V fib treatment acls

In ACLS, Lidocaine is used intravenously for the treatment of ventricular arrhythmias. (VT/VF) It is also useful for the treatment of stable monomorphic VT with preserved ventricular function and for stable polymorphic VT with preserved left ventricular function, normal QT interval, and correction of any electrolyte imbalances.

V fib treatment acls. Pulseless ventricular tachycardia (VT) and Ventricular fibrillation (VF) are life-threatening cardiac rhythms that result in ineffective ventricular contractions. The ventricular motion of VF is not synchronized with atrial contractions. VT or VTach (Figure 25) is a condition in which the ventricles contract more than 100 times per minute.

Control of ventricular rate in patients with atrial fibrillation who do not have heart failure: Pharmacologic therapy Direct laryngoscopy and endotracheal intubation in …

In this 2018 ACLS guidelines focused update, the updated treatment recommendations include consideration of either amiodarone or lidocaine for shock-refractory VF/pVT, whereas previous guidelines favored amiodarone as the first-line therapy.Abstract. Ventricular fibrillation (VF) and sudden cardiac death (SCD) are predominantly caused by channelopathies and cardiomyopathies in youngsters and coronary heart disease in the elderly. Temporary factors, e.g., electrolyte imbalance, drug interactions, and substance abuses may play an additive role in arrhythmogenesis.In one recent case series on 12 patients in refractory VF ( Cortez 2016 ), double sequential defibrillation resulted in ROSC in 3 patients (25%, 95% CI 9% to 53%), all of whom survived to hospital discharge. Two of these patients had good neurologic outcomes at discharge (CPC scores of 1 and 2) while the third had a CPC score of 3.Used to treat Atrial Fibrillation, Atrial Flutter, Atrial Tach, and Symptomatic VT. Shock performed at peak of R wave. Requires proper lead/pad placement to monitor ECG. Pediatric shock energy level: Monophasic or Biphasic: 0.5-1.0 J/kg Assure the patient is sedated and comfortable during shock delivery. Defibrilation: Used to treat VF and ...This “2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support” summarizes the most recent published evidence for and …May 13, 2019 ... LiveWithLauren: Today we are learning about Ventricular Fibrillation and Pulseless Ventricular Tachycardia in ACLS.

Oct 24, 2017 ... ... treatment for Asystole involves high quality ... https://www.proacls.com - ACLS ... Pulseless Arrest Ventricular Fibrillation Teaching (ACLS ...Asystole, colloquially referred to as flatline, represents the cessation of electrical and mechanical activity of the heart. Asystole typically occurs as a deterioration of the initial non-perfusing ventricular rhythms: ventricular fibrillation (V-fib) or pulseless ventricular tachycardia (V-tach). Additionally, pulseless electrical activity (PEA) can cease and become asystole. Victims of ...Discover how form templates can improve user experience and boost conversions for your site visitors, leads, and customers. Trusted by business builders worldwide, the HubSpot Blog... In ACLS, Lidocaine is used intravenously for the treatment of ventricular arrhythmias. (VT/VF) It is also useful for the treatment of stable monomorphic VT with preserved ventricular function and for stable polymorphic VT with preserved left ventricular function, normal QT interval, and correction of any electrolyte imbalances. N Engl J Med. 2019;380:1499-1508. Atrial fibrillation (AF) is an abnormal rhythm caused by the rapid firing of multiple cells in the atria, the upper chambers of the heart, which cause the atria to quiver ineffectively. Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in clinical practice and is associated ...

International ACLS Guidelines 2015 updated November 2015/Feb 2017. Ventricular Fibrillation/ Pulseless Ventricular Tachycardia. SHOCK FIRST x 1 (If defibrillator not immediately available start CPR then shock ASAP) 200 J Biphasic, 360 J Monophasic . ↓. High Quality CPR* x 2 min (then. rhythm and pulse check) (Ventilate, IV/IO Access) ↓ ...Over the past decade, evidence has consistently shown that the best treatment of atrial fibrillation requires multiple stakeholders committed to providing comprehensive patient-centered care. In addition, as emphasized in this guideline, AF should be thought of in a more holistic sense over an individual patient’s lifetime. ...Atrial fibrillation is generally considered a tachyarrhythmia, (an arrhythmia with a heart rate of more than 100 beats per minute). Patients experiencing atrial fibrillation generally have the following characteristics: P waves are absent. The QRS complex is narrow (less than 0.12 seconds) The R-R intervals are consistently irregular.Ventricular fibrillation ("VF" or " V-fib ") is a life-threatening. cardiac arrhythmia. characterized by disorganized, high-frequency ventricular contractions that result in diminished. cardiac output. and hemodynamic collapse. V-fib usually begins with. ventricular tachycardia.

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During ACLS, epinephrine can be given 3 ways: intravenous; intraosseous, and endotracheal tube. Dosing. Intravenous Push/IO: 1mg epinephrine IV is given every 3-5 minutes. IV infusion for bradycardia: 1mg epinephrine is mixed with 500ml of NS or D5W. The infusion should run at 2-10 micrograms/min (titrated to effect).Efficacy of magnesium-amiodarone step-up scheme in critically ill patients with new-onset atrial fibrillation: a prospective observational study. J Intensive Care Med. 2008 Jan-Feb;23(1):61-6. doi: 10.1177/0885066607310181Adult Dosage of Amiodarone. When using amiodarone to treat V-Fib or pulseless V-tach cardiac arrest which is unresponsive to CPR, shock, and vasopressors, a first dose is given at 300 mg via IV or IO push. And a second dose is delivered at half that, or 150 mg, also via IV or IO push. For life-threatening arrhythmias, a maximum accumulated dose ...If atrial fibrillation develops, the normal rate-limiting effects of the atrioventricular (AV) node are bypassed, and the resultant excessive ventricular rates (sometimes 200 to 300 beats/minutes) may lead to ventricular fibrillation (see figure Atrial fibrillation in Wolff-Parkinson-White syndrome) and sudden death. Patients with concealed WPW ...Background: American Heart Association Advanced Cardiac Life Support (ACLS) guidelines support the use of either amiodarone or lidocaine for cardiac arrest caused by ventricular tachycardia or ventricular fibrillation (VT/VF) based on studies of out-of-hospital cardiac arrest. Studies comparing amiodarone and lidocaine in adult populations with in-hospital …International ACLS Guidelines 2015 updated November 2015/Feb 2017. Ventricular Fibrillation/ Pulseless Ventricular Tachycardia. SHOCK FIRST x 1 (If defibrillator not immediately available start CPR then shock ASAP) 200 J Biphasic, 360 J Monophasic . ↓. High Quality CPR* x 2 min (then. rhythm and pulse check) (Ventilate, IV/IO Access) ↓ ...

Atrial fibrillation (A-fib) ECG / EKG interpretation, treatment, causes, and nursing review for nurses, nursing students, and NCLEX.Quiz: https://www.registe...If ROSC, go to Post–Cardiac Arrest Care. Consider appropriateness of continued resuscitation. Go to 5 or 7. VF/pVT Asystole/PEA. CPR Quality. Push hard (at least 2 inches [5 cm]) and fast (100-120/min) and allow complete chest recoil. Minimize int erruptions in compressions. Avoid e xcessive v entilation.Ventricular fibrillation is a potentially fatal, uncoordinated series of very rapid, ineffective contractions of the ventricles (lower chambers of the heart) caused by many chaotic electrical impulses. Ventricular fibrillation causes unconsciousness in seconds, and if the disorder is not rapidly treated, death follows.About Arrhythmia. Ventricular Fibrillation. Ventricular fibrillation, or VF, is considered the most serious abnormal heart rhythm. VF is extremely dangerous and can lead to sudden cardiac death. Without treatment, the condition is fatal within minutes.Learn how to treat cardiac arrest patients in ventricular tachycardia (VTach) or ventricular fibrillation (VFib) with defibrillation, CPR, epinephrine and amiodarone. See the ACLS algorithm and online … Atrial fibrillation (AF) is an abnormal rhythm caused by the rapid firing of multiple cells in the atria, the upper chambers of the heart, which cause the atria to quiver ineffectively. Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in clinical practice and is associated with increased risk of stroke ... Atrial fibrillation is the most common type of abnormal heart rhythm. Nearly 4 million emergency room visits from 2007 to 2014 in the United States were for atrial fibrillation. ... Without treatment, A-fib with RVR can lead to heart disease, heart failure or a stroke. Catheter ablation provides an effective, minimally invasive treatment of ...Autosomal recessive is one of several ways that a trait, disorder, or disease can be passed down through families. Autosomal recessive is one of several ways that a trait, disorder...Cardiac defibrillation is the act of administering a transthoracic electrical current to a person experiencing one of the two lethal ventricular dysrhythmias, ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). Under Advanced Cardiac Life Support (ACLS) guidelines, pulseless VT and VF are treated the same. Heart disease ...The key steps to treating ventricular fibrillation are: Rapid assessment to confirm cardiac arrest. Starting CPR. Applying the defibrillator and delivering the first shock as soon as … It’s administered over 10 minutes. Should the V-tach, whether it’s polymorphic or monomorphic, lapse into V-fib, which can happen, immediately go into your V-fib algorithm. Let’s look at ventricular fibrillation. No pulse. No cardiac output. First drug of choice is epinephrine 1:10,000 1 mg IV push every 3 to 5 minutes. There’s no max ...

The 2020 ACLS guidelines provide recommendations on the medication-specific management for arrhythmias including wide-complex tachycardia, regular narrow-complex tachycardia, atrial fibrillation/flutter, and bradycardia [ 1 ]. There are also our 2020 ACLS guideline summaries on vasopressor and non-vasopressor medications used …

For this case, you use the Acute Coronary Syndromes Algorithm to guide the assessment and management of patients with signs and symptoms of acute coronary syndromes. A key focus of the case is the identification and treatment of ST-segment elevation myocardial infarction (STEMI). You use a 12-lead ECG to evaluate the patient's rhythm.V-tach can be life-threatening if it's sustained (lasting more than 30 seconds). VFib. A fast, abnormal rhythm starts in the ventricles and prevents blood from being pumped throughout the body. Ventricle walls twitch or quiver uncontrollably and irregularly. VFib is always life-threatening, causing sudden cardiac arrest.Ventricular fibrillation, or VF, is considered the most serious abnormal heart rhythm. VF is extremely dangerous and can lead to sudden cardiac death. Without …Arrhythmia Recognition. Interpret all ECG and rhythm information within the context of total patient assessment. Inaccurate diagnoses and inappropriate therapy occur when ACLS providers base their decisions solely on cardiac rhythm and neglect to evaluate the patient’s clinical signs, such as ventilation, oxygenation, heart rate, blood pressure, level of consciousness, and other signs of ...V-tach can be life-threatening if it's sustained (lasting more than 30 seconds). VFib. A fast, abnormal rhythm starts in the ventricles and prevents blood from being pumped throughout the body. Ventricle walls twitch or quiver uncontrollably and irregularly. VFib is always life-threatening, causing sudden cardiac arrest.Atrial Fibrillation (AFib) rhythm video by the ACLS Certification Institute. To view more videos, check out the ACLS Certification Institute at http://www.ac...V-fib / V-tach CPR until shock is avaliable then shock Epi 1mg q 3-5 min Vasopressin 40 units can replace 1st/2nd dose of epi Amiodarone 300mg af anytime after either of 1st two Asystole/PEA Treatment. For the purposes of ACLS, atrial flutter is treated the same as atrial fibrillation. When atrial flutter produces hemodynamic instability and serious signs and symptoms, it is treated using ACLS protocol. For the patient with unstable tachycardia due to this tachyarrhythmia (atrial flutter), immediate cardioversion is recommended.

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Used to treat Atrial Fibrillation, Atrial Flutter, Atrial Tach, and Symptomatic VT. Shock performed at peak of R wave. Requires proper lead/pad placement to monitor ECG. Pediatric shock energy level: Monophasic or Biphasic: 0.5-1.0 J/kg Assure the patient is sedated and comfortable during shock delivery. Defibrilation: Used to treat VF and ... This 2018 American Heart Association (AHA) focused update on the advanced cardiovascular life support (ACLS) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular …Show up and participate in class. Get your American Heart Association (AHA) certification. We are an authorized American Heart Association (AHA) training site for certification in BLS, ACLS, PALS, CPR AED, First Aid, and CPR Instructor training.The H’s and T’s of ACLS is a mnemonic used to help recall the major contributing factors to pulseless arrest including PEA, Asystole, Ventricular Fibrillation, and Ventricular Tachycardia. These H’s and T’s will most commonly be associated with PEA, but they will help direct your search for underlying causes to any of arrhythmias ...Makeup containers have a way of multiplying and spreading over counters. This clever DIY magnetic board from the Laura Thoughts blog puts all your makeup where you can see it and f...Following a rules change, the only international agreement to curb airline emissions will now miss almost all of them. 2020 was supposed to be a pivotal year for the airline indust...As the treatments for asystole and ventricular fibrillation are different, it is important to differentiate between the two. If in doubt, it is acceptable to deliver a shock. If it is fine v-fib, you may terminate the rhythm; however, if the rhythm is asystole, defibrillation will be ineffective and you can follow the asystole protocol with ...It’s administered over 10 minutes. Should the V-tach, whether it’s polymorphic or monomorphic, lapse into V-fib, which can happen, immediately go into your V-fib algorithm. Let’s look at ventricular fibrillation. No pulse. No cardiac output. First drug of choice is epinephrine 1:10,000 1 mg IV push every 3 to 5 minutes. There’s no max ...The Insider Trading Activity of Poliakoff Abba David on Markets Insider. Indices Commodities Currencies Stocks1. Description of the problem. Early diagnosis and rapid defibrillation of ventricular fibrillation (Vfib) and pulseless ventricular tachycardia can significantly increase chances for survival ... ….

Jul 13, 2016 · Ventricular Fibrillation (V-Fib) Hypertrophic Cardiomyopathy; Recurrent Hemodynamically; Unstable Ventricular Tachycardia; Supraventricular Tachyarrhythmias; Amiodarone Dosage. For VT / V-Fib: 300 mg IV/IO. May administer additional 150 mg following initial dose if VF/pVT persists after 3-5 minutes. For Tachy / VT: 150 mg IV/IO over 10 minutes ... Acute ventricular fibrillation (VF) is treated according to Advanced Cardiac Life Support (ACLS) protocols. [ 81, 82] ) Interest in improving rates of public...Jul 18, 2022 ... Ventricular Tachycardia (VT) ECG Interpretation, Treatment (ACLS Management), Lectures, USMLE, NCLEX. MedNerd - Dr. Waqas Fazal•48K views · 7:46.Atrial fibrillation (A-fib) ECG / EKG interpretation, treatment, causes, and nursing review for nurses, nursing students, and NCLEX.Quiz: https://www.registe...Summary. Ventricular fibrillation ("VF" or " V-fib ") is a life-threatening. cardiac arrhythmia. characterized by disorganized, high-frequency ventricular …It’s administered over 10 minutes. Should the V-tach, whether it’s polymorphic or monomorphic, lapse into V-fib, which can happen, immediately go into your V-fib algorithm. Let’s look at ventricular fibrillation. No pulse. No cardiac output. First drug of choice is epinephrine 1:10,000 1 mg IV push every 3 to 5 minutes. There’s no max ...Atrial Fibrillation (AFib) rhythm video by the ACLS Certification Institute. To view more videos, check out the ACLS Certification Institute at http://www.ac...Atrial fibrillation is when multiple electrical impulses are being generated in the atria at the same time. This causes chaotic myocardial responses that may diminish both the pre-load and effectiveness of the cardiac contraction. This can lead to: Development of microemboli due to stagnant blood flow from the atria.Epinephrine. Catecholamine vasopressor, Inotrope. Cardiac arrest; anaphylaxis; symptomatic bradycardia after atropine; shock when pacing and atropine are not effective. Cardiac arrest: 1.0 mg (1:10000) IV or 2-2.5 mg (1:1000) per ET tube every 3-5 minutes; follow with. 0.1-0.5 mcg/kg/minute infusion titrated to response.In ACLS, Lidocaine is used intravenously for the treatment of ventricular arrhythmias. (VT/VF) It is also useful for the treatment of stable monomorphic VT with preserved ventricular function and for stable polymorphic VT with preserved left ventricular function, normal QT interval, and correction of any electrolyte imbalances. V fib treatment acls, Abstract. Ventricular fibrillation (VF) and sudden cardiac death (SCD) are predominantly caused by channelopathies and cardiomyopathies in youngsters and coronary heart disease in the elderly. Temporary factors, e.g., electrolyte imbalance, drug interactions, and substance abuses may play an additive role in arrhythmogenesis., Part 10.4: Hypothermia. Unintentional hypothermia is a serious and preventable health problem. Severe hypothermia (body temperature <30°C [86°F]) is associated with marked depression of critical body functions that may make the victim appear clinically dead during the initial assessment. But in some cases hypothermia may exert a protective ..., Indications for ACLS Vasoconstriction effects : epinephrine binds directly to alpha-1 adrenergic receptors of the blood vessels (arteries and veins) causing direct vasoconstriction, thus, improving perfusion pressure to the brain and heart. , Figure 3. Adult Cardiac Arrest Algorithm. CPR indicates cardiopulmonary resuscitation; ET, endotracheal; IO, intraosseous; IV, intravenous; PEA, pulseless electrical ... , Atrial Fibrillation. A 68-year-old male presents with palpitations, lightheadedness, and weakness. These symptoms appear to worsen with increased alcohol intake. Medical history is significant for hypertension being treated with hydrochlorothiazide. On physical exam, the patient appears uncomfortable., Atrial Fibrillation. A 68-year-old male presents with palpitations, lightheadedness, and weakness. These symptoms appear to worsen with increased alcohol intake. Medical history is significant for hypertension being treated with hydrochlorothiazide. On physical exam, the patient appears uncomfortable., Ventricular Fibrillation which occurs in the out-of-hospital setting should be treated with CPR and an AED. Effective CPR and early defibrillation are the keys to positive outcomes for the unresponsive patient who is in ventricular fibrillation. This ACLS scenario will usually involve one or two rescuers in an out-of-hospital setting., Jeff Bezos, the founder and CEO of Amazon and owner of the Washington Post, is the worlds richest man. His employees average $78,000 a year. By clicking "TRY IT", I agree to receiv..., Ethan Deckert, MD, examines treatment options for refractory ventricular fibrillation. ... Life Support Strategy for Out-of-Hospital Refractory V Fib; ... standard ACLS algorithms. 39 There are ..., Oct 5, 2021 · Ethan Deckert, MD, examines treatment options for refractory ventricular fibrillation. ... Life Support Strategy for Out-of-Hospital Refractory V Fib; ... standard ACLS algorithms. 39 There are ... , Advanced Cardiovascular Life Support (ACLS) certification is a crucial requirement for healthcare professionals who are responsible for managing cardiac arrest and other life-threa..., It’s administered over 10 minutes. Should the V-tach, whether it’s polymorphic or monomorphic, lapse into V-fib, which can happen, immediately go into your V-fib algorithm. Let’s look at ventricular fibrillation. No pulse. No cardiac output. First drug of choice is epinephrine 1:10,000 1 mg IV push every 3 to 5 minutes. There’s no max ..., An initial energy of 50 to 100 J MDS is often sufficient, with stepwise increases in energy if initial shocks fail. 23 24 25 Transthoracic cardioversion of atrial fibrillation with a low-energy (120-J), rectilinear, first-pulse biphasic waveform was superior to 200 J MDS in a recent controlled trial. 26 Cardioversion with biphasic waveform is ..., In patients with cardiac arrest refractory to standard ACLS, vasopressin induced an increase in blood pressure, and in some cases, ROSC. 51 In a similar clinical evaluation after approximately 40 minutes of unsuccessful ACLS, 4 of 10 patients responded to vasopressin and had a mean increase in coronary perfusion pressure of 28 mm Hg. 46 In a ..., Out-of-hospital cardiac arrest accounts for more than 350,000 unexpected deaths each year in North America; nearly 100,000 of these cardiac arrests are attributed to ventricular fibrillation or ..., Many tachyarrhythmias of a rate >150 will deteriorate into pulselessness if timely treatment is not given. Pulseless ventricular tachycardia is treated using the left branch of the cardiac arrest algorithm., Review guidelines for the pediatric cardiac arrest algorithm with our free resources. Start CPR. Start CPR with hard and fast compressions, around 100 to 120 per minute, allowing the chest to completely recoil. Give the patient oxygen and attach a monitor or defibrillator. Make sure to minimize interruptions in chest compressions and avoid ..., For this case, you use the Acute Coronary Syndromes Algorithm to guide the assessment and management of patients with signs and symptoms of acute coronary syndromes. A key focus of the case is the identification and treatment of ST-segment elevation myocardial infarction (STEMI). You use a 12-lead ECG to evaluate the patient's rhythm., Ventricular Fibrillation which occurs in the out-of-hospital setting should be treated with CPR and an AED. Effective CPR and early defibrillation are the keys to positive outcomes for the unresponsive patient who is in ventricular fibrillation. This ACLS scenario will usually involve one or two rescuers in an out-of-hospital setting. , Atrial flutter is considered a supraventricular arrhythmia that has a rapid or variable ventricular rate. Multiple atrial contractions occur for each ventricular contraction. On an ECG, atrial flutter: Displays a “sawtooth pattern”. Has consistent and identical flutter waves. Has an atrial rate of 250-350 beats per minute., ACLS Tachycardia Algorithm. The ACLS Tachycardia Algorithm is used for patients who have marked tachycardia, usually greater than 150 beats per minute, and a palpable pulse. Some patients may have cardiovascular instability with tachycardia at heart rate less than 150 bpm. It is important to consider the clinical context when treating adult ..., Review guidelines for the pediatric cardiac arrest algorithm with our free resources. Start CPR. Start CPR with hard and fast compressions, around 100 to 120 per minute, allowing the chest to completely recoil. Give the …, Pharmacological rate control is the recommended initial treatment for stable, rapid atrial fibrillation/flutter (≥120 bpm) regardless of its duration. Specific drug …, International ACLS Guidelines 2015 updated November 2015/Feb 2017. Ventricular Fibrillation/ Pulseless Ventricular Tachycardia. SHOCK FIRST x 1 (If defibrillator not immediately available start CPR then shock ASAP) 200 J Biphasic, 360 J Monophasic . ↓. High Quality CPR* x 2 min (then. rhythm and pulse check) (Ventilate, IV/IO Access) ↓ ..., Figure. Atrial fibrillation, also known as a-fib, is the most common dysrhythmia that nurses will encounter. Characterized by uncoordinated atrial activation with consequent loss of atrial mechanical function, a-fib is most likely to occur in those age 80 years and older. 1 The number of men and women affected by a-fib is projected to more than ..., Following a rules change, the only international agreement to curb airline emissions will now miss almost all of them. 2020 was supposed to be a pivotal year for the airline indust..., Amiodarone is an antiarrhythmic agent used in ACLS to treat VF or pulseless VT that does not respond to treatment with defibrillation, CPR, or vasopressors. ... For VT / V-Fib: 300 mg IV/IO. May administer additional 150 mg following initial dose if VF/pVT persists after 3-5 minutes., Treatment includes risk factor elimination including smoking cessation, and treatment with vasodilators including dihydropyridine calcium channel blockers with or without nitrates. A more detailed summary of …, Ventricular fibrillation, or V-fib or VF, is a dangerous arrhythmia that causes the heart's lower chambers (ventricles) to erratically quiver instead of pumping blood as they should. V-fib results ..., Atrial flutter is considered a supraventricular arrhythmia that has a rapid or variable ventricular rate. Multiple atrial contractions occur for each ventricular contraction. On an ECG, atrial flutter: Displays a “sawtooth pattern”. Has consistent and identical flutter waves. Has an atrial rate of 250-350 beats per minute., Iran doesn't need nukes to be dangerous. The only reason to watch Binyamin Netanyahu speak to the US Congress today is for the mildly amusing spectacle of a room full of American p..., Used to treat Atrial Fibrillation, Atrial Flutter, Atrial Tach, and Symptomatic VT. Shock performed at peak of R wave. Requires proper lead/pad placement to monitor ECG. Pediatric shock energy level: Monophasic or Biphasic: 0.5-1.0 J/kg Assure the patient is sedated and comfortable during shock delivery. Defibrilation: Used to treat VF and ... , Ventricular fibrillation is always pulseless and must be confirmed by EKG or defibrillator monitor. Defibrillation is the treatment of choice and should occur as soon as possible. The video below shows an example of what ventricular fibrillation will look like when you see it on the defibrillator monitor.