›Repeat dose: 0.5-0.75 mg/kg every 5-10 minutes
›Maximum total dose: 3 mg/kg
›Magnesium (for torsades de pointes only)
›Magnesium sulfate 2 g IV over 5-10 minutes
›Magnesium not beneficial for refractory VF unrelated to TdP (Class III: No Benefit) [1][8]
›Medications to avoid during arrest
›Calcium channel blockers (verapamil, diltiazem) in wide-complex arrest (Class III: Harm) [8]
›Procainamide in out-of-hospital VF arrest (associated with worse outcomes) [2][8]
›Prophylactic lidocaine in suspected AMI (Class III: Harm) [8]
Post-ROSC Hemodynamic Management
›Vasopressor support
›Norepinephrine 0.1-0.5 mcg/kg/min titrated to MAP 65 mmHg
›Dopamine 5-20 mcg/kg/min as alternative
›Vasopressin 0.03-0.04 units/min as adjunct for refractory hypotension
›Inotropic support
›Dobutamine 2.5-20 mcg/kg/min for low cardiac output state
›Epinephrine 0.05-0.5 mcg/kg/min for combined vasopressor-inotrope need
›Mechanical circulatory support
›IABP or Impella for cardiogenic shock refractory to vasopressors
›ECMO (VA-ECMO) for refractory cardiac arrest or VT storm
Targeted Temperature Management
›Temperature control protocol [19][20]
›Maintain constant temperature 32-37.5 degrees C for at least 36 hours post-ROSC
›Active fever prevention mandatory (target less than 37.7 degrees C) for 72 hours [19]
›Cooling method: endovascular or surface cooling devices preferred
›Temperature monitoring: continuous esophageal or bladder thermometry
›Rewarming
›Rate of rewarming no faster than 0.25-0.5 degrees C per hour
›Avoid rebound hyperthermia during and after rewarming
Post-ROSC Antiarrhythmic Maintenance
›Beta-blocker therapy
›IV metoprolol 5 mg IV over 5 minutes (may repeat x3) for recurrent VF or VT storm
›Transition to oral metoprolol succinate 25-200 mg daily
›Beta blockers are cornerstone of long-term arrhythmia prevention [4]
›IV amiodarone infusion post-resuscitation
›Amiodarone 150 mg IV over 10 minutes for recurrence
›Followed by 1 mg/min infusion for 6 hours then 0.5 mg/min for 18 hours
›Maximum daily dose 2.2 g IV (cumulative including arrest doses)
Coronary Revascularization
›Emergency PCI
›STEMI on post-ROSC ECG: emergent PCI regardless of coma status (Class I) [6][8]
›Suspected ACS without ST elevation: urgent angiography within 24 hours
›One-third of patients without ST elevation have a culprit lesion [8]
›CABG
›For patients with multivessel CAD not suitable for PCI after stabilization
›ICD implantation
›Indicated for all VF survivors after evaluation excludes completely reversible cause (Class I) [8][12]
›Not indicated if VF due to completely reversible cause without structural heart disease (e.g., isolated electrolyte abnormality, drug toxicity) [12]
›Wearable defibrillator (LifeVest) as bridge to ICD or during evaluation
›Catheter ablation
›For recurrent VF triggered by consistent PVC morphology (PVC-triggered VF) [8]
›VT storm: ablation after failure of antiarrhythmic therapy
›Stellate ganglion block for refractory electrical storm
›VT/VF storm definition
›Three or more distinct episodes of VT or VF within 24 hours requiring intervention
›Medical management
›Deep sedation and analgesia (morphine, propofol, or ketamine)
›IV amiodarone infusion (as above)
›IV beta blocker (esmolol infusion 500 mcg/kg bolus then 50-300 mcg/kg/min)
›Address reversible triggers (electrolytes, ischemia, fever)
›Procedural management
›Emergent catheter ablation
›Stellate ganglion block (left-sided) for refractory sympathetic storm