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Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!
You are seeing a 19 year old with a history of illicit drug use brought in with sudden onset cardiac arrest. He received bystander CPR immediately after the arrest, and is in a ventricular fibrillation rhythm that has persisted despite 5 shocks, epinephrine, and amiodarone following the ACLS algorithm.
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October 28, 2018 at 10:02 pm
There are several case reports of successful resuscitation using double sequential defibrillation in adults with refractory ventricular fibrillation.
What is refractory? Some have used the definition: still in V Fib after 5 shocks, epinephrine, and an antiarrhythmic (usually amiodarone).
How is it done? Two sets of pads are placed, and they are attached to two separate defibrillators, both charged to maximum voltage; the two defibrillators are discharged simultaneously. (see references below for pad placement figures)
Does it work? The jury is out. There are case reports of successes, but larger case series and cohorts have not shown an increased survival to hospital discharge.
What else should I do first? This article https://www.jems.com/articles/supplements/special-topics/ems-state-of-the-science/double-defibrillation.html reviews some troubleshooting to consider: make sure the V-fib is truly refractory and not just recurrent, make sure pads are optimally positioned, and minimize resistance if possible.
Has this been done in kids? Not that I found reported on Pubmed or Google. Remember, PALS states that defibrillation doses can be as high as 10 J/kg in kids.
References: https://www.jems.com/articles/print/volume-41/issue-5/departments-columns/case-of-the-month/using-double-sequential-defibrillation-to-help-cardiac-arrest-patients.html
http://www.nuemblog.com/blog/double-defib
Cabañas JG et al. Prehosp Emerg Care 2015;19(1):126-130