In ALS version 5.4, the medical cardiac arrest directive talks about DSD or VCD for refractory VF or pulseless VT. It defines refractory as persistent VF or pulseless VT after 3 consecutive shocks. Does each of those 3 shockable rhythms have to be only VF or only pulseless VT or could those 3 consecutive shocks have been from a mixture of VF and pulseless VT? Essentially is any sequence of 3 consecutive shockable rhythms grounds to perform DSD or VCD?

I was hoping to get clarification on the appropriate fluid bolus amounts for a patient suspected to be in cardiogenic shock but not having an identified STEMI. The patient I attended to in this call was found to be in rapid atrial fibrillation and hypotensive, along with appearing pale and having complaints of dizziness. From the 12-lead ECG we did not identify any STEMI. The patient did complain of nausea/vomiting earlier in the day, and also did have a fall approx 1 week earlier where pt fell on his left side. There were multiple factors at play here which may have contributed to this patient’s complaints of dizziness and hypotension. In hindsight, I am now suspicious that this patient was in cardiogenic shock. In the cardiogenic shock auxiliary directive, it states that the patient needs to have a STEMI positive 12-lead ECG and be in cardiogenic shock to be administered a halved saline fluid bolus (10mL/kg). However, in the IV fluid auxiliary directive, it only requires the patient to be in cardiogenic shock to have the halved saline fluid bolus administered. In hindsight, I believe I should have administered approx 500ml of saline instead of the 1000ml I did administer.