Ventricular Fibrillation in Emergency Medicine Differential Diagnoses

Updated: Dec 30, 2015
  • Author: Keith A Marill, MD; Chief Editor: Erik D Schraga, MD  more...
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Diagnostic Considerations

Important considerations

Note the following:

  • Address underlying causes of VF and refer patient to appropriate care provider
  • Initiate defibrillation following diagnosis of VF
  • Adequately train personnel on use of defibrillation equipment
  • Keep all equipment properly maintained and fully charged

Special concerns

Ventricular fibrillation (VF) is the initial rhythm in 4-9% of pediatric cardiac arrests in multiple series. [8] In addition to witnessed arrest and bystander CPR, near-drowning etiology is associated with a better prognosis.

Postcardiac arrest survival

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. [9] 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. The cutting edge "cardiocerebral resuscitation" approach appears to benefit those patients older than age 80 years as well as younger age groups. [10]

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.

Presence of family members

Family presence during resuscitation is practiced in some health care facilities. Although 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. [11]

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.

Other problems to be considered

Other conditions to be considered in patients with suspected ventricular fibrillation include the following:

  • Ventricular flutter
  • Wide complex tachycardia
  • Supraventricular tachycardia
  • Pulseless electrical activity (PEA)
  • Digitalis toxicity
  • Electrolyte disturbances
  • Acute pulmonary disorders
  • Acute toxidromes (eg, cocaine toxicity)

Differential Diagnoses