Double shocks for refractoy v-fib (ACLS- EP stuff)

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Double Down for Refractory VT/VF

from clic-em

No doubt you have encountered a patient in persistent ventricular fibrillation (VF) cardiac arrest and have run out of options.  Beyond high quality uninterrupted CPR, biphasic defibrillation, pressors, and antiarrhythmics, therapy remains limited.

Enter double sequential defibrillation for the refractory VF cardiac arrest patient.  First described by Dr. David Hoch in 1994, this concept utilizes two defibrillators set up to provide sequential shocks seconds apart for patients with refractory VF during routine electrophysiology (EP) testing.

Hoch et al. found that 5 out of 2990 consecutive patients undergoing 5450 routine EP studies in a 3-year period experienced refractory VF (estimated incidence of 0.1%).  These 5 patients received multiple single transthoracic defibrillatory shocks (initial shock at 200J, subsequent shocks at 360J monophasic) without success.  

This was followed by double sequential shocks, delivered externally at 0.5-4.5 seconds apart by means of two defibrillators (each set at 360J monophasic) with separate pairs of electrodes.  All 5 patients were successfully cardioverted with their first double sequential shock.

To perform double sequential defibrillation in your ED, attach a second set of pads placed just left of the patient’s existing pads, creating a new vector.  At the time of defibrillation, both shock buttons are depressed as near-simultaneously as possible – delivering as much as 720J monophasic – resulting in a delay between the shocks from each defibrillator.  This is consistent with the sequential description by Hoch.

I have had personal success with double sequential defibrillation for persistent refractory ventricular fibrillation, with one ROSC using 720J and one nonresponder using 400J.

EMS Systems in Fort Worth, TX, Wake County, NC and New Orleans, LA have presented good data on this method.  At the 2011 EMS State of Sciences Conference in Dallas, TX, Dr. Juliette Saussy, former EMS Medical Director of New Orleans, shared that 4 of 16 deployments of double sequential defibrillation for refractory VF in New Orleans resulted in ROSC.  One of the four was a 64  year-old female who went home neurologically intact.  Reports from Wake County have been similar with good rhythm conversion by double sequential defibrillation and mixed success in achieving ROSC and neurologic preservation at discharge.

Lessons learned from the street are invaluable for practice in the ED.  Next time you have a patient in refractory ventricular fibrillation and have exhausted the algorithm, consider using a second defibrillator.

– Eric Beck, DO, EMT-P

References:

Hoch DM, WP Batsford, SM Greenberg, CM McPherson, LE Rosenfeld, M Marieb, and JH Levine.  “Double sequential external shocks for refractory ventricular fibrillation.”  Journal of the American College of Cardiology.  April 1994.  23(5): 1141-5.

 

 

SOURCE:  http://crashingpatient.com/resuscitation/bcls-acls-cardiac-arrest-care.htm/

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Chain of Survival: Link 4

The fourth link within the Chain of Survival is Early Advanced Care. Paramedics, emergency department staff, and other highly trained personnel offer this care, which may include identification of the root cause of the cardiac arrest, continued defibrillation, administration of cardiac medication, and the insertion of an endotracheal (breathing) tube.

This kind of advanced care will facilitate the heart in VF to respond, and maintain a  rhythm after successful defibrillation.  This type of early advanced care is called Advanced Cardiac Life Support, a course also offered by Carpenter CPR Solutions.

Chain of Survival, Link 3

This step is commonly known as the most important link within the Chain of Survival, because, generally, treatment with an automatic external defibrillator(AED) will restore a normal beat to a heart quivering from SCA by delivering a measured electric shock.

Timing is vital. According to the American Heart Association, reducing the interval between cardiac arrest and delivery of a shock by even a couple of seconds will increase an individual's chance of survival. for each minute that passes prior to defibrillation, the probabilities for survival reduce 7-10%. After ten minutes, survival is unlikely.

CPR alone cannot totally resuscitate an individual in SCA. Most SCA victims are in a ventricular fibrillation arrhythmia (VF), an electrical malfunction of the heart that causes it to twitch without coordinated beats.  Defibrillation, the delivery of  a shock to the heart, will restore traditional heart operation if it happens within minutes of SCA onset.

Chain of Survival: Link 2

Cardiopulmonary resuscitation (CPR) is that second link within the Chain of Survival. This step should buy life-saving time between the primary link (Early Access to Emergency Care) and the third link (Early Defibrillation).

Early CPR is a vital link within the Chain of Survival. throughout cardiopulmonary arrest, the heart quivers and twitches, and can't pump blood effectively through the body. CPR keeps blood flowing  through the body, sustaining life till a defibrillator, or alternative advanced treatment, arrives.

CPR is composed of 2 basic activities:
Chest compressions
Rescue breaths - either mouth-to-mouth or mouth-to-mask breaths

An SCA victim's likelihood of survival doubles if CPR happens before medical services arrives. In some communities,
911 medical dispatchers are trained  to advise on instructions over the phone, but this is less than ideal. That's why it's very important that the people in your community understand CPR and may act quickly in an emergency.

Chain of Survival: Link 1

Lets check out the Heart Association's Chain of Survival:


The first link within the Chain of Survival is Early Access.

Imagine you're at the airport expecting a plane, sitting in your workplace,or eating at a  restaurant, or sitting in your workplace. Suddenly, the person sitting next to you slumps over. you opt to take action and check on the person, however he or she will not respond to you. What do you have to do?

Call 9-1-1! This is the primary link in the Chain of Survival. it's referred to as "Early Access" due to the fact that seeking emergency care as quickly as possible is vital to SCA (Sudden Cardiac Arrest) survival. each minute counts.

Could you recognize the symptoms of SCA?

 Loss of consciousness
 Unresponsiveness
 Lack of pulse
Lack of breathing

SCA isn't the same as a heart attack; however, a victim of either condition needs an immediate 911 call.