![]() ![]() 1-5 RVF depends on multiple variables: time in VF, body habitus (despite animal models showing inverse relationship with defibrillation), total defibrillator energy used, chronic lung disease, and use of antiarrhythmic agents. One consistent description is persistent VF without response to three or more defibrillations. Refractory ventricular fibrillation (RVF)’s definition varies. ACLS, however, says nothing about it, let alone how to do it or if it even works. ![]() At this point, someone in the resuscitation team suggests performing double defibrillation (DD). VF is seen yet again, and a seventh shock is administered. Calcium gluconate is given, in addition to another dose of epinephrine, all while good-quality CPR is being continued. On the next pulse check, VF is seen again, so another shock is delivered. CPR is continued, and amiodarone is administered. VF is noted on the hospital monitor, and a fifth shock is delivered. A total of three shocks, and two doses of epinephrine were given in route, all with on-going CPR. The EMS crew arrives and states that the initial rhythm was ventricular fibrillation (VF). Bystander hands-only CPR was performed, and one shock was delivered by an automated external defibrillator (AED). The cluster units will be defined by emergency medical service (EMS) agency and each cluster will crossover at 6 month intervals throughout the duration of the study.EMS calls ahead with notification of a 54-year-old male who collapsed while walking on a college campus. All study arms will continue to receive antiarrhythmic use and epinephrine as per current provincial standards. All adult (≥ 18 years) patients presenting in refractory VF/pulseless ventricular tachycardia (pVT) (defined as patients presenting in VF/pVT and remaining in VF/pVT after three consecutive standard defibrillation attempts each separated by 2 minutes of CPR) during out-of-hospital cardiac arrest of presumed cardiac etiology will be assigned to be treated by one of three strategies: (1) continued resuscitation using standard defibrillation (2) resuscitation involving DSED (two defibrillators, one using anterior-posterior pad placement and the second using anterior- anterior pad placement delivering two rapid sequential shocks for all subsequent defibrillation attempts) or (3) resuscitation involving vector change (change of defibrillation pads from anterior-anterior to an anterior-posterior pad position) defibrillation. This cluster randomized trial will be conducted in the regions of Peel, Halton, Simcoe, and the cities of London, Ottawa, and Toronto, Ontario, Canada over a three year time period. As such, a well-designed randomized controlled trial (RCT) employing a standardized approach to alternative defibrillation strategies early in the treatment of refractory VF is required to determine whether these treatments may impact clinical outcomes. However, currently there is insufficient evidence to support widespread implementation of this therapy. Why Should I Register and Submit Results?ĭouble sequential external defibrillation (DSED) and vector change defibrillation have been proposed as viable options for patients in refractory ventricular fibrillation (VF) during out-of-hospital cardiac arrest. ![]()
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