A Link To “BCE 73 Esmolol in Refractory Ventricular Fibrillation” From Emergency Medicine Cases

Here is the link to the podcast and show notes of the outstanding BCE 73 Esmolol in Refractory Ventricular Fibrillation from Emergency Medicine Cases.

The following are excerpts from the show notes of the above:

In anticipation of EM Cases Episode 112 on Tachydysrhthmias with Amal Mattu and Paul Dorion, Melanie Baimel tells her Best Case Ever of a previously healthy young man who presents in refractory ventricular fibrillation after receiving multiple single shocks, ongoing chest compressions, several rounds of epinephrine, amiodarone and dual sequence defibrillation without ROSC…

Why esmolol for refractory Ventricular Fibrillation?

In refractory Ventricular Fibrillation there is a huge increase in sympathetic tone at least partially due to the epinephrine given, which results in increased myocardial oxygen demand, exacerbation of myocardial ischemia, and depression of the VF threshold. Esmolol is the perfect sympatholytic and it increases the fibrillation threshold. It has the fastest onset and shortest half-life of any B-blocker.

What is the evidence for esmolol for refractory Ventricular Fibrillation?

A 2014 out of a single center in the U.S. compared 6 patients who got esmolol after usual ACLS care with 19 controls who just got usual ACLS care. All 6 patients achieved ROSC after 500mcg/kg IV bolus followed by a drip of a maximum of 100mcg/kg/minunte – with 4 of them achieving sustained ROSC. And here’s the amazing part – survival to discharge with a good neurologic outcome was 50% in the esmolol group vs 11% in the control group. Tiny study with impressive results.

Then in 2016 there was another retrospective study of out of hospital cardiac arrests in Korea comparing 16 patients who got esmolol to 25 patients who didn’t. They used the same dosing of esmolol as the previous study, again after usual ACLS care – 3 shocks, 3mg of epinephrine and 300mg amiodarone – and they found similar outcomes: improved rates of ROSC and survival to the ICU.

So while we’re waiting for some bigger multicentre RCTs, for now, consider esmolol after 3 shocks, 3mg of epi and 300mg of amiodarone in your refractory Ventrcular Fibrillation patients. While esmolol isn’t ready for routine use in this setting, it should be considered as part of the “kitchen sink” when nothing else is working.

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