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cardio.post-arrest.shockable-rhythm.v1

Post-cardiac-arrest care — initial shockable rhythm (VF/pVT)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.post-arrest.core.v1 — narrowed to initial shockable-rhythm (VF/pVT) cohort. Cardiac etiology >80%; STEMI emergent cath (AHA 2020 Class I); non-STEMI shockable + stable → routine (delayed) cath strategy per COACT (PMID 30883045) + TOMAHAWK (PMID 34587023). Secondary-prevention ICD per AVID (PMID 9411221) if VF/VT unrelated to reversible cause; primary-prevention ICD per MADIT-II at 40-90 d if EF ≤30 + ischemic CMP. Inherits manifest + design-brief pointer from parent. 5 setting playbooks (ed, icu, inpatient, transition, outpatient). 5 severity triggers: STEMI on post-ROSC ECG, recurrent VF/pVT, ICD secondary-prevention indication window, ARREST-criteria refractory VF, cardiogenic shock. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute.

Entry points (3)

  • symptom
    ROSC after VF/pVT cardiac arrest — cardiac etiology >80% probability (AHA 2020)
    rosc_after_vfib_pvt_arrest
  • imaging
    STEMI on first post-ROSC ECG following shockable-rhythm arrest → emergent cath (AHA 2020 Class I)
    stemi_post_rosc_shockable
  • history
    VF/VT-driven arrest unrelated to reversible cause → ICD secondary-prevention indication (AVID PMID 9411221)
    icd_secondary_prevention_window

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    ICD eligibility framing + ECPR window (ARREST: 18-75); MADIT-II horizon if EF ≤30 + ischemic CMP
  • arrest_witnessedrequired
    history • used at CONTEXT
    Witnessed + bystander CPR + low-flow time → favourable neuro prognosis; CAHP/OHCA score inputs (AHA 2020)
  • initial_rhythmrequired
    history • used at CONTEXT
    VF/pVT confirmed at first analysis — cardiac etiology presumption; differentiates from PEA/asystole pathway
  • low_flow_time_minrequired
    history • used at CONTEXT
    CPR duration → ECPR eligibility per ARREST (PMID 33308475 — <60 min low-flow); neuro prognosis weighting
  • cardiac_history
    history • used at CONTEXT
    Prior MI / EF / ICD / channelopathy — drives ICD upgrade decision + secondary-prevention pathway (AVID; HRS 2017)
  • sbprequired
    vital • used at TREATMENT
    Hemodynamic stability post-ROSC; SCAI staging if shock develops
  • core_temprequired
    vital • used at TREATMENT
    TTM target 33-37.5 °C × 24h (TTM2 PMID 34133859)
  • spo2required
    vital • used at TREATMENT
    Avoid hyperoxia: SpO2 92-98% (AHA 2020 Class IIa)
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    STEMI → emergent cath within 90 min (AHA 2020 Class I); non-STEMI → routine cath strategy per COACT/TOMAHAWK
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Cardiac etiology workup; serial trending; STEMI/NSTEMI distinction (4th UDMI 2018)
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Tissue hypoperfusion + clearance (SCAI 2022 PMID 35718438)
  • creatininerequired
    lab • used at CONTEXT
    Contrast nephropathy + drug renal-adjustment (AHA 2020)
  • potassiumrequired
    lab • used at CONTEXT
    Arrhythmogenic — replete to 4-4.5 mmol/L (AHA 2020 Class I)
  • echo_post_rosc
    imaging • used at INITIAL_WORKUP
    LV/RV function, valvular cause, structural disease — drives ICD strategy + advanced HF eval
  • cor_angio
    imaging • used at BRANCHING_WORKUP
    STEMI emergent (Class I); shockable non-STEMI routine timing per COACT (Lemkes NEJM 2019 PMID 30883045) + TOMAHAWK (Desch NEJM 2021 PMID 34587023)

12-phase flow (12)

  1. 1FRAME
    Initial shockable-rhythm (VF/pVT) OHCA cohort: cardiac etiology >80% probability; favourable survival + neurologic outcome compared with non-shockable; route immediately to parent cardio.post-arrest.core.v1 for TTM + neuroprog arc
    inputs: initial_rhythm
    advance: shockable rhythm confirmed at first analysis
  2. 2ENTRY
    ECG within 10 min, bedside echo, mobilize cath team, continue ACLS for recurrent VF (AHA 2020 Class I)
    inputs: age, arrest_witnessed
    advance: cards consult activated + ECG obtained
  3. 3CONTEXT
    Prior CAD/EF/device, code status, current GDMT, channelopathy/family history (AHA 2020)
    inputs: cardiac_history, sbp, core_temp, spo2, creatinine, potassium
    advance: context complete + GOC documented
  4. 4RED_FLAGS
    Recurrent VF/pVT, refractory shock, STEMI on ECG, mechanical complication, severe acidosis pH <7.1, hyperkalemia >6 (AHA 2020; SCAI 2022)
    inputs: sbp, spo2, potassium
    actions: protocol.cardiogenic_shock
    advance: red flags screened or escalated
  5. 5INITIAL_WORKUP
    ECG + serial troponin + BMP + lactate + ABG + CBC + CXR + bedside echo; trend troponin q2h × 3 (AHA 2020; 4th UDMI 2018)
    inputs: ecg_12_lead, troponin, lactate, echo_post_rosc
    actions: post_arrest_care, panel.cardiac, panel.renal
    advance: workup complete + STEMI/non-STEMI decided
  6. 6BRANCHING_WORKUP
    STEMI → emergent cath within 90 min (AHA 2020 Class I); non-STEMI shockable + hemodynamically stable → routine (delayed) cath strategy per COACT (PMID 30883045) + TOMAHAWK (PMID 34587023); refractory VF → ECPR per ARREST (PMID 33308475)
    inputs: cor_angio
    actions: acs_pathway
    advance: reperfusion / non-cath decision made
  7. 7DIFFERENTIAL
    ACS / structural CAD / ischemic CMP / non-ischemic CMP / channelopathy (LQT, Brugada, CPVT) / WPW / commotio cordis (HRS 2017 PMID 28219760)
    advance: working etiology established + EP referral plan
  8. 8RISK_STRATIFICATION
    CAHP score (PMID 26491110) + OHCA score (PMID 16424733) for neuro prognosis; LVEF + troponin peak for ICD eligibility horizon (MADIT-II PMID 11907286); SCAI shock stage if applicable
    inputs: initial_rhythm, low_flow_time_min, sbp
    actions: calc.heart, calc.map, calc.ckd_epi_2021
    advance: risk class + ICD pathway documented
  9. 9TREATMENT
    Reperfusion if STEMI; TTM 33-37.5 °C × 24h then rewarm 0.25-0.5 °C/h; antiplatelet/AC per ACS regimen if PCI; antiarrhythmic infusion (amiodarone) if recurrent VF; secondary-prevention ICD pathway per AVID (PMID 9411221)
    inputs: sbp, core_temp, spo2, creatinine
    actions: protocol.cardiogenic_shock
    advance: reperfusion + TTM + antiarrhythmic bundle delivered
  10. 10DISPOSITION
    CICU / ICU per local pathway; cardiology + EP co-management for ICD planning (AHA 2020 Class I)
    advance: unit + service-line ownership assigned
  11. 11MONITORING
    Continuous telemetry + arterial line + central line + Foley; lactate q2-4h; BMP q6-12h; serial troponin until peak; multimodal neuroprog ≥72h post-rewarm (Sandroni ERC-ESICM 2021 PMID 33745427)
    inputs: creatinine, potassium
    actions: panel.renal, panel.cardiac
    advance: monitoring + neuroprog timeline documented
  12. 12FOLLOWUP
    EP follow-up at 1-2 weeks for ICD planning; LVEF reassessment at 40-90 d if MADIT-II eligible; secondary-prevention ICD per AVID if VF/VT unrelated to reversible cause; cardiac rehab
    advance: EP + ICD + rehab + family screening (if channelopathy) booked