Double Sequential External Defibrillation in Out-of-Hospital Refractory Ventricular Fibrillation: A Report of Ten Cases

Abstract

Background. Ventricular fibrillation (VF) is considered the out-of-hospital cardiac arrest (OOHCA) rhythm with the highest likelihood of neurologically intact survival. Unfortunately, there are occasions when VF does not respond to standard defibrillatory shocks. Current American Heart Association (AHA) guidelines acknowledge that the data are insufficient in determining the optimal pad placement, waveform, or energy level that produce the best conversion rates from OOHCA with VF. Objective. To describe a technique of double sequential external defibrillation (DSED) for cases of refractory VF (RVF) during OOHCA resuscitation. Methods. A retrospective case series was performed in an urban/suburban emergency medical services (EMS) system with advanced life support care and a population of 900,000. Included were all adult OOHCAs having RVF during resuscitation efforts by EMS providers. RVF was defined as persistent VF following at least 5 unsuccessful single shocks, epinephrine administration, and a dose of antiarrhythmic medication. Once the patient was in RVF, EMS personnel applied a second set of pads and utilized a second defibrillator for single defibrillation with the new monitor/pad placement. If VF continued, EMS personnel then utilized the original and second monitor/defibrillator charged to maximum energy, and shocks were delivered from both machines simultaneously. Data were collected from electronic dispatch and patient care reports for descriptive analysis. Results. From 01/07/2008 to 12/31/2010, a total of 10 patients were treated with DSED. The median age was 76.5 (IQR: 65-82), with median resuscitation time of 51minutes (IQR: 45-62). The median number of single shocks was 6.5 (IQR: 6-11), with a median of 2 (IQR: 1-3) DSED shocks delivered. VF broke after DSED in 7 cases (70%). Only 3 patients (30%) had ROSC in the field, and none survived to discharge. Conclusion. This case series demonstrates that DSED may be a feasible technique as part of an aggressive treatment plan for RVF in the out-of-hospital setting. In this series, RVF was terminated 70% of the time, but no patient survived to discharge. Further research is needed to better understand the characteristics of and treatment strategies for RVF.

Double Sequential Defibrillation for Refractory Ventricular Fibrillation: A Case Report

“…A retrospective case series of 10 patients with out-of-hospital DSD successfully broke refractory VF in 7 of the 10 patients after a range of 6-11 single shocks. 11 None of the 10 patients, however, survived to hospital discharge. An ED-based case report in 2014 described a male with refractory VF successfully treated with DSD.…”

Dual defibrillation in out-of-hospital cardiac arrest: A retrospective cohort analysis

“…22 To date, the only published data on double sequential defibrillation in the prehospital environment have been case series and case reports. [22][23][24] The current study is the first to compare the outcomes of standard therapy and dual defibrillation in the out-ofhospital setting.…”

First Report of Survival in Refractory Ventricular Fibrillation After Dual-Axis De brillation and Esmolol Administration

“…In 2015, Cabañas reported on 10 cases of refractory VF treated with double-axis external defibrillation in the prehospital setting. Three of these patients had return of spontaneous circulation (ROSC), but none survived to discharge with their protocols 10. Although the guidelines call for no higher than 200J of biphasic energy and 360J of monophasic energy, multiple studies have shown no ill effects with higher dose shocks, even as high as 720 J (monophasic) delivered using two defibrillators 9…”