Justin Haynes MD 362020 I have no disclosures

Justin Haynes MD 3/6/2020

§ I have no disclosures.

§ To discuss the application of double sequential defibrillation § To discuss the current evidence and clinical relevance of double sequential defibrillation.

65 y/o male presents via EMS as code blue from scene. Patient had reported several hours of heart burn prior to collapse. Witnesses started chest compressions immediately. EMS has delivered 10 rounds of CPR and 10 defibrillation attempts prior to arrival without ROSC or termination of ventricular fibrillation. Total down time of 30 minutes prior to arrival.

§ Dual External Defibrillation (DED) § Dual External Simultaneous Defibrillation (DESD) § Dual Sequential Defibrillation (DSD) § Double External Sequential Defibrillation (DESD) § Double External defibrillation (DED) § Double Defibrillation (DD)

§ The use of two defibrillators in sequence to give a longer and more complete depolarization of the cardiac myocytes. § The theoretical goal is to have a higher percentage of cells depolarized and subsequently a better chance at ROSC.

§ Increased total joules delivered § Reduction of resistance to defibrillation on second attempt § Vector change for more complete defibrillation

§ Failed External Defibrillation for ventricular fibrillation 3 times. § Not currently recommended for ventricular tachycardia but has been used.

§ Not really any contraindications § Only one defibrillator

EMS delivers the patient to you. You have just heard about double sequential external defibrillation (DSED) and you want to try it out. But how? Where do the pads go?

§ Maximum joules, 200 biphasic or 360 monophasic. § Simultaneous or sequential § Identical defibrillators

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Emcrit

Emcrit

§ Delivery of dual defibrillation is highly variable. Efforts to make defibrillation simultaneous are only successful in 52. 8% of attempts in controlled lab setting. § Poor data on optimal timing of defibrillation. Cardiac myocytes of 50 -75 ms refractory period.

Cheskes, Sheldon et al. The impact of double sequential external defibrillation on termination of refractory ventricular fibrillation during out-of-hospital cardiac arrest. Resuscitation, Volume 139, 275 -281 § Retrospective review of 252 patients, 51 DSED. § Shocks 4 -8 with DSED had ROSC of 15. 7% vs 5. 4% § Overall ROSC was statistically similar between groups

Cheskes, Sheldon et al. , Double sequential external defibrillation for refractory ventricular fibrillation: The DOSE VF pilot randomized controlled trial. Resuscitation, online. § ROSC was achieved in 25. 0%, 39. 3% and 40. 0% of standard, VC and DSED groups, respectively § Pulse on arrival to ED. 19% standard care, 25% vector change, and 33% double sequence

Mapp JG, Prehospital Double Sequential Defibrillation: A Matched Case-Control Study. Acad Emerg Med. 2019 Sep; 26(9): 994 -1001. doi: 10. 1111/acem. 13672. Epub 2019 Jan 6. § Matched Case Control § 64 matched cases out of 205 out-of-hospital cardiac arrests § No change in survival to hospital admission 48% vs 50% § Neurologically intact for DSED 12% and 19. 4% for conventional § Conclusion of paper is that DSED is ineffective

§ DSED is employed late in many cases § If ECMO is available patients may not require repeated attempts at defibrillation § Very limited prospective data, no randomized trials § What is the important part of DSED? Vector? Total dose? Timing?

§ https: //www. jems. com/2019/08/13/double-sequential-external-defibrillation-for- refractory-ventricular-fibrillation/ § https: //www. acep. org/how-we-serve/sections/critical-care-medicine/news/april- 2019/double-defibrillation-wheres-that-on-the-acls-algorithm/ § https: //emcrit. org/emcrit/double-defibrillation/ § https: //upload. wikimedia. org/wikipedia/commons/3/3 c/Ventricular_fibrillation_%28 from _ecg-quiz. com%29. jpg

§ Richard J. Hamilton, Mark Ramzy, Jamie Teufel, Glenn Laub & J. Yasha Kresh (2019) Dual Defibrillation is Highly Variable: An Analysis of Pulse Interval Delivered in Dual Defibrillation, Prehospital Emergency Care, DOI: 10. 1080/10903127. 2019. 1621411 § Miraglia D, Miguel LA, Alonso W, Ayala JE. Double sequential defibrillation for out-of- hospital refractory ventricular fibrillation: A scoping review. Am J Emerg Med. 2019 Dec 24. pii: S 0735 -6757(19)30851 -4. doi: 10. 1016/j. ajem. 2019. 12. 047. [Epub ahead of print] Review. Pub. Med PMID: 31937443.