Refractory States and the Impact on Transport Decisions

div style="font-weight:500">With the revised cardiac arrest medical directive defining refractory VF/pulseless VT as persistent after 3 consecutive shocks—and advising DSED or VCD thereafter, with transport following three DSED or VCD attempts—does this mean transport now occurs after a total of 6 consecutive shocks instead of 3? if not when is transport advised?

Under ALS PCS v5.4, refractory VF/pulseless VT remains defined as a shockable rhythm that persists after 3 consecutive shocks. For Primary Care Paramedics (PCPs): The transport decision is based solely on defibrillation attempts. In this case:• Initiate DSED (if authorized) or VCD (if DSED is not available/authorized) after the first 3 consecutive shocks.• If the patient remains in VF/pulseless VT after 3 additional DSED/VCD shocks (i.e., after the 6th shock total), transport is advised.In simpler terms for PCPs:Transport after 6 total shocks (3 standard + 3 DSED/VCD), assuming the rhythm remains refractory. For Advanced Care Paramedics (ACPs):The transport decision is based on defibrillation attempts AND epinephrine doses, assuming that IV/IO/CVAD/ETT access is available. In this case:• Initiate DSED (if authorized) or VCD (if DSED is not available/authorized) after the first 3 consecutive shocks, AND• Administer 3 rounds of epinephrine, prior to considering a transport decision. Important Note: If no access for epinephrine exists, the same guidance for PCPs applies — transport after the 6th shock. For ALL Paramedics - Always consider early transport in special circumstances (e.g., presumed ≥20-week pregnancy or known reversible cause that cannot be addressed on scene), as outlined in the directive.