Ventricular fibrillation

Cardiovascular

Clinicals - History

Fact Explanation
Asymptomatic Some patients are asymptomatic especially if the VF is non-sustained. VF is common in patients who are 45 to 75 years old. Asymptomatic
Some patients are asymptomatic especially if the VF is non-sustained. VF is common in patients who are 45 to 75 years old.
History of coronary artery disease Patients with coronary artery disease and a history of myocardial infarction are at high risk of VF. Presence of cardiovascular risk factors (obesity, unhealthy dietary practices, physical inactivity, smoking) should also be looked for. History of coronary artery disease
Patients with coronary artery disease and a history of myocardial infarction are at high risk of VF. Presence of cardiovascular risk factors (obesity, unhealthy dietary practices, physical inactivity, smoking) should also be looked for.
Syncope Patients experience syncope or near syncope. Ventricular tachycardia causes rapid and unproductive ventricular contractions, leading to reduced cerebral perfusion and syncope. Syncope
Patients experience syncope or near syncope. Ventricular tachycardia causes rapid and unproductive ventricular contractions, leading to reduced cerebral perfusion and syncope.
Sudden cardiac death VF is the commonest cause of sudden cardiac death. Sudden cessation of cardiac output leads to sudden death. Presence of family history of sudden cardiac death is also an important risk factor of VF. Sudden cardiac death
VF is the commonest cause of sudden cardiac death. Sudden cessation of cardiac output leads to sudden death. Presence of family history of sudden cardiac death is also an important risk factor of VF.
History of arrhythmia History of frequent ventricular ectopy, premature ventricular contractions or rapid ventricular tachycardia are risk factors of VF.
Patients may develop VF after therapeutic cardioversion as well.
History of arrhythmia
History of frequent ventricular ectopy, premature ventricular contractions or rapid ventricular tachycardia are risk factors of VF.
Patients may develop VF after therapeutic cardioversion as well.
History of cardiomyopathy Patients with dilated cardiomyopathy and hypertrophic cardiomyopathy are at risk of VF. History of cardiomyopathy
Patients with dilated cardiomyopathy and hypertrophic cardiomyopathy are at risk of VF.
History of myocarditis Myocarditis is another cause for the development of VF. History of myocarditis
Myocarditis is another cause for the development of VF.
History of structural heart diseases Structural heart diseases, surgical repair of congenital heart diseases (Tetralogy of Fallot, Ebstein’s anomaly, single ventricle, transposition of the great arteries carry the highest risk of VF. Atrial septal defect and valvar pulmonary stenosis carry a small risk of VF. ) and valvular heart diseases can lead to VF. Sarcoidosis and other infiltrative heart diseases and right ventricular dysplasia are other causes of VF. History of structural heart diseases
Structural heart diseases, surgical repair of congenital heart diseases (Tetralogy of Fallot, Ebstein’s anomaly, single ventricle, transposition of the great arteries carry the highest risk of VF. Atrial septal defect and valvar pulmonary stenosis carry a small risk of VF. ) and valvular heart diseases can lead to VF. Sarcoidosis and other infiltrative heart diseases and right ventricular dysplasia are other causes of VF.
History of ECG abnormalities Patients with ECG evidence of long QT syndrome, Wolff-Parkinson-White syndrome and Brugada syndrome can have VF. History of ECG abnormalities
Patients with ECG evidence of long QT syndrome, Wolff-Parkinson-White syndrome and Brugada syndrome can have VF.
Triggering factors VF can be triggered by antiarrhythmic drugs, hypoxia, electrolyte imbalances, myocardial ischemia, cardioversion, and competitive ventricular pacing. Triggering factors
VF can be triggered by antiarrhythmic drugs, hypoxia, electrolyte imbalances, myocardial ischemia, cardioversion, and competitive ventricular pacing.

Clinicals - Examination

Fact Explanation
Level of consciousness Most patients are unconscious at the time of presentation. Level of consciousness
Most patients are unconscious at the time of presentation.
Pulse In the emergency setting patient can be pulseless. More than ten seconds should not be spent trying to palpate the pulse because life saving measures should be immediately carried out. Pulse
In the emergency setting patient can be pulseless. More than ten seconds should not be spent trying to palpate the pulse because life saving measures should be immediately carried out.
Blood pressure Hypotension is commonly observed. This is due to diminished cardiac output which occurs secondary to unproductive ventricular contractions. Blood pressure
Hypotension is commonly observed. This is due to diminished cardiac output which occurs secondary to unproductive ventricular contractions.
Cardiac auscultation No heart sounds are audible during a VF. This is due to uncoordinated atrial and ventricular contractions. Cardiac auscultation
No heart sounds are audible during a VF. This is due to uncoordinated atrial and ventricular contractions.

Investigations - Diagnosis

Fact Explanation
ECG There are few characteristic features of the ECG. The waves are bizarre and irregular. The QRS complexes and P waves can not be clearly identified and the baseline is irregular. ECG
There are few characteristic features of the ECG. The waves are bizarre and irregular. The QRS complexes and P waves can not be clearly identified and the baseline is irregular.
Exercise ECG Exercise induced arrhythmia can be detected by the exercise ECG. Exercise ECG
Exercise induced arrhythmia can be detected by the exercise ECG.
Holter monitoring Holter monitoring is indicated if VF is strongly suspected and if the ECG is normal. Holter monitoring
Holter monitoring is indicated if VF is strongly suspected and if the ECG is normal.
Echocardiography Reduced ejection fraction and abnormal left ventricular wall motion predicts the risk of VF. Transesophageal echocardiogram demonstrates irregular ventricular oscillations. Echocardiography
Reduced ejection fraction and abnormal left ventricular wall motion predicts the risk of VF. Transesophageal echocardiogram demonstrates irregular ventricular oscillations.

Investigations - Management

Fact Explanation
ECG VF can recur even after treatment, so ECG monitoring is necessary. ECG
VF can recur even after treatment, so ECG monitoring is necessary.

Management - Supportive

Fact Explanation
Basic life support Cardiopulmonary resuscitation should be immediately started. Assessment of the airway, breathing and circulation should be carried out but it should not delay cardiac defibrillation. Oxygen should be delivered via a face mask and if the patient is unconscious immediate intubation and bag and mask ventilation is necessary. Patient should be connected to a cardiac monitor. Administration of intravenous fluid is considered if necessary. Some patients with severe cardiac failure and cardiogenic shock may require mechanical cardiac support. Intravenous adrenaline is also helpful because it is a vasoconstrictor and increases the cerebral perfusion.
Patients should be given intensive care because of the high risk of recurrence.
Basic life support
Cardiopulmonary resuscitation should be immediately started. Assessment of the airway, breathing and circulation should be carried out but it should not delay cardiac defibrillation. Oxygen should be delivered via a face mask and if the patient is unconscious immediate intubation and bag and mask ventilation is necessary. Patient should be connected to a cardiac monitor. Administration of intravenous fluid is considered if necessary. Some patients with severe cardiac failure and cardiogenic shock may require mechanical cardiac support. Intravenous adrenaline is also helpful because it is a vasoconstrictor and increases the cerebral perfusion.
Patients should be given intensive care because of the high risk of recurrence.
Correct any electrolyte imbalances Electrolyte imbalance especially hypomagnesaemia and hypokalemia can precipitate arrhythmia and it is reversible. If present magnesium supplementation should be done. Correct any electrolyte imbalances
Electrolyte imbalance especially hypomagnesaemia and hypokalemia can precipitate arrhythmia and it is reversible. If present magnesium supplementation should be done.

Management - Specific

Fact Explanation
Defibrillation Defibrillation is the most important management option in managing VF. Early defibrillation is lifesaving in emergencies. Ideally it should be done within two minutes in the emergency department. The two paddles should be kept over the right upper sternum and over the cardiac apex or over the tip of the left scapula and anterior left chest. Defibrillation
Defibrillation is the most important management option in managing VF. Early defibrillation is lifesaving in emergencies. Ideally it should be done within two minutes in the emergency department. The two paddles should be kept over the right upper sternum and over the cardiac apex or over the tip of the left scapula and anterior left chest.
Implantation of defibrillator Insertion of internal cardioverter-defibrillator (ICD) is recommended in all patients with VF even in the absence of non-sustained VF. Implantation of defibrillator
Insertion of internal cardioverter-defibrillator (ICD) is recommended in all patients with VF even in the absence of non-sustained VF.
Catheter ablation Catheter ablation of the premature ventricular contraction triggers are useful in some patients. Catheter ablation
Catheter ablation of the premature ventricular contraction triggers are useful in some patients.
Medical management Isoproterenol and quinidine are used in the acute and long term management of VF respectively. Beta blockers are proven to reduce the risk of recurrence of VF. Amiodarone is the drug of choice if defibrillation fails. Medical management
Isoproterenol and quinidine are used in the acute and long term management of VF respectively. Beta blockers are proven to reduce the risk of recurrence of VF. Amiodarone is the drug of choice if defibrillation fails.

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