Refractory VF; Roadside to Resus

Refractory ventricular fibrillation (VF) requires a systematic, evidence-based approach to resuscitation, prioritizing high-quality chest compressions and optimized defibrillation. When standard shocks fail, shifting to an anterior-posterior pad placement changes the electrical vector, potentially increasing current delivery to the myocardium. Double sequential defibrillation (DSD) offers a viable strategy for refractory cases, supported by the Dose VF trial, which demonstrated improved survival compared to standard care. Pharmacological interventions, including amiodarone and lignocaine, remain standard, though their long-term neurological benefits are debated. Emerging evidence suggests that excessive adrenaline may exacerbate myocardial dysfunction, prompting consideration for dose adjustments. While advanced therapies like ECMO and intra-arrest PCI show promise in specific systems, the foundation of successful outcomes remains the rapid, precise application of fundamental resuscitation techniques and the ability to adapt strategies when initial efforts prove ineffective.