The management of shock-resistant arrhythmias: a clinical audit

Background/rationale ‐ Although defibrillation has been shown to improve outcome from cardiac arrest, there is a group of patients that presents with ventricular fibrillation/pulseless ventricular tachycardia that is resistant to defibrillation. In these patients, amiodarone has been shown to improve short-term outcome of survival to hospital admission and improve the response to defibrillation. In addition, refractory ventricular fibrillation may fail to be terminated by pads placed in the standard sternal-apical position, and consideration of a pad-position change is advocated by current UK and European resuscitation guidelines.

The aim of this audit was to determine Yorkshire Ambulance Service ambulance crew compliance with current resuscitation guidelines, for adult patients with shockable rhythms that are resistant to defibrillation.

Methods ‐ All adult (≥ 18 years) medical cardiac arrests during the audit period (1 July 2016‐30 September 2016) presenting with ventricular fibrillation/pulseless ventricular tachycardia, and requiring three or more shocks, were reviewed for compliance with three standards. These standards related to the appropriate administration of amiodarone (first 300 mg dose and second 150 mg dose), and pad position change (or consideration of change) for refractory ventricular fibrillation/pulseless ventricular tachycardia after five shocks.

Results ‐ Within the audit period dates, there were 1584 adult cardiac arrests, with resuscitation attempted in 635 incidents. The presenting rhythm was ventricular fibrillation/pulseless ventricular tachycardia in 176 of cases. In the audit sample, there were 53 documented 300 mg amiodarone administrations and 22 documented 150 mg amiodarone administrations. One patient received 150 mg amiodarone but not a first dose of 300 mg. Of the patients who received three or more shocks, 94.9% (94/99) had IV access. It was possible to determine the sequence of rhythms for 76.3% (29/38) of the cardiac arrests that received more than five shocks. Of these patients, 26 had a refractory ventricular fibrillation/pulseless ventricular tachycardia and one patient had a pad position change, or documented consideration of a pad position change.

Conclusion ‐ Compliance with amiodarone administration in shock-resistant arrhythmias is poor and pad position change is not being considered by clinicians for patients in refractory ventricular fibrillation/pulseless ventricular tachycardia. A review of advanced life support training provision and assessment is required within Yorkshire Ambulance Service, and strategies for increasing awareness of amiodarone administration in eligible patients and pad position change are needed.