Defibrillation Strategies for Refractory Ventricular Fibrillation

Stu Berger, MD, Citizen CPR Foundation President, shares the following summary of “Defibrillation Strategies for Refractory Ventricular Fibrillation,” recently published in the New England Journal of Medicine:

Outcomes from sudden cardiac arrest have improved over the years as a result of technological advances in defibrillation techniques and technology. Other interventions that have included community CPR-AED education have also proved to be beneficial. However, shock-refractory ventricular fibrillation (VF) is not uncommon during out-of-hospital-cardiac-arrest (OHCA). This study offers an important discussion of exciting alternatives to shock strategies when conventional approaches fail.

In a randomized-controlled study reported by Cheskes et al. in the New England Journal of Medicine in November 2022, double sequential external defibrillation (rapid sequential shocks from two defibrillators) and vector-change defibrillation (switching defibrillator pads to the anterior-posterior position) have been proposed as techniques to improve outcomes.

In this study, 405 patients were enrolled with a total of 136 (33.6%) receiving standard defibrillation, 144 (35.6%) receiving vector-change defibrillation, and 125 (30.9%) receiving double-sequential external defibrillation. Of importance is the fact that survival to hospital discharge was more common in the double-sequential external defibrillation group than in the standard group (30.4% vs. 13.3%) and more common in the vector-change group than in the standard group (21.7% vs. 13.3%). Double-sequential external defibrillation was associated with a higher recovery of patients having a good neurologic outcome than standard defibrillation.

This paper offers an exciting possibility for improved outcomes by the employment of alternative methods for defibrillation in heretofore shock-refractory VF. Although the logistics of having a second defibrillator present and available might be challenging, the use of vector-change defibrillation with single defibrillator systems might be an alternative strategy when a second defibrillator is not available.

Although this trial was accompanied by/associated with some limitations, particularly with its institution around the time of the COVID-19 pandemic, and the operational challenges associated with that, this trial is indeed significant in that it does show that survival to hospital discharge was significantly improved with double-sequential external defibrillation and vector-change defibrillation compared to standard defibrillation in patients with shock-refractory VF during OHCA. We look forward to more data on these techniques, as well strategies for implementation. Although this is but one study, it is indeed a report of some exciting alternatives to conventional approaches and we look forward to additional studies and education with regard to implementation, if appropriate.

Read the full article on the NLM website >>








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