrillation. Patients with VF arrest who receive AICDs have improved survival compared with those receiving only medications. However, patients with AICDs may also require oral antidysrhythmic therapy to minimize recurrent device activation.

Deterrence/Prevention

  • In the setting of acute myocardial infarction, beta-adrenergic blocking therapy with agents such as metoprolol decrease the likelihood of ventricular dysrhythmias including ventricular fibrillation, and they lower overall mortality. Administer a beta-adrenergic blocking agent during acute myocardial infarction unless contraindicated by bradycardia, heart block, congestive heart failure, or reactive airway disease.

Complications

  • CNS ischemic injury
  • Myocardial injury
  • Postdefibrillation arrhythmias
  • Aspiration pneumonia
  • Defibrillation injury to self or others
  • Injuries from CPR and resuscitation
  • Skin burns
  • Damage to implanted electronics (eg, AICD, pacemaker)
  • Death

Prognosis

  • The prognosis for survivors of VF strongly depends on the time elapsed between onset and medical intervention. Early defibrillation often makes the difference between long-term disability and functional recovery.
  • Postresuscitation death and disability after successful resuscitation directly correlate with the amount of CNS damaged during the event. Without intervention, by 4-6 minutes after onset of VF, the prognosis is poor. Few survive when VF lasts more than 8 minutes without intervention.
  • The reported rate of survival from VF in the community varies from 4-33%. Survival is worst in dense urban and sparse rural areas, principally due to prolonged EMS response times.
  • AICD implantation is the primary treatment of survivors of VF. Antidysrhythmic and beta-adrenergic blocking medicines may also be helpful to prevent VF recurrence. While these interventions lower the risk of sudden dysrhythmic death, the AICD in particular does not prevent or retard the progressive congestive heart failure that is often present in these patients.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to address underlying causes of VF or to refer patient to appropriate care provider
  • Failure to initiate defibrillation immediately following diagnosis of VF
  • Failure to adequately train personnel on use of defibrillation equipment
  • Failure to keep equipment properly maintained and fully charged

Special Concerns

  • VF is the initial rhythm in 4-9% of pediatric cardiac arrests in multiple series. In addition to witnessed arrest and bystander CPR, near-drowning etiology is associated with a better prognosis.
  • Survival from cardiac arrest decreases with advancing age, but resuscitation of very elderly persons is not necessarily futile. Nineteen (3.3%) of 512 community-dwelling patients aged 80 years and older survived to discharge in one report.1 Survival of elderly persons may also be negatively confounded by the observation that they are more likely to arrest in the home, which carries a worse prognosis.
  • Hypothermia and VF
    • Endotracheal intubation is recommended when available regardless of body temperature.
    • For patients with moderate hypothermia, 30-34 degrees Centigrade (86-93.2 degrees Fahrenheit), CPR and defibrillation are administered as per the standard algorithm. Active internal rewarming should be administered simultaneously. Intravenous resuscitation medicines should be administered, spaced at longer intervals than normal due to reduced drug metabolism.
    • For patients with severe hypothermia, less than 30 degrees Centigrade (86 degrees Fahrenheit), and VF, a single defibrillation can be attempted. After this, CPR and active internal rewarming should begin. Further defibrillation and resuscitation medications are withheld until a core temperature of 30 degrees Centigrade is reached.
  • Family presence during resuscitation is practiced in some health care facilities. While this does not seem to impair or benefit the resuscitation efforts, it may be beneficial to the patient's family members in reconciling the imminent loss of a loved one.
  • Termination of resuscitation efforts

    • The optimal juncture to cease unsuccessful resuscitation efforts and to declare death is controversial. Decision rules have been formulated, but there will always be patients who defy such algorithms.
    • Patients who are pulseless and not severely hypothermic upon arrival by EMS and do not have a return of spontaneous circulation after 25 minutes of ACLS have a dismal prognosis.
    • The decision to terminate resuscitation efforts must be made on an individual basis by the clinician after assessing any possible extenuating factors. Visualization of the heart and a lack of spontaneous cardiac motion on ultrasonography may also be helpful in confirming the prognosis and outcome.
 


More on Ventricular Fibrillation

Overview: Ventricular Fibrillation
Differential Diagnoses & Workup: Ventricular Fibrillation
Treatment & Medication: Ventricular Fibrillation
Follow-up: Ventricular Fibrillation
Multimedia: Ventricular Fibrillation
References
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References

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Further Reading

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Keywords

VF, ventricular fibrillation, sudden cardiac death, SCD, tachycardia, ventricular tachycardia, VT, pulseless electrical activity, PEA, asystole, acute cardiac ischemia, acute cardiac infarction, acute myocardial infarction, MI, cardiac arrest

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Contributor Information and Disclosures

Author

Keith A Marill, MD, Faculty, Department of Emergency Medicine, Massachusetts General Hospital
Keith A Marill, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

A Antoine Kazzi, MD, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon
A Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Mazen K Khalil, MD, Post Doctoral Research Fellow, Department of Cell Biology, Lerner Research Institute, Cleveland Clinic Foundation
Mazen K Khalil, MD is a member of the following medical societies: American College of Physicians
Disclosure: Nothing to disclose.

Aaron Bright, MD, Staff Physician, Department of Emergency Medicine, University of Southern California Keck School of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Steven A Conrad, MD, PhD, Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center
Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Gary Setnik, MD, Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School
Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians and National Association of EMS Physicians
Disclosure: Intellicare Salary Management position; South Middlesex EMS Consortium Salary Management position

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Charles V Pollack, Jr, MD, MA, FACEP, Professor, Department of Emergency Medicine, University of Pennsylvania College of Medicine; Chairman, Department of Emergency Medicine, Pennsylvania Hospital
Charles V Pollack, Jr, MD, MA, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: sanofi-aventis Honoraria Consulting; sanofi-aventis Honoraria Speaking and teaching; Schering-Polugh Honoraria Consulting; Schering-Plough Honoraria Speaking and teaching; The Medicines Company Honoraria Consulting; GlaxoSmithKline Grant/research funds Other

 
 
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