Please cite this article in press as: Driver BE, et al. Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with refractory ventricular fibrillation. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.06.032 ARTICLE IN PRESS G Model RESUS-6071; No. of Pages 5 Resuscitation xxx (2014) xxx–xxx Contents lists available at ScienceDirect Resuscitation j ourna l h o me pa g e : www.elsevier.com/locate/resuscitation Clinical paper Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with refractory ventricular fibrillation Brian E. Driver a,∗ , Guillaume Debaty a,b,c , David W. Plummer a , Stephen W. Smith a a Hennepin County Medical Center, Department of Emergency Medicine, 701 Park Ave S, MC 825, Minneapolis, MN 55415, USA b University of Minnesota, Department of Medicine-Cardiovascular Division, Mayo Mail Code 508, 420 Delaware Street SE, Minneapolis, MN 55455, USA c UJF-Grenoble 1/CNRS/CHU de Grenoble/TIMC-IMAG UMR 5525, Grenoble, F-38041, France a r t i c l e i n f o Article history: Received 4 March 2014 Received in revised form 24 June 2014 Accepted 30 June 2014 Keywords: Cardiopulmonary resuscitation Defibrillation Cardiac arrest a b s t r a c t Introduction: We compare the outcomes for patients who received esmolol to those who did not receive esmolol during refractory ventricular fibrillation (RVF) in the emergency department (ED). Methods: A retrospective investigation in an urban academic ED of patients between January 2011 and January 2014 of patients with out-of-hospital or ED cardiac arrest (CA) with an initial rhythm of ventri- cular fibrillation (VF) or ventricular tachycardia (VT) who received at least three defibrillation attempts, 300 mg of amiodarone, and 3 mg of adrenaline, and who remained in CA upon ED arrival. Patients who received esmolol during CA were compared to those who did not. Results: 90 patients had CA with an initial rhythm of VF or VT; 65 patients were excluded, leaving 25 for analysis. Six patients received esmolol during cardiac arrest, and nineteen did not. All patients had ventricular dysrhythmias refractory to many defibrillation attempts, including defibrillation after admin- istration of standard ACLS medications. Most received high doses of adrenaline, amiodarone, and sodium bicarbonate. Comparing the patients that received esmolol to those that did not: 67% and 42% had tem- porary return of spontaneous circulation (ROSC); 67% and 32% had sustained ROSC; 66% and 32% survived to intensive care unit admission; 50% and 16% survived to hospital discharge; and 50% and 11% survived to discharge with a favorable neurologic outcome, respectively. Conclusion: Beta-blockade should be considered in patients with RVF in the ED prior to cessation of resuscitative efforts. © 2014 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Refractory ventricular fibrillation (RVF) is a severe form of electrical storm in which rapidly clustering episodes of ventri- cular fibrillation (VF) recur or persist after multiple defibrillation attempts, precluding any period of sustained return of sponta- neous circulation (ROSC). No formal definition exists for either RVF or electrical storm. 1 In RVF, the approaches outlined in the American Heart Association Advanced Cardiac Life Sup- port (ACLS) guidelines are often unsuccessful in achieving and maintaining ROSC, and mortality is high. 1–4 Patients in car- diac arrest (CA) have high levels of endogenous and exogenous (if administered) catecholamines. 5,6 While the activation of - 1 receptors by adrenaline (epinephrine) causes vasoconstriction ∗ Corresponding author. E-mail address: briandriver@gmail.com (B.E. Driver). and increased coronary perfusion pressure, the activation of -1 and -2 receptors has deleterious effects by increasing myocar- dial oxygen requirements, worsening ischemic injury, lowering the VF threshold, and worsening post-resuscitation myocardial function. 5,7 Blocking -adrenergic receptors has shown promise in ter- minating electrical storm in recent animal and human trials. 5–9 Esmolol is a short acting (half-life, approximately 9 min) 1- adrenergic receptor antagonist which we have increasingly been using in our Emergency Department (ED) for patients in VF unresponsive to defibrillation despite administration of recom- mended antidysrhythmic medications. Esmolol is used because its ultra-short half-life allows for rapid cessation in case of cardiogenic shock, a known adverse effect of -adrenergic blockade. 10 The objective of this study was to compare the outcomes of patients who received esmolol to those who did not receive esmolol during RVF in the ED. http://dx.doi.org/10.1016/j.resuscitation.2014.06.032 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.