Refibrillation after defibrillation: The shocking truth

Cheskes, Sheldon; Drennan, Ian R.

doi:10.1016/j.resuscitation.2020.10.010

Cited by 2 publications

(2 citation statements)

References 26 publications

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“…For example, one strategy might use the algorithm to provide earlier or higher-dose antiarrhythmic treatment or a lower or delayed dose of a vasopressor such as epinephrine (given its potential proarrhythmic effects) for those at high risk of refractory VF. [8][9][10][11][12][13][14][15] The algorithm might also be used to inform which patients could be considered for modified shock delivery strategies (vector change or double sequential defibrillation) or early transport for advanced hospital care such as an emergent coronary artery intervention or extracorporeal CPR. [16][17][18][19][20][21]…”

Section: Clinical Implications Of Algorithm Performancementioning

confidence: 99%

“…[5][6][7] Hence, the ability to predict refractory VF in advance of repeated shock failure could enable preemptive interventions targeted at improving the relatively poor outcomes of the refractory VF subgroup. Such therapies might include earlier or increased antiarrhythmic dose administration, [8][9][10][11][12] reconsideration of epinephrine use or dosage, [13][14][15] changes in how shocks are administered, 16 or expedited invasive interventions. [17][18][19][20][21] By contrast, empiric treatment of all patients with VF OHCA using such strategies may unnecessarily expose patients who achieve best outcomes under the current protocol, introducing potential risk among those unlikely to benefit.…”

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confidence: 99%

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Prediction of Shock-Refractory Ventricular Fibrillation During Resuscitation of Out-of-Hospital Cardiac Arrest

et al. 2023

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BACKGROUND: Out-of-hospital cardiac arrest due to shock-refractory ventricular fibrillation (VF) is associated with relatively poor survival. The ability to predict refractory VF (requiring ≥3 shocks) in advance of repeated shock failure could enable preemptive targeted interventions aimed at improving outcome, such as earlier administration of antiarrhythmics, reconsideration of epinephrine use or dosage, changes in shock delivery strategy, or expedited invasive treatments. METHODS: We conducted a cohort study of VF out-of-hospital cardiac arrest to develop an ECG-based algorithm to predict patients with refractory VF. Patients with available defibrillator recordings were randomized 80%/20% into training/test groups. A random forest classifier applied to 3-s ECG segments immediately before and 1 minute after the initial shock during cardiopulmonary resuscitation was used to predict the need for ≥3 shocks based on singular value decompositions of ECG wavelet transforms. Performance was quantified by area under the receiver operating characteristic curve. RESULTS: Of 1376 patients with VF out-of-hospital cardiac arrest, 311 (23%) were female, 864 (63%) experienced refractory VF, and 591 (43%) achieved functional neurological survival. Total shock count was associated with decreasing likelihood of functional neurological survival, with a relative risk (95% CI) of 0.95 (95% CI, 0.93–0.97) for each successive shock ( P <0.001). In the 275 test patients, the area under the receiver operating characteristic curve (95% CI) for predicting refractory VF was 0.85 (95% CI, 0.79–0.89), with specificity of 91%, sensitivity of 63%, and a positive likelihood ratio of 6.7. CONCLUSIONS: A machine learning algorithm using ECGs surrounding the initial shock predicts patients likely to experience refractory VF, and could enable rescuers to preemptively target interventions to potentially improve resuscitation outcome.

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Section: Clinical Implications Of Algorithm Performancementioning

confidence: 99%

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confidence: 99%

Prediction of Shock-Refractory Ventricular Fibrillation During Resuscitation of Out-of-Hospital Cardiac Arrest

et al. 2023

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Recurrence of ventricular fibrillation in out‐of‐hospital cardiac arrest: Clinical evidence and underlying ionic mechanisms

Pandit,

Lampe,

Silver

2024

The Journal of Physiology

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Defibrillation remains the optimal therapy for terminating ventricular fibrillation (VF) in out‐of‐hospital cardiac arrest (OHCA) patients, with reported shock success rates of ∼90%. A key persistent challenge, however, is the high rate of VF recurrence (∼50–80%) seen during post‐shock cardiopulmonary resuscitation (CPR). Studies have shown that the incidence and time spent in recurrent VF are negatively associated with neurologically‐intact survival. Recurrent VF also results in the administration of extra shocks at escalating energy levels, which can cause cardiac dysfunction. Unfortunately, the mechanisms underlying recurrent VF remain poorly understood. In particular, the role of chest‐compressions (CC) administered during CPR in mediating recurrent VF remains controversial. In this review, we first summarize the available clinical evidence for refibrillation occurring during CPR in OHCA patients, including the postulated contribution of CC and non‐CC related pathways. Next, we examine experimental studies highlighting how CC can re‐induce VF via direct mechano‐electric feedback. We postulate the ionic mechanisms involved by comparison with similar phenomena seen in commotio cordis. Subsequently, the hypothesized contribution of partial cardiac reperfusion (either as a result of CC or CC independent organized rhythm) in re‐initiating VF in a globally ischaemic heart is examined. An overview of the proposed ionic mechanisms contributing to VF recurrence in OHCA during CPR from a cellular level to the whole heart is outlined. Possible therapeutic implications of the proposed mechanistic theories for VF recurrence in OHCA are briefly discussed. image

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Refibrillation after defibrillation: The shocking truth

Cited by 2 publications

References 26 publications

Prediction of Shock-Refractory Ventricular Fibrillation During Resuscitation of Out-of-Hospital Cardiac Arrest

Prediction of Shock-Refractory Ventricular Fibrillation During Resuscitation of Out-of-Hospital Cardiac Arrest

Recurrence of ventricular fibrillation in out‐of‐hospital cardiac arrest: Clinical evidence and underlying ionic mechanisms

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