In a patient with refractory ventricular fibrillation unresponsive to defibrillation and amiodarone in ACLS, which additional antiarrhythmic drug is now recommended as an alternative by AHA guidelines?
- A Bretylium 5 mg/kg IV
- B Sotalol 40 mg IV over 5 minutes
- C Lidocaine 1–1.5 mg/kg IV ✓
- D Procainamide 100 mg IV
Correct answer: C. Lidocaine 1–1.5 mg/kg IV
Explanation
AHA 2020 ACLS guidelines recommend amiodarone (300 mg first dose, 150 mg second) or lidocaine (1–1.5 mg/kg first dose, 0.5–0.75 mg/kg second) as acceptable antiarrhythmics for shock-refractory VF/pVT. The ALPS trial showed no survival-to-discharge advantage of amiodarone over lidocaine over placebo. Lidocaine has re-emerged as an alternative particularly when amiodarone is unavailable. Bretylium was removed from guidelines years ago due to adverse effects and lack of proven benefit.
Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.
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