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Today's cardiology pearl provided by EMS guru Dr. Ben Lawner. Consider this one if you are caring for a patient with what appears to be shock-resistant VFib.
An intervention that has its roots in the electrophysiology lab has now gained traction on the front lines of resuscitation: double sequential defibrillation. Prospective studies are currently underway to examine the feasibility of this technique. New Orleans (LA) EMS boasts several anectodal accounts of survival, with neurologically intact recovery, from refractory ventricular fibrillation. The next time you can’t stop the fibbing, consider this:
· Apply TWO sets of defibrillator pads to the patient; one in traditional sternum/apex configuration and the other in anterior/posterior configuration
· If ventricular fibrillation persists despite several shocks, coordinate the simultaneous firing of BOTH defibrillators
Some caveats:
This treatment is based upon EP lab data; each MONOPHASIC defibrillator was set at 360J. EMS services in New Orleans and Wake County (NC) have used two biphasic defibrillators, each set a 200J. There is not sufficient data to make any widespread recommendation, but the idea of double sequential defibrillation may be another tool in a limited ACLS bag of tricks for patients who simply cannot come out of V-fib. New Orleans EMS has initiated the double-defib protocol after four shocks, and Wake County’s protocol recommends initiation after five. Wake's protocol also recommends firing the defirbillators "as synchronously as possible."
References
DH Hoch, WP Batsford, SM Greenberg, CM McPherson, et al. Double sequential defibrillation for refractory ventricular defibrillation. J. Am Cardiol. 1994;23:1141-45.