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Double Sequential External Defibrillation in Out-

of-Hospital Refractory Ventricular Fibrillation: A
Report of Ten Cases

Article in Prehospital Emergency Care September 2014

DOI: 10.3109/10903127.2014.942476

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 DOUBLE SEQUENTIAL EXTERNAL DEFIBRILLATION IN OUT-OF-HOSPITAL
REFRACTORY VENTRICULAR FIBRILLATION: A REPORT OF TEN CASES
Jose G. Cabanas, MD, MPH, J. Brent Myers, MD, MPH, Jefferson G. Williams, MD, MPH,
Valerie J. De Maio, MD, MSc, Michael W Bachman, MHS, EMT-P
ABSTRACT
Background. Ventricular fibrillation (VF) is considered the
out-of-hospital cardiac arrest (OOHCA) rhythm with the
highest likelihood of neurologically intact survival. Unfor-
tunately, 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,
Prehosp Emerg Care Downloaded from informahealthcare.com by 162.89.0.59 on 09/22/14
waveform, or energy level that produce the best conversion
rates from OOHCA with VF. Objective. To describe a tech-
nique 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 resus-
citation efforts by EMS providers. RVF was defined as per-
sistent VF following at least 5 unsuccessful single shocks,
For personal use only.
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 defib-
rillator for single defibrillation with the new monitor/pad
placement. If VF continued, EMS personnel then utilized the
original and second monitor/defibrillator charged to max-
imum energy, and shocks were delivered from both ma-
chines simultaneously. Data were collected from electronic
Received January 31, 2014 from the Wake County EMS System,
Raleigh, North Carolina (JGC, JBM, JGW, MWB), Austin-Travis
County EMS System, Austin, Texas (JGC), and Emergency Services
Institute, Clinical Research Unit, WakeMed Health & Hospitals,
Raleigh, North Carolina (JBM, JGW, VJD). Revision received June 8,
2014; accepted for publication June 16, 2014.
Presented at the National Association Physicians annual meeting in
2013, Bonita Springs, Florida.
The authors report no conflicts of interest. The authors alone are re-
sponsible for the content and writing of the paper.
The authors thank Brian Lanier, Ryan Lewis, and Joseph Zalkin for
their valuable contributions. We also want to acknowledge the emer-
gency medical dispatchers, firefighter first responders, and BLS, and
ALS members of the Wake EMS System for the commitment to pro-
vide prompt, compassionate, clinically excellent care.
Address correspondence to Jose G. Cabanas, MD, MPH, Deputy
Medical Director, Office of the Medical Director, Austin/Travis
County EMS System, 517 S Pleasant Valley Road, Austin, Texas
78741, USA. E-mail: jgcabanas@me.com
doi: 10.3109/10903127.2014.942476
1
dispatch and patient care reports for descriptive analysis.
Results. From 01/07/2008 to 12/31/2010, a total of 10 pa-
tients were treated with DSED. The median age was 76.5
(IQR: 6582), with median resuscitation time of 51minutes
(IQR: 4562). The median number of single shocks was 6.5
(IQR: 611), with a median of 2 (IQR: 13) DSED shocks de-
livered. 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 under-
stand the characteristics of and treatment strategies for RVF.
Key words: double sequential; defibrillation; out-of-
hospital; cardiac arrest; ventricular fibrillation
PREHOSPITAL EMERGENCY CARE 2014;Early Online:15
INTRODUCTION
Out-of-hospital cardiac arrest (OOHCA) remains a
common cause of death in the United States, with
an estimated 424,000 incidents every year and an
overall survival of 10.4%.1 Ventricular fibrillation (VF)
is considered the OOHCA rhythm with the highest
likelihood of neurologically intact survival.24 Current
out-of-hospital treatment strategies focus on early
defibrillation and effective quality chest compressions
with minimal interruptions.5 External defibrillation re-
mains the primary treatment for VF.6,7 Unfortunately,
there are occasions when VF does not respond to
current out-of-hospital treatment strategies, including
standard defibrillatory shocks.
Refractory VF (RVF) is considered a rare clini-
cal event with an estimated incidence of 0.50.6 per
100,000 population.8 The actual number of events of
RVF, however, is difficult to accurately estimate, in
large part due to lack of a standard definition.810 Sev-
eral authors report that approximately 1025% of car-
diac arrest cases could develop RVF or recurrent VF
at some point during resuscitation efforts, with dismal
outcomes.8,9,11,12 One of the most common definitions
for RVF is persistent VF without response to five stan-
dard shocks.10,13 Current American Heart Association
(AHA) guidelines for emergency cardiovascular care
(ECC) acknowledge the data are insufficient in deter-
mining the best treatment strategy for such rare events.
Successful defibrillation is likely dependent on several
factors, including pad placement, waveform, and/or
 2 PREHOSPITAL EMERGENCY CARE OCTOBER/DECEMBER 2014 EARLY ONLINE

energy levels that produce the best conversion rates

from OOHCA with VF.14
Double sequential external defibrillation (DSED) has
been used by clinical electrophysiologists to manage
RVF induced during elective procedures for different
types of dysrhythmias.15,16 DSED has never been ap-
plied in the out-of-hospital environment as part of
the standard approach to managing RVF. The primary
purpose of this retrospective case series is to describe
DSED for OOHCA cases of RVF, and to encourage the
development of prospective multicenter studies that
further evaluate the use of this treatment modality.

MATERIALS AND METHODS

We performed a retrospective case series of adult RVF
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cases from 01/07/2008 to 12/31/2010. This study met

all requirements of the local institutional review board
and was approved for waiver of informed consent.
Our study was conducted in Wake County, North
Carolina. The Wake County EMS System (WCEMS)
is the sole provider of 9-1-1 EMS responses for all
of Wake County. The EMS system has an annual call
volume of approximately 85,000 requests for service FIGURE 1. Pad placement for double sequential external defibrilla-
each year, and responds to approximately 700 cases of tion.
For personal use only.

suspected cardiac arrest. All requests for service are

prioritized by certified emergency medical dispatch-
ers at a public safety answering point. The state-of-
the-art computer-assisted dispatch system dispatches
a firefighter automated external defibrillator (AED)-
equipped first responder apparatus, the nearest two
ambulances, and an advanced practice paramedic or
field supervisor for all presumed cardiac arrest inci-
dents. All paramedic-staffed units are equipped with
a manual monitor/defibrillator that utilizes biphasic
truncated exponential technology that offers up to 360
J (Physio-Control, LIFEPAK 12,15, Redmond WA). As
standard clinical practice in WCEMS, every manual
defibrillation is delivered at 360 J. All first responders
and paramedics operate under unified medical direc-
tion with system-wide protocols for OOHCA resusci-
tation, which includes the use of an epinephrine drip,
calculated to deliver 1 mg every 34 minutes for pro-
long resuscitations and administration of antiarrhyth-
mic medications as indicated.
RVF was defined as persistent VF following at least 5
unsuccessful single shocks with a single set of pads, in-
cluding AED shocks, and a single dose of antiarrhyth-
mic medication without change. Once in RVF, EMS
personnel prepared additional sites for the attachment
of an additional set of external defibrillation pads by
drying the sites and minimizing adhesion interference
from hair or other obstacles. A second set of pads was
then placed, during a scheduled pulse/rhythm check
(<5 seconds), opposite the first set of pads, in either
an anteriorposterior pad location or an antero-lateral
location, depending on placement of the first set. A sec-
ond monitordefibrillator was utilized for single defib-
rillation with the new monitor/pad placement to pro-
duce a different current vector than the first set (Fig-
ure 1). If VF continued, EMS personnel then utilized
the original and second monitor/defibrillator together,
both charged to the maximum energy, and shocks were
delivered from both machines as synchronously as
possible. The code commander ensured that quality
cardiopulmonary resuscitation (CPR) was not compro-
mised during this process and that the resuscitation
checklist was completed. CPR resumed as appropriate,
with brief rhythm/pulse checks occurring per proto-
col and current OOHCA guidelines. Both cardiac mon-
itors were removed from service and examined by the
manufacturer to determine if any harm occurred to the
devices. For this study, data were collected from the
electronic dispatch and patient care reports for descrip-
tive analysis.
RESULTS
From 01/07/2008 to 12/31/2010 a total of 10 patients
(9 male, 1 female) were treated with DSED (Table 1).
The median age was 76.5 years old (IQR: 6582), with
a median resuscitation time of 51 minutes (IQR: 4562).
All resuscitation efforts occurred on scene regardless of
total scene time, per local protocol instructing rescuers
to resuscitate at the scene of the arrest except in ex-
treme or extenuating circumstances. The initial cardiac
rhythms were VF in 6 patients, asystole in 3 patients,
 et al.
J. G. Cabanas SEQUENTIAL SHOCKS IN REFRACTORY FIBRILLATION 3

TABLE 1. Clinical characteristics of cases with refractory ventricular fibrillation

First Response AED Bystander Initial Single DSED Time to
Case Age Gender Witnessed Time Shocks CPR Rhythm Shocks Shocks First DSED

Case-1 82 M Bystander < 5 minutes 2 Yes V-fib 9 3 30 minutes

Case-2 72 M Bystander < 5 minutes 2 Yes V-fib 14 8 43 minutes
Case-3 20 M No < 5 minutes None No Asystole 6 1 38 minutes
Case-4 76 M Bystander < 5 minutes None Yes PEA 5 2 29 minutes
Case-5 23 M No 5-10 minutes None Yes Asystole 6 1 40 minutes
Case-6 77 F Bystander < 5 minutes 1 Yes V-fib 4 1 32 minutes
Case-7 86 M Bystander < 5 minutes None No Asystole 7 2 51 minutes
Case-8 82 M No < 5 minutes 1 No V-fib 18 5 44 minutes
Case-9 83 M Bystander 6 minutes 2 No V-fib 6 2 39 minutes
Case-10 65 M Bystander < 5 minutes None Yes V-fib 6 2 22 minutes

and pulseless electrical activity in 1 patient. The me- logic study. In this single-center study, all patients
dian number of single shocks was 6.5 (IQR: 611), with were successfully resuscitated using double sequential
a median of 2 (IQR: 13) DSED shocks delivered. VF shocks.17
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terminated after DSED in 7 cases (70%). Only 3 patients
(30%) had ROSC in the field, and none survived to hos-
pital discharge (Table 2).
There were no reported delays or protocol devia-
tions in standard cardiac arrest care to patients and
no cardiac monitor failures reported by EMS providers
or identified by the manufacturer during the study
period.
For personal use only.
As with any new treatment, it is important to
consider safety in addition to potential clinical effec-
tiveness. One concern is the potential for myocardial
damage with the use of double sequential shocks to
convert RVF. Previous preliminary reports suggest
that this technique is safe.13,1518 For instance, Mar-
rouche and colleagues studied 46 patients in the EP
lab with chronic atrial fibrillation. Atrial fibrillation
patients who failed traditional cardioversion were

enrolled in the study and treated with the quadruple

DISCUSSION
We report the first case series of DSED in the out-
of-hospital setting during resuscitation efforts from
OOHCA in patients with RVF. These preliminary re-
sults show that DSED may be a promising and safe
strategy to manage RVF. We found that RVF termi-
nated 70% of time in this single-center study. Unfor-
tunately, no patients survived to hospital discharge.
Our study highlights the importance of developing
new treatment strategies for complex cases of out-of-
hospital resuscitation where traditional clinical man-
agement practices may not be effective.
A few clinical studies have described the use of
DSED to manage patients with secondary VF after
elective cardioversion for clinical dysrhythmias. Hoch
and colleagues reported a case series of 5 patients
with refractory VF during a routine electrophysio-
pad approach. This approach required placement
of two antero-posterior pad sets for the delivery of
two simultaneous 360-J shocks. The authors measured
success of cardioversion, post-treatment CK-MB,
and troponin. They report that quadruple pads
were successful in 14 of 19 (74%) patients without
significant changes in cardiac enzymes.16 Another
potential concern is whether this procedure delivers
a higher intracardiac voltage gradient, which may be
deleterious to the myocardium. This is unlikely given
that biphasic defibrillation at the maximum available
energy has been shown to produce equivalent voltage
strength compared to other biphasic defibrillators
with different energy settings.19
Even though cases of RVF appear to be relatively rare
events, the true incidence of RVF remains unknown;
nevertheless, these cases present an enormous clinical

TABLE 2. Clinical outcomes of cases with refractory ventricular fibrillation

Terminated Total Resuscitation Field
Case V-Fib ROSC Time Termination Transported Survival

Case-1 Yes Yes 45 minutes No Yes No

Case-2 Yes Yes 65 minutes No Yes No
Case-3 Yes No 50 minutes Yes N/A N/A
Case-4 No No 46 minutes Yes N/A N/A
Case-5 Yes No 45 minutes Yes N/A N/A
Case-6 Yes No 52 minutes Yes N/A N/A
Case-7 Yes No 60 minutes Yes N/A N/A
Case-8 No No 82 minutes No Yes No
Case-9 No No 62 minutes Yes N/A N/A
Case-10 Yes Yes 31 minutes No Yes No
 4 PREHOSPITAL EMERGENCY CARE
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For personal use only.
FIGURE 2. Case 8: Double external sequential defibrillation shock #5, +56 minutes.
challenge for prehospital providers, as patients in VF
are considered the most likely cases of OOHCA to be
resuscitated. For the last decade there has been a sig-
nificant advance in the management of OHCA. How-
ever, no recent advancements have been made in the
treatment of RVF. In fact, current ECC guidelines lack
specific recommendations for the management of cases
with RVF. We believe that as EMS systems continue
to implement evidenced-based practices for OHCA re-
suscitation, the incidence of RVF may increase as an
effect of higher quality resuscitation efforts.
Our study did not find any evidence of harm to the
devices, nor do we believe this treatment decreases
the chances of ROSC in these small series of cases.
Even though none of our patients survived to hospi-
tal discharge, the use of two defibrillators for DSED
seems to terminate VF. Survival to neurologically in-
tact discharge may be related to known confounders
not assessed in this small case series. For instance, a
high cumulative dose of epinephrine during a pro-
longed resuscitation can have a detrimental effect in
the defibrillation threshold, requiring more defibrilla-
tory shocks.20
One potential reason why we did not see survivors
to hospital discharge in this series may be because
DSED was performed too late into the resuscitation.
Our study protocols allowed for utilizing the tech-
nique after 5 unsuccessful shocks with the original pad
placement and at least one single shock with an alter-
OCTOBER/DECEMBER 2014 EARLY ONLINE
native pad placement; thus, our cases received a me-
dian of 6.5 single shocks before the first DSED. In ad-
dition, in 6 cases, the first DSED shock was received
after more than 35 minutes of resuscitation, which
would make us consider revising the protocols for ear-
lier administration for a better opportunity for success
(Figure 2).
Another consideration for the occurrence of RVF is
that pad placement for shock delivery is not located in
the vector in which the shock will be effective at termi-
nating VF. The DSED procedure essentially translates
into the rapid delivery of two high-energy shocks in
two different vectors without interruption. Also, this
technique minimizes the interruption of chest com-
pressions, which has a clear association with survival.
Our study has several limitations that deserve par-
ticular attention. Even though we have a robust car-
diac arrest resuscitation quality monitoring program,
including participation in the CARES registry, and are
thus satisfied we captured all of the RVF cases, the total
number of cases is small and does not allow us to eval-
uate the effectiveness of this technique for RVF cases.
As a result, a number of unmeasured cofounders could
have influenced the effects of DSED in these cases. Due
to our extensive cardiac arrest quality monitoring pro-
gram, and our participation in the CARES registry, we
believe we have identified all cases of RVF during the
review period. Furthermore, we relied on the exist-
ing electronic care record (ECR) to capture all clinical
 et al.
J. G. Cabanas SEQUENTIAL SHOCKS IN REFRACTORY FIBRILLATION
variables. As this ECR did not capture data directly
from the cardiac monitor, we did not have consistent
data on timing of DSED, pad position, and detailed
ECG recordings from the cardiac monitors. Also, we
did not collect data on body mass index or anatomic
impedance. Our present data capture system will be
able to identify these data for future cases to support
future investigation into the use of DSED for RVF. A
more detailed data capture of OOHCA care for RVF
cases, perhaps across multiple sites, may also allow for
cohort-level studies that would further elucidate the
effects of this procedure. Finally, there is a clear need
for consensus on the definition of RVF so that future
studies are comparable and can build on the experi-
ences of one another.
Prehosp Emerg Care Downloaded from informahealthcare.com by 162.89.0.59 on 09/22/14
CONCLUSION
This case series demonstrates that DSED may be a fea-
sible 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. Until further research provides
definitive protocols for the management of RVF, EMS
medical directors may consider utilizing this treatment
For personal use only.
strategy on a case-by-case basis for RVF unresponsive
to established resuscitation techniques.
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