Contemporary Practices in Refractory Out-of-Hospital Cardiac Arrest: A Narrative Review
Abstract
1. Introduction
2. Double Sequential Defibrillation (DSD)
3. Beta-Adrenergic Receptor Antagonist Infusion
4. Extracorporeal Cardiopulmonary Resuscitation (ECPR)
- Dual-pump ECMO, enabling pulsatile flow and controlled oxygenation;
- Adjustment of 14 blood parameters (e.g., electrolyte disbalance, osmolarity, oxygenation, free radical scavengers, etc.);
- Comprehensive real-time monitoring (cardiac output, heart rate, invasive blood pressure, blood gas, and electrolyte analysis);
- Out-of-hospital CARL option [45].
5. Conclusions
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
Abbreviations
OHCA | Out-of-hospital cardiac arrest |
PEA | Pulseless electrical activity |
pVT | Pulseless ventricular tachycardia |
VF | Ventricular fibrillation |
ROSC | Return of spontaneous circulation |
ICU | Intensive care unit |
ECPR | Extracorporeal cardiopulmonary resuscitation |
EMS | Emergency medical services |
DSD | Double sequential defibrillation |
ACLS | Advanced cardiac life support |
RCT | Randomized control trial |
DOSE VF | DOuble SEquential external defibrillation for refractory Ventricular Fibrillation |
VC | Vector change |
ERC | European Resuscitation Council |
STEMI | ST-elevation myocardial infarction |
V-A ECMO | Veno-arterial extracorporeal membrane oxygenation |
CPR | Cardiopulmonary resuscitation |
CARL | Controlled automated reperfusion of the whole body |
MoA | Mechanism of action |
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Criterion | Typical Threshold/Requirement |
---|---|
Age | <65 years |
Witnessed arrest | Yes, with immediate (<5 min) high-quality CPR |
Initial rhythm | Shockable rhythm (VF/pVT) |
ROSC | Present |
Low-flow time (arrest-to-ECPR) | <60 min |
Cause | Reversible cardiac |
Underlying MoA | Target Organ System | Agent | Explanation | Reference | |
---|---|---|---|---|---|
Electrophysiological | Cardiac | DSD | Higher energy overcomes the defibrillation threshold (threshold theory). The first shock primes cardiomyocytes, rendering them susceptible to subsequent shock. Vector theory (see below). | [6,16,19] | |
VC | Altering the vector of electrical current increases the probability of successful defibrillation (vector theory). | [10,11,16,19] | |||
Pharmaceutical | Cardiac | Beta-adrenergic receptor blockade | Esmolol | Counteracting the adverse beta-adrenergic effects of epinephrine, which include increased myocardial oxygen demand and heightened arrhythmogenicity, which take place particularly in high doses. | [13,15,17,19,22] |
Mechanical | Cardiopulmonary | ECPR | ECMO | Provides temporary mechanical support for both cardiac and pulmonary functions, ensuring oxygenated blood flow to vital organs while the underlying causes of cardiac arrest are addressed. | [7,24,25,26] |
CARL | Pulsatile flow, blood parameter control, and real-time monitoring simulate physiologic conditions, decreasing the deleterious effects of ischemia–reperfusion injury to the brain. | [44,45,46] |
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Jezeršek, J.; Strnad, M. Contemporary Practices in Refractory Out-of-Hospital Cardiac Arrest: A Narrative Review. Medicina 2025, 61, 1053. https://doi.org/10.3390/medicina61061053
Jezeršek J, Strnad M. Contemporary Practices in Refractory Out-of-Hospital Cardiac Arrest: A Narrative Review. Medicina. 2025; 61(6):1053. https://doi.org/10.3390/medicina61061053
Chicago/Turabian StyleJezeršek, Jan, and Matej Strnad. 2025. "Contemporary Practices in Refractory Out-of-Hospital Cardiac Arrest: A Narrative Review" Medicina 61, no. 6: 1053. https://doi.org/10.3390/medicina61061053
APA StyleJezeršek, J., & Strnad, M. (2025). Contemporary Practices in Refractory Out-of-Hospital Cardiac Arrest: A Narrative Review. Medicina, 61(6), 1053. https://doi.org/10.3390/medicina61061053