Has stubborn refractory VF finally met its match?? Defibrillation practices are a great topic of conversation these days and like most things in medicine, its clearly up for debate as a general consensus has yet to be reached -- even among resuscitation science experts.
During our initial CPR courses (maybe even before we officially entered this field) the content reinforced that CPR when coupled with timely unsynchronized cardioversion (defibrillation) positively impacted outcomes in out of hospital cardiac arrest.
However, despite our best pre-hospital efforts + exhaustion of traditional ACLS measures - sometimes patients continue to remain in VF for extended periods of time. In my experience, I have personally seen an individual shocked 60 times and be discharged neurologically intact (Rankin Score of 0 / CPC score of 1). Safe to say this is a rare exception versus the rule.
In recent years some of the literature has proposed the use of dual sequential defibrillation (rapid shocks from two defibrillators in succession) OR vector change defibrillation (altering pad positioning - from the classic sterno-apical position to anterior-posterior or other variations) to terminate this VF the just won't respond. The overarching goals of these novel approaches are to increase survivability and ensure cerebral function is restored or minimally impacted. Quality of life and/or reduced disability matter. I think it can also be said that time to intervention also matters a great deal.
Source: New England Journal of Medicine: Cheskes S et al. DOI: 10.1056/NEJMoa2207304
The pads should never physically touch one another.
Lots of international research has been done on this very topic over the past decade and while ultimately the jury is still out -- majority of the data seems promising; we just need more of it.
The current AHA stance is this: "At this time, a systematic review reveals that the usefulness of double sequential defibrillation for refractory shockable rhythm has not been established (Class 2b, LOE C-LD)". This simply means that there is limited data (LD) and the recommendation strength, more specifically the intervention's efficacy is less well established. That is why the wording is so important. Most literature is using conservative language that states may be considered versus a stronger stance that states, this intervention is indicated or recommended.
Keep in mind that most cardiac monitor manufacturers like Zoll, Physio, Philips also describe dual sequential defibrillation as an off-label use of their devices. They will likely shy away from giving official recommendations for your agency. It's also unclear about how this may affect the warranty of your device. As always, follow your local protocols and consult medical direction early and often regarding these cases OR any case for that matter that may need expert consultation that is beyond your training. We do it for tachydysrhythmias all of the time.
Never lose sight of the fact that the hospital and their ED staff are a great personal resource. Train together, build long lasting relationships. Don't be afraid to interface regularly with the physicians and physician extenders. Ask questions and seek follow-up. It will help you solidify your credibility (they will know who you are), and assist you in becoming a better provider, which in turn will be advantageous to the patients who call for your assistance.
Best of luck on your next resuscitation!!
July 3, 2023
Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP
Pass with PASS, LLC.