Management of persistent shockable rhythms during cardiac arrest: a national survey from the REVIVE group (REVIVE-2)

A number of novel treatment strategies have been proposed for managing persistent/refractory ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT). This survey investigated current practices amongst UK Helicopter Emergency Medical Services (HEMS) in preparation for a clinical trial of esmolol for persistent VF/pVT.

This was a cross-sectional survey of the prehospital management of persistent VF/pVT by UK HEMS. A peer-reviewed, pre-piloted survey was distributed to all 21 UK HEMS in January 2025 via the National HEMS Research and Audit forum. The survey included the operationalised definitions of persistent VF/pVT and pharmacological/non-pharmacological management strategies used by services. The survey was distributed via Google Forms and analysed in R (v4.4).

Of UK HEMS services that attend medical cardiac arrests, 19/20 (95%) responded. A formal protocol for the management of persistent VF/pVT existed in 10/19 (53%) services, with 8/10 (80%) defining persistent/refractory as ≥ 3 failed shocks. Modification of adrenaline dosing from the standard treatment algorithm was performed in 9/19 (47.4%) services (de-emphasised in all cases). Esmolol administration as part of a persistent VF/pVT protocol was reported by 2/19 (11%) of services. Most services administered intravenous lidocaine (14/19) and/or magnesium (18/19) for persistent rhythms or at the clinician's discretion. All services permitted vector change defibrillation technique for persistent VF/pVT, with 6/19 (32%) services additionally permitting dual sequential defibrillation.

Treatment strategies for managing persistent VF/pVT vary widely between UK HEMS. Further data is required to support an evidence-based pharmacological approach to this cohort.