eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology

Ventricular Fibrillation: Differential Diagnoses & Workup

Author: Elizabeth A Stephenson, MD, MSc, Assistant Professor of Pediatrics, University of Toronto; Consulting Staff, Division of Cardiology, The Hospital for Sick Children
Coauthor(s): Charles Berul, MD, Associate Professor of Pediatrics, Harvard Medical School; Senior Associate, Department of Cardiology, Children's Hospital of Boston
Contributor Information and Disclosures

Updated: Jul 17, 2008

Differential Diagnoses

Long QT Syndrome
Ventricular Tachycardia

Other Problems to Be Considered

Torsade de pointes
Asystole
Electrocardiographic artifact (electrode/lead failure)

Workup

Laboratory Studies

The workup in patients who have been resuscitated from ventricular fibrillation is aimed at determining any preventable triggers or risk factors for the ventricular arrhythmias that may degenerate into ventricular fibrillation. A detailed discussion of triggers and risk factors is offered in Ventricular Tachycardia.

  • Electrolyte levels: In particular, serum magnesium, potassium, and calcium levels are most relevant to assessing ventricular arrhythmia vulnerability.
  • Blood gases: Blood gases, particularly pH, are determined because acidemia promotes arrhythmia susceptibility.
  • Drug levels: Clinicians may want to obtain drug levels, particularly to assess for any of the medications that may prolong the QT interval and any proantiarrhythmic agents to which the patient may have been exposed. Medications such as procainamide and amiodarone have arrhythmogenic potential, as do many antiarrhythmic drugs.
  • Toxicology screen: In particular, stimulant drugs of abuse, such as cocaine and amphetamines, may promote ventricular arrhythmias. Other illicit drugs, including phencyclidine, lysergic acid diethylamide (LSD), ecstasy, and even marijuana may increase vulnerability to arrhythmias, including ventricular fibrillation. Legal stimulants, such as caffeine, theophylline, and pseudoephedrine, may promote ventricular arrhythmias, particularly in individuals with underlying susceptibility.
  • Genetic testing: Extensive research is ongoing regarding identification of cardiac channelopathies which cause many of the primary electrical diseases. Commercial testing is becoming available for some of these channelopathies; however, many genetic variants have yet to be identified.

Imaging Studies

  • Chest radiography
  • Echocardiography
  • Cardiac MRI: This should particularly concentrate on the potential for arrhythmogenic right ventricular dysplasia. Fibrofatty infiltration may be evident in patchy distribution within the right, and sometimes left, ventricle.

Other Tests

  • Electrocardiography: A 12-lead ECG is most helpful in formulating differential diagnoses following ventricular fibrillation arrest.
  • Holter monitor
  • Event monitor
  • Additional tests indicated based on suspected precipitating factors
    • Provocative testing to elicit arrhythmias may be helpful in determining the electrophysiologic etiology.
    • Noninvasive provocative testing is predominantly by means of exercise stress testing.
    • Less commonly, infusion of cardioactive medications, such as isoproterenol or epinephrine, has been used to provoke ventricular arrhythmias in individuals with potential susceptibility.
    • In addition, infusion of sodium channel blocking antiarrhythmic drugs, such as ajmaline or procainamide, has been used to provoke an electrocardiographic phenotype of Brugada syndrome.
    • These tests may increase sensitivity in the identification of individuals with potential susceptibility, although specificity may be sacrificed. The value of the use of these provocative tests in pediatric patients has not yet been fully defined.

Procedures

  • Electrophysiologic studies
    • An invasive electrophysiologic (EP) study may be warranted in patients at high risk for ventricular fibrillation (eg, sustained or nonsustained ventricular tachycardia, averted sudden cardiac death). An EP study usually consists of programmed atrial and ventricular stimulation to determine the presence or absence of inducible ventricular tachycardia/ventricular fibrillation. Other potential arrhythmia substrates such as WPW with rapid antegrade conduction may also be examined.
    • Pharmacologic provocation studies (eg, using isoproterenol or other catecholaminergic agents for arrhythmia induction) may also be used during an EP study. Medications that may promote ECG signatures for specific disease states, such as a type I antiarrhythmic agents (eg, flecainide, ajmaline), may be administered to unmask the classic ECG pattern found in patients with Brugada syndrome.
    • Because diagnostic predictive value is limited, negative EP study findings do not exclude the possibility of a sudden cardiac event in the future, particularly in patients with structural congenital heart disease.

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

  1. Safranek DJ, Eisenberg MS, Larsen MP. The epidemiology of cardiac arrest in young adults. Ann Emerg Med. Sep 1992;21(9):1102-6. [Medline].

  2. Mogayzel C, Quan L, Graves JR, et al. Out-of-hospital ventricular fibrillation in children and adolescents: causes and outcomes. Ann Emerg Med. Apr 1995;25(4):484-91. [Medline].

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  4. Pedersen DH, Zipes DP, Foster PR, Troup PJ. Ventricular tachycardia and ventricular fibrillation in a young population. Circulation. Nov 1979;60(5):988-97. [Medline].

  5. Cecchin F, Jorgenson DB, Berul CI, et al. Is arrhythmia detection by automatic external defibrillator accurate for children?: sensitivity and specificity of an automatic external defibrillator algorithm in 696 pediatric arrhythmias. Circulation. May 22 2001;103(20):2483-8. [Medline].

  6. Vlay S. A Practical Approach to Cardiac Arrhythmias. Boston, MA: Little Brown & Co; 1996.

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Further Reading

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Keywords

ventricular fibrillation, VF, ventricular tachycardia, VT, cardiac arrest, heart attack, malignant arrhythmia, cardiac arrhythmia, primary ventricular fibrillation, ventricular arrhythmia, malignant ventricular arrhythmia, congenital heart disease, cardiac tumors, long QT syndrome, torsade de pointes, sudden cardiac death, tetralogy of Fallot, aortic stenosis, deafness, congestive heart failure, low cardiac output, myocarditis, abnormal heart sounds, aortic stenosis, ventricular outflow obstruction, electrolyte abnormalities, proarrhytmic medications, hypothermia, hyperthermia, hypoxia/ischemia, Wolff-Parkinson-White syndrome, WPW syndrome, Chagas disease, atrial fibrillation, AF, commotio cordis

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Contributor Information and Disclosures

Author

Elizabeth A Stephenson, MD, MSc, Assistant Professor of Pediatrics, University of Toronto; Consulting Staff, Division of Cardiology, The Hospital for Sick Children
Elizabeth A Stephenson, MD, MSc is a member of the following medical societies: American Heart Association, Canadian Cardiovascular Society, Heart Rhythm Society, and Pediatric and Congential Electrophysiology Society
Disclosure: Nothing to disclose.

Coauthor(s)

Charles Berul, MD, Associate Professor of Pediatrics, Harvard Medical School; Senior Associate, Department of Cardiology, Children's Hospital of Boston
Charles Berul, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, Heart Rhythm Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Christopher Johnsrude, MD, Associate Professor of Pediatrics, Director of Electrophysiology, University of Louisville School of Medicine; Consulting Staff, Pediatric Cardiology Associates, PSC
Christopher Johnsrude, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Cardiology
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Alvin J Chin, MD, Professor of Pediatrics, Division of Cardiology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine
Alvin J Chin, MD is a member of the following medical societies: American Association for the Advancement of Science and American Heart Association
Disclosure: Nothing to disclose.

CME Editor

Gilbert Herzberg, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Cardiology, New York Medical College
Gilbert Herzberg, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Chief Editor

Stuart Berger, MD, Professor of Pediatrics, Division of Cardiology, Medical College of Wisconsin; Chief of Pediatric Cardiology, Medical Director of Pediatric Heart Transplant Program, Medical Director of The Heart Center, Children's Hospital of Wisconsin
Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

 
 
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