Ventricular Fibrillation Guidelines

Updated: Jun 06, 2018
  • Author: Sandeep K Goyal, MD, FHRS; Chief Editor: Jeffrey N Rottman, MD  more...
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Guidelines Summary

Advanced cardiac life support (ACLS) guidelines

Updated cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) guidelines were issued in 2015, 2017, and/or 2018 by the following organizations:

  • American Heart Association (AHA) [81, 107, 108]
  • European Resuscitation Council (ERC) [109]
  • The International Liaison Committee on Resuscitation (ILCOR) [82, 110]

The following summarizes the AHA adult cardiac arrest algorithm for ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) [81, 107, 108] :

  • Activate the emergency response system.
  • Initiate CPR and give oxygen when available.
  • Rescuers trained in CPR using chest compressions and ventilation (rescue breaths) should provide a compression-to-ventilation ratio of 30:2 for adults in cardiac arrest (class IIa).
  • Verify the patient is in VF as soon as possible (ie, automated external defibrillator [AED] and quick look with paddles).
  • Defibrillate once: Use device-specific recommendations (ie, 120-200 J for biphasic waveform; if unknown, use the maximum available. Use 360 J for monophasic waveform).
  • Resume CPR immediately without pulse check and continue for five (5) cycles. One (1) cycle of CPR equals 30 compressions and 2 breaths; 5 cycles of CPR should take roughly 2 minutes (compression rate of 100-120 per minute). Do not check for rhythm/pulse until 5 cycles of CPR are completed.
  • During CPR, minimize interruptions while securing intravenous (IV)/intraosseous (IO) access and performing endotracheal intubation. Once the patient is intubated, continue CPR at 100-120 compressions per minute without pauses for respirations, and administer respirations at 10 breaths per minute.
  • Check the cardiac rhythm after 2 minutes of CPR.
  • Repeat a single defibrillation if  VF/pVT persists at the rhythm check. The selection of fixed versus escalating energy for subsequent shocks is based on the specific manufacturer’s instructions. [81] For a manual defibrillator capable of escalating energies, using higher energy for the second and subsequent shocks may be considered.
  • Resume CPR for 2 minutes immediately after defibrillation.
  • Continuously repeat the cycle of (1) rhythm check, (2) defibrillation, and (3) 2 minutes of CPR.
  • Administer a vasopressor: Give a vasopressor during CPR before or after the shock when IV/IO access is available. Administer epinephrine 1 mg every 3-5 minutes.
  • Administer antidysrhythmics: Give an antidysrhythmic during CPR before or after the shock. Administer amiodarone 300 mg IV/IO once; then, consider administering an additional 150 mg, once.

In addition, correct the following causes if necessary and/or possible [81] :

  • Hypovolemia
  • Hypoxia
  • Hydrogen ion (acidosis): Consider bicarbonate therapy.
  • Hyperkalemia/hypokalemia and other metabolic derangements
  • Hypoglycemia (Check fingerstick or administer glucose.)
  • Hypothermia (Check the core rectal temperature.)
  • Toxins
  • Tamponade, cardiac (Assess with ultrasonography.)
  • Tension pneumothorax (Consider needle thoracostomy.)
  • Thrombosis, coronary or pulmonary: Consider thrombolytic therapy, if suspected.

The AHA indicates that If all the following conditions are present, termination of resuscitation in out-of-hospital cardiac arrest (OHCA) may be considered [111] :

  • Arrest was not witnessed by emergency medical services (EMS) personnel
  • No return of spontaneous circulation (ROSC) prior to transport
  • No AED shock delivered prior to transport

In addition, in intubated patients, failure to achieve an end-tidal carbon dioxide (ETCO2) level above 10 mm Hg by waveform capnography after 20 minutes of CPR may be considered as one component of a multimodal approach to decide when to end resuscitative efforts. [111, 112] However, no studies of nonintubated patients have been reviewed, thus, ETCO2 should not be used as an indication to end resuscitative efforts. [111, 112]


AHA recommendations for defibrillation include the following [81] :

  • Defibrillators (using biphasic truncated exponential [BTE], rectilinear biphasic [RLB], or monophasic waveforms) to treat atrial and ventricular arrhythmias (class I)
  • Defibrillators using biphasic waveforms (BTE or RLB) are preferred for atrial and ventricular arrhythmias (class IIa).
  • A single-shock strategy (as opposed to stacked shocks) for defibrillation (class IIa).
  • The benefit of using a multimodal defibrillator in manual instead of automatic mode is uncertain (class IIb).
  • The value of VF waveform analysis to guide management of defibrillation is uncertain (class IIb). [113]

Overall, the ERC and ILCOR guidelines concur with the AHA, [82, 109, 110] but the ERC includes an additional recommendation for self-adhesive defibrillation pads, which are preferred over manual paddles and should always be used when they are available. [109]

Adjuncts for airway control and ventilation

The AHA guidelines provide the following recommendations for airway control and ventilation [81, 108, 113] :

  • Advanced airway placement in cardiac arrest should not delay initial CPR and defibrillation for VF cardiac arrest (class I).
  • Use supplementary oxygen when it is available, at the maximal feasible inspired oxygen concentration, during CPR (class IIb).
  • Before placement of an advanced airway (supraglottic airway [SGA] or endotracheal tube [ETT]), it is reasonable for EMS providers to perform CPR with cycles of 30 compressions and 2 breaths (class IIa); before placement of an advanced airway, it may be reasonable for EMS providers to use a rate of 10 breaths per minute (1 breath every 6 seconds) to provide asynchronous ventilation during continuous chest compressions (class IIb).
  • If advanced airway placement will interrupt chest compressions, consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (class IIb).
  • The routine use of cricoid pressure in cardiac arrest is not recommended (class III).
  • Either a bag-mask device or an advanced airway may be used for oxygenation and ventilation during CPR in both the in-hospital and out-of-hospital setting (class IIb). The choice of bag-mask device versus advanced airway insertion should be determined by the skill and experience of the provider (class I).
  • For healthcare providers trained in their use, either an SGA device or an ETT may be used as the initial advanced airway during CPR (class IIb).
  • Whenever an advanced airway (SGA or ETT) is inserted during CPR, it may be reasonable for providers to perform continuous compressions with positive-pressure ventilation delivered without pausing chest compressions (class IIb); it may be reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths per minute) while continuous chest compressions are being performed (class IIb).
  • Providers who perform endotracheal intubation should undergo frequent retraining (class I).
  • To facilitate delivery of ventilations with a bag-mask device, oropharyngeal airways can be used in unconscious (unresponsive) patients with no cough or gag reflex and should be inserted only by trained personnel (class IIa).
  • In the presence of known or suspected basal skull fracture or severe coagulopathy, an oral airway is preferred (class IIa).
  • Continuous waveform capnography plus clinical assessment is the most reliable method of confirming and monitoring correct placement of an ETT (class I).
  • If continuous waveform capnometry is not available, a nonwaveform carbon dioxide (CO 2) detector, esophageal detector device, or ultrasound used by an experienced operator is a reasonable alternative (class IIa).
  • After placement of an advanced airway, it is reasonable for the provider to deliver one (1) breath every 6 seconds (10 breaths/min) while continuous chest compressions are performed (class IIb).
  • Automatic transport ventilators (ATVs) can be useful for ventilation of adult patients in noncardiac arrest who have an advanced airway in place in both out-of-hospital and in-hospital settings (class IIb).

There are no significant differences in the recommendations from the ERC or ILCOR. [82, 109, 110]

Medication management

The 2015 AHA guidelines offers the following recommendations for the administration of drugs during cardiac arrest [81] :

  • Amiodarone may be considered for VF or pVT that is unresponsive to CPR, defibrillation, and a vasopressor therapy; lidocaine may be considered as an alternative (both class IIb).
  • Routine use of magnesium for VF/pVT is not recommended in adult patients (class III).
  • Inadequate evidence exists to support the routine use of lidocaine after cardiac arrest. However, the initiation or continuation of lidocaine may be considered immediately after ROSC from cardiac arrest due to VF/pVT (class IIb).
  • Inadequate evidence exists to support the routine use of a β-blocker after cardiac arrest. However, the initiation or continuation of an oral or IV β-blocker may be considered early after hospitalization from cardiac arrest due to VF/pVT (class IIb).
  • Atropine during pulseless electrical activity (PEA) or asystole is unlikely to have a therapeutic benefit (class IIb).
  • Standard-dose epinephrine (1 mg every 3-5 minutes) may be reasonable for patients in cardiac arrest (class IIb); high-dose epinephrine is not recommended for routine use in cardiac arrest (class III).
  • Vasopressin has been removed from the Adult Cardiac Arrest Algorithm because it offers no advantage in combination with epinephrine or as a substitute for standard-dose epinephrine (both class IIb)
  • It may be reasonable to administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial nonshockable rhythm (class IIb).

ICD therapy

In their 2008 joint guidelines for device-based therapy, the American College of Cardiology /American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) provided recommendations that included those outlined below. [102]

Class I

ICD therapy is indicated for the following people:

  • Survivors of cardiac arrest due to VF or hemodynamically unstable sustained VT after evaluation to determine the etiology and to exclude any completely reversible causes (level of evidence [LOE]: A)

  • Patients with structural heart disease and spontaneous sustained VT, whether hemodynamically stable or unstable (LOE: B)

  • Patients with syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT/VF induced at electrophysiological study (EPS) (LOE: B)

  • Patients with an LVEF up to 35% due to prior myocardial infarction (MI) who are at least 40 days post-MI and are in New York Heart Association (NYHA) functional class II or III (LOE: A)

  • Patients with nonischemic dilated cardiomyopathy (DCM) who have an LVEF up to 35% and who are in NYHA functional class II or III (LOE: B)

  • Patients with LV dysfunction due to prior MI who are at least 40 days post-MI, have an LVEF up to 30%, and are in NYHA functional class I (LOE: A)

  • patients with nonsustained VT due to prior MI, LVEF up to 40%, and inducible VF or sustained VT at EPS

Class IIa

ICD implantation is reasonable for patients with the following:

  • Sustained VT and normal or near-normal ventricular function (LOE: C)
  • Catecholaminergic polymorphic VT who have syncope and/or documented sustained VT while receiving beta blockers. (LOE: C)
  • Brugada syndrome who have had (1) syncope or (2) documented VT that has not resulted in cardiac arrest (LOE: C)
  • Unexplained syncope, significant LV dysfunction, and nonischemic DCM (LOE: C)
  • Hypertrophic cardiomyopathy (HCM) who have one or more major risk factors for sudden cardiac death (SCD) (LOE: C)
  • Cardiac sarcoidosis, giant cell myocarditis, or Chagas disease (LOE: C)

ICD implantation is also reasonable for (1) reduction of SCD in patients with long-QT syndrome who are experiencing syncope and/or VT while receiving beta blockers (LOE: B) or (2) prevention of SCD in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy) (ARVD/C) who have one or more risk factors for SCD (LOE: C).

Class III

ICD implantation is not indicated for the following patients:

  • Those who do not have a reasonable expectation of survival with an acceptable functional status for at least 1 year, even if they meet ICD implantation criteria specified above (LOE: C)

  • Those with incessant VT or VF (LOE: C)

  • Those with significant psychiatric illnesses that may be aggravated by device implantation or that may preclude systematic follow-up (LOE: C)

  • Those with syncope of undetermined cause in a patient without inducible ventricular tachyarrhythmias and without structural heart disease. (LOE: C)

  • When VF or VT is amenable to surgical or catheter ablation (eg, atrial arrhythmias associated with the Wolff-Parkinson-White syndrome, RV or LV outflow tract VT, idiopathic VT, or fascicular VT in the absence of structural heart disease) (LOE: C)

  • Those with ventricular tachyarrhythmias due to a completely reversible disorder in the absence of structural heart disease (eg, electrolyte imbalance, drugs, or trauma) (LOE: B)

In the 2012 ACC Foundation/AHA/HRS focused update, after a review of all published evidence since the publication of the 2008 guidelines, it was determined that no changes were warranted in the recommendations for ICD indications. [114]

Idiopathic VF 

In its 2013 expert consensus statement on inherited primary arrhythmia syndromes, the Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society (HRS/EHRA/APHRS) recommended a diagnosis of idiopathic VF when a resuscitated cardiac arrest victim, preferably with documentation of VF, has known cardiac, respiratory, metabolic, and toxicologic etiologies excluded through clinical evaluation. [115]

Treatment recommendations include [115] :

  • ICD implantation (class I)
  • Consider antiarrhythmic therapy with quinidine, programmed electrical stimulation guided or empirical, in patients in conjunction with ICD implantation or when ICD implantation is contraindicated or refused (class IIb).
  • Consider ablation of Purkinje potentials in patients presenting with uniform morphology premature ventricular contractions in conjunction with ICD implantation or when ICD implantation is contraindicated or refused (class IIb)
  • If a first-degree relative presents with unexplained syncope and no identifiable phenotype, then after careful counseling an ICD implant may be considered (class IIb).

Guidelines released in 2015 by the European Society of Cardiology (ESC) for the management of ventricular arrhythmias and prevention of SCD, include the following recommendations for the treatment of idiopathic VF (all class I) [116] :

  • ICD implantation is recommended in all survivors of idiopathic VF.
  • When performed by experienced operators, catheter ablation can terminate premature ventricular complexes (PVCs) triggering recurrent VF that lead to ICD interventions, or of PVCs leading to electrical storm.