Question 1 · Environmental & Analgesia · Moderate
A patient in cardiac arrest with a core temperature of 27 °C is in ventricular fibrillation. Which statement about advanced life support (ALS) in this patient is correct?
- AGive up to three shocks, then hold further shocks and adrenaline until the core is above 30 °C
- BFollow standard ALS, with a shock every two minutes and adrenaline 1 mg every 3 to 5 minutes
- CGive up to three shocks, then keep shocking with adrenaline 1 mg every 6 to 10 minutes
- DWithhold every shock and every drug until the core temperature has risen above 30 °C
- EGive up to three shocks and adrenaline, and recognise life extinct if asystole then follows
Show answer
Answer: A
Give up to three shocks, then hold further shocks and adrenaline until the core is above 30 °C
Resuscitation Council UK Guidelines 2025 (Special circumstances, accidental hypothermia): if ventricular fibrillation persists after three shocks, delay further defibrillation until the core temperature is above 30 °C. Below 30 °C adrenaline accumulates and may do more harm than good, so it is withheld, and 1 mg is given once the core reaches 30 °C; a single 300 mg loading dose of amiodarone may be given for a shockable rhythm, with further doses delayed until the core exceeds 30 °C. The 6 to 10 minute adrenaline interval applies between 30 and 35 °C, not at 27 °C. Defibrillation is not contraindicated: the first three shocks are given as normal. Standard ALS is therefore modified, and asystole in a deeply hypothermic patient does not justify recognising life extinct on scene: the Oxford Handbook advises that the decision to stop should ideally be taken in hospital, and that hypothermia must be excluded before resuscitation is stopped for asystole. Know the divergence: the Oxford Handbook (2021) withholds all drugs below 30 °C, while JRCALC's adrenaline and amiodarone monographs allow a single dose below 30 °C or at an unrecordable temperature. None of them permits repeated adrenaline at 27 °C.
Where this comes from
- Special circumstances guidelines 2025Resuscitation Council UK, October 2025·Accidental hypothermia: defibrillation“Delay further defibrillation attempts if ventricular fibrillation (VF) persists after three shocks”Open at this sentence
- Special circumstances guidelines 2025Resuscitation Council UK, October 2025·Accidental hypothermia: adrenaline below 30 °C“Below 30°C, adrenaline will accumulate and may have more detrimental than beneficial effects.”Open at this sentence
- Special circumstances guidelines 2025Resuscitation Council UK, October 2025·Accidental hypothermia: adrenaline at 30 °C“Give IV 1 mg adrenaline (1:10,000) once the core temperature reaches 30°C”Open at this sentence
- Special circumstances guidelines 2025Resuscitation Council UK, October 2025·Accidental hypothermia: adrenaline interval at 30 to 35 °C“Increase administration intervals for adrenaline to 6-10 min if the core temperature is 30-35°C.”Open at this sentence
- Special circumstances guidelines 2025Resuscitation Council UK, October 2025·Accidental hypothermia: amiodarone“Give a loading dose of 300 mg amiodarone if a shockable rhythm is present”Open at this sentence
- Oxford Handbook of Pre-Hospital Care
- Ch. 9 The hostile environment · Hypothermia: cardiac arrest management, defibrillation · pp. 543–544“no further shocks should be given until the temperature reaches 30oC”
- Ch. 9 The hostile environment · Hypothermia: drug administration · pp. 543–544“Drugs should be withheld when the patient’s temperature is below 30oC”
- Ch. 9 The hostile environment · Hypothermia: you're not dead until you're warm and dead · pp. 543–544“ideally the decision to cease resuscitative efforts should be taken in hospital.”
- Ch. 2 Acute medical and surgical problems · Advanced life support: terminating resuscitation · p. 78“as long as hypothermia, pregnancy, drowning, overdose, or poisoning have been excluded”
- JRCALC Clinical Guidelines — Adrenaline 1 mg in 10 ml (1 in 10,000)JRCALC / AACE·Cautions: hypothermia“Adrenaline 1 in 10,000 — cautions row (hypothermia)”
- JRCALC Clinical Guidelines — Amiodarone hydrochlorideJRCALC / AACE·Contra-indications: hypothermia“Amiodarone hydrochloride — contra-indications row (hypothermia)”