Refractory Cardiac Arrest - A Clinical Practice Update with Dr Rebecca Mathew

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Feb 10, 2025

Dr. Rebecca Mathew, a cardiologist and critical care specialist at the University of Ottawa Heart Institute, shares insights on refractory cardiac arrest practices. She discusses advanced techniques like double sequential defibrillation and the use of antiarrhythmics like amiodarone and lidocaine. The episode highlights the role of ECPR and the challenges of patient selection. Additionally, Dr. Mathew emphasizes the importance of patient engagement in critical care and the need for a cultural shift in clinical trial participation to improve treatment outcomes.

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INSIGHT

Defining Refractory Cardiac Arrest

Refractory cardiac arrest is defined as requiring 10+ minutes of CPR or more than three defibrillations.
Clinically, persistent unremitting ventricular arrhythmia after multiple shocks also defines it.

INSIGHT

Antiarrhythmics: Amiodarone vs Lidocaine

ALPS trial showed no survival difference between amiodarone, lidocaine, or placebo for shockable rhythms.
Lidocaine is favored anecdotally for ischemia-driven arrhythmias but both drugs are options.

ADVICE

Using Amiodarone and Lidocaine Together

Start with amiodarone as first-line then add lidocaine after total 450 mg amiodarone.
Use pragmatic lidocaine bolus doses (100 mg) and continue boluses if ongoing arrest.

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Recorded live at the Critical Care Canada Forum 2024, this episode is part of our special Cardiac ICU Series.

Dr. Rebecca Mathew, cardiologist and critical care specialist at the University of Ottawa Heart Institute, joins us to discuss the latest refractory cardiac arrest practice updates, including antiarrhythmic drugs, defibrillation strategies, and the role of ECPR.

Chapters:

• Defining refractory cardiac arrest

• Antiarrhythmic drugs: amiodarone vs. lidocaine

• Defibrillation strategies: vector change and double sequential defibrillation

• Emerging therapies: stellate ganglion blocks and electrical storm management

• ECPR: who qualifies and what the trials say

• Equity and feasibility challenges in cardiac arrest management

• ICU recovery clinics and patient-centered outcomes

• Clinical trials: barriers to enrollment and the need for change

References:

1. ROC ALPS Trial: 1. Kudenchuk PJ, Brown SP, Daya M, et al. Resuscitation Outcomes Consortium-Amiodarone, Lidocaine or Placebo Study (ROC-ALPS): Rationale and Methodology Behind an Out-of-Hospital Cardiac Arrest Antiarrhythmic Drug Trial. American Heart Journal. 2014;167(5):653-9.e4. doi:10.1016/j.ahj.2014.02.010. PMID: 24766974.[1]

2. DOSE VF: Cheskes S, Drennan IR, Turner L, Pandit SV, Dorian P. The Impact of Alternate Defibrillation Strategies on Shock-Refractory and Recurrent Ventricular Fibrillation: A Secondary Analysis of the DOSE VF Cluster Randomized Controlled Trial. Resuscitation. 2024;198:110186. doi:10.1016/j.resuscitation.2024.110186. PMID: 38522736

3. ARREST: Yannopoulos D, Bartos J, Raveendran G, et al. Advanced Reperfusion Strategies for Patients With Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation (ARREST): A Phase 2, Single Centre, Open-Label, Randomised Controlled Trial. Lancet (London, England). 2020;396(10265):1807-1816. doi:10.1016/S0140-6736(20)32338-2. PMID: 33197396

4. INCEPTION: Ubben JFH, Suverein MM, Delnoij TSR, et al. Early Extracorporeal CPR for Refractory Out-of-Hospital Cardiac Arrest - A Pre-Planned Per-Protocol Analysis of the INCEPTION-trial. Resuscitation. 2024;194:110033. doi:10.1016/j.resuscitation.2023.110033. PMID: 37923112

Disclaimer:

This episode is for educational purposes only and does not constitute medical advice. The views expressed are those of the hosts and guests and do not necessarily reflect their employers.