The optimal sequence of events that should follow for a persistent shockable rhythm is not known. The sequence cannot be prescribed exactly but the general principles that should be followed are listed here.
- At all times, interruptions to compressions should be minimised.
- After an unsuccessful attempt at defibrillation a 2-minute period of CPR is recommended before the rhythm is reassessed.
- If when the rhythm is reassessed a shockable rhythm persists, repeat defibrillation (second shock).
- After the second attempt at defibrillation on recommencing chest compressions administer 1 mg adrenaline, continue CPR for 2 minutes and then reassess and repeat defibrillation if indicated (third shock).
- Adrenaline should subsequently be administered at a rate of 1 mg approximately every three minutes until Return of Spontaneous Circulation. For simplicity, adrenaline could be administered in alternate loops. A period of at least 1-2 minutes of good CPR is recommended after each dose of adrenaline to help circulate the drug.
- If the subsequent attempt at defibrillation is also unsuccessful, a 2-minute period of CPR is again recommended before the rhythm is reassessed.
- If VF is still present after the administration of adrenaline and one further shock, consider administration of an anti-arrhythmic before defibrillation (fourth shock).
- At any stage if a rhythm is present that should be associated with a pulse, then formal checking for signs of life (including a pulse check) should be performed. If there are no signs of life (including a pulse) then the non-shockable sequence should be followed.
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