Scar related ventricular tachycardia after prior MI (I25.2)
Decompensated heart failure with ventricular arrhythmia (I50.20)
Drug induced ventricular arrhythmia from stimulants (F15.90)
Acute myocarditis (I40.9)
Less common
Less common and specific syndromes
Long QT syndrome (I45.81)
Torsades de pointes transition pattern
QT prolonging medication exposure
Brugada syndrome (I49.8)
Fever trigger
Brugada pattern after ROSC
Hypertrophic cardiomyopathy (I42.1)
Exertional syncope history
Family history of sudden death
Commotio cordis (S20.20)
Blunt precordial impact
Immediate collapse during sports
Past Medical History
Cardiovascular history
Prior cardiac diagnoses
Coronary artery disease
Prior MI
Heart failure
Ventricular arrhythmia history
ICD shocks history
Comorbid conditions
Non cardiac conditions affecting risk
Chronic kidney disease
Diabetes mellitus (E11.9)
COPD (J44.9)
Obstructive sleep apnea (G47.33)
Procedures and devices
Prior procedures
Coronary stent placement
Coronary bypass surgery
Pacemaker implantation
ICD implantation
Physical Exam
Intra arrest assessment
Resuscitation focused exam
Pulse checks limited to less than 10 seconds
Airway patency and chest rise
Breath sounds bilaterally
Signs of trauma
Evidence of external bleeding
Post ROSC examination
Comprehensive post ROSC exam
Hemodynamic status with perfusion markers
Pupillary size and reactivity
Focal neurologic deficits
Skin temperature and diaphoresis
Signs of infection source
Device related findings
Cardiac device assessment
Visible ICD or pacemaker pocket
Magnet availability and plan for inappropriate shocks
Defibrillation pad placement away from device pocket
Lab Studies
Point of care during resuscitation
Immediate actionable labs
Point of care glucose
Hypoglycemia correction threshold local protocol dependent
Hyperglycemia context for metabolic derangements
Electrolytes focused panel
Potassium level interpretation for hyperkalemia management
Magnesium level for torsades risk context
Venous or arterial blood gas
pH assessment for severe acidosis
Lactate for global hypoperfusion context
After ROSC
Broad evaluation for etiology and complications
High sensitivity troponin series
Early false negative risk with very early sampling
Interpretation integrated with ECG and clinical context
CBC
Anemia or hemorrhage clues
Leukocytosis context for infection
CMP
Renal function for contrast planning
Transaminases for shock liver context
Coagulation studies
Anticoagulant effect detection
Procedure readiness
Toxicology tests when indicated
Acetaminophen level
Salicylate level
Targeted drug levels when available
Imaging
Scoring Systems
Risk and prognostication tools
Cardiac arrest etiology framework using 4H 4T checklist
Post ROSC neurologic prognostication delayed and multimodal local protocol dependent
MRI
Neuro imaging after ROSC
Brain MRI for hypoxic ischemic injury assessment in selected cases
MRI timing and sequence selection local protocol dependent
CT
Etiology and complication evaluation
CT head for alternative diagnosis when collapse unclear
CT pulmonary angiography when pulmonary embolism suspected
CT angiography chest when aortic catastrophe suspected
Contrast nephropathy risk assessment in unstable patients
Ultrasound
POCUS integration
Cardiac POCUS for tamponade and severe dysfunction
Lung POCUS for pneumothorax
IVC assessment for volume status context
POCUS guided identification of reversible causes
Special Tests
Resuscitation monitoring
Bedside physiologic monitoring adjuncts
Waveform capnography
End tidal carbon dioxide as CPR quality marker
Sudden rise suggesting ROSC
Defibrillator rhythm analysis
Fine VF versus asystole recognition
Artifact minimization during rhythm checks
Device evaluation
Cardiac device diagnostics
ICD interrogation after ROSC when available
Pacemaker interrogation for failure to capture or sensing issues
ECG
Rhythm identification
Shockable rhythm patterns
Ventricular fibrillation
Pulseless monomorphic ventricular tachycardia
Polymorphic ventricular tachycardia
Torsades de pointes pattern
Post ROSC ECG strategy
Ischemia detection and cath pathway triggers
12 lead ECG as soon as feasible after ROSC
ST elevation pathway activation local protocol dependent
Serial ECG when initial ECG nondiagnostic and suspicion persists
Assessment
Working problem list
Cardiac arrest with shockable rhythm
Ventricular fibrillation present
Pulseless ventricular tachycardia present
Refractory VF or VT definition after multiple shocks with ongoing arrest local protocol dependent
Etiology assessment
Reversible cause synthesis using 4H 4T
Hypoxia
Hypovolemia
Hydrogen ion acidosis
Hypo or hyperkalemia
Hypothermia
Tension pneumothorax
Tamponade
Toxins
Thrombosis coronary
Thrombosis pulmonary
Plan
First 5 minutes workflow
Immediate shockable rhythm actions
High quality CPR immediately
Compression rate 100 to 120 per minute
Compression depth 5 to 6 cm in adults
Full recoil and minimal interruptions
Switch compressor every 2 minutes
Defibrillation as soon as available
Biphasic defibrillation initial dose 200 J if unknown manufacturer
Escalating energy strategy for subsequent shocks
Monophasic defibrillation dose 360 J
Rhythm check and shock cycles every 2 minutes
Pulse check only if organized rhythm appears
Rhythm check pause less than 10 seconds
Airway and ventilation
Oxygenation and ventilation targets
Bag valve mask with two person technique
Advanced airway when interruptions minimized
Once advanced airway in place continuous compressions
Ventilation rate 10 breaths per minute with advanced airway
Waveform capnography confirmation for endotracheal tube
Vascular access
Access strategy
IV access preferred
IO access if IV delayed
Central access deferred until ROSC unless needed
Medications during VF or pulseless VT
Vasopressor strategy
Epinephrine IV or IO 1 mg
Repeat every 3 to 5 minutes
Timing typically after second shock
Antiarrhythmic strategy for refractory VF or VT
Amiodarone IV or IO 300 mg bolus
Additional amiodarone IV or IO 150 mg bolus
Lidocaine IV or IO 1 to 1.5 mg per kg if amiodarone unavailable or ineffective
Additional lidocaine 0.5 to 0.75 mg per kg
Maximum lidocaine 3 mg per kg
Torsades focused therapy when polymorphic VT with prolonged QT
Magnesium sulfate IV 2 g
Over 1 to 2 minutes in arrest context
Defibrillation technique
Shock optimization
Pad placement anterolateral or anteroposterior
Ensure dry chest and remove medication patches
No one touching patient during shock
Immediate CPR resumption after shock without rhythm recheck
Refractory VF or VT options
Escalation therapies local protocol dependent
Vector change defibrillation pad repositioning
Double sequential external defibrillation local protocol dependent
Esmolol bolus and infusion for refractory VF local protocol dependent
ECPR referral criteria and activation local protocol dependent
Treat reversible causes
Targeted interventions based on suspected cause
Hyperkalemia treatment bundle
Calcium chloride IV 1 g via central line when available
Calcium gluconate IV 3 g via peripheral line alternative
Regular insulin IV 10 units
Dextrose IV 25 g if glucose not elevated
Sodium bicarbonate IV 50 mmol if severe acidosis or hyperkalemia with ECG changes
Tension pneumothorax
Needle decompression local protocol dependent
Finger thoracostomy local protocol dependent
Cardiac tamponade
Pericardiocentesis local protocol dependent
Trauma surgery activation when traumatic
Coronary thrombosis
Cath lab activation after ROSC when STEMI or high suspicion local protocol dependent
Post ROSC immediate care
Stabilization after ROSC
Target oxygen saturation 92 to 98 percent
Avoid hyperventilation
Maintain systolic blood pressure at least 90 mmHg local protocol dependent
Treat hypotension with fluids and vasopressors
Temperature management strategy local protocol dependent
Special populations
Pregnancy considerations
Manual left uterine displacement during CPR after mid pregnancy
Early obstetric activation
Perimortem cesarean consideration local protocol dependent
Pediatric considerations
Defibrillation first shock 2 J per kg
Subsequent defibrillation at least 4 J per kg
Epinephrine IV or IO 0.01 mg per kg of 0.1 mg per mL concentration
Amiodarone IV or IO 5 mg per kg bolus
Hypothermia considerations
Continue resuscitation until rewarmed local protocol dependent
Limit shocks to 3 until temperature above 30 C local protocol dependent
Disposition
Level of care
Post ROSC disposition pathways
ICU admission for all comatose survivors
Cath lab pathway for STEMI or high suspicion local protocol dependent
Neurologic critical care involvement when prolonged coma
Termination considerations
Termination of resuscitation framework local protocol dependent
Persistent arrest despite appropriate algorithm and reversible cause treatment
Unwitnessed arrest with no bystander CPR and prolonged downtime context
Decision aligned with local TOR rules and medical control
Discharge Instructions
Copy discharge instructions
Discharge planning uncommon after VF or pulseless VT arrest
Hospital admission expected for monitoring and definitive evaluation
If discharged after full inpatient evaluation local protocol dependent
Return immediately for chest pain
Return immediately for fainting or near fainting
Return immediately for palpitations with dizziness
Return immediately for shortness of breath
Follow up with cardiology within timeframe provided by inpatient team
Medication list reviewed with patient and caregiver
Driving and activity restrictions per cardiology guidance
References
Guideline and evidence sources
Core resuscitation references
American Heart Association Guidelines for CPR and Emergency Cardiovascular Care 2020
European Resuscitation Council Guidelines 2021 adult advanced life support
International Liaison Committee on Resuscitation CoSTR 2020
ALPS trial amiodarone lidocaine placebo in out of hospital shock refractory VF or VT 2016
Project instructions
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.