Ventricular Fibrillation, ROSC after perfusion restored by ECMO, then ECG. Protocols can be overridden by Physician Judgment.

A middle-aged male had sudden chest pain and called 911.  First responders arrived.  Then the patient arrested.  Chest compressions were started immediately.  Paramedics arrived a few seconds later and found the patient in ventricular fibrillation.  He could not be defibrillated after 3 attempts.  He was intubated, given epinephrine and amiodarone, and transported.He arrived in the ED 35 minutes after arrest.  He remained pulseless and in V Fib.Defibrillation was not successful.Cannulation for ECMO (Extracorporeal life support -- ECLS) was begun.He was debribrillated again and had brief (15 second) ROSC with a pulse and some function on TEE.  But it degenerated into ventricular fibrillation again.Shortly thereafter, his lactate returned unmeasurably high at greater than 17.5.  This is an exclusion criterion for our ECMO protocol, as it is associated with prolonged and profound hypoperfusion, and thus with futility.Cannulation was paused and we briefly discussed the situation:Because we had achieved 15 seconds of ROSC with a pulse, we determined that exclusion criteria for the refractory ventricular fibrillation protocol should not apply to this patient. Cannulation was continued.He was successfully cannulated for ECMO  and at 50 minutes after arrest was on the pump and perfusing with a good blood pressure.While on pump, he was defibrillated again, successfully (sustained ROSC).His ED TEE (transesophageal echo) is her...

Source: Dr. Smith's ECG Blog - January 23, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs