Accepted Manuscript Double sequential defibrillation for refractory ventricular fibrillation

Chady El Tawil, Sandra Mrad, Basem F. Khishfe PII: DOI: Reference:

S0735-6757(17)30734-9 doi: 10.1016/j.ajem.2017.09.009 YAJEM 56954

To appear in: Received date: Revised date: Accepted date:

29 July 2017 6 September 2017 7 September 2017

Please cite this article as: Chady El Tawil, Sandra Mrad, Basem F. Khishfe , Double sequential defibrillation for refractory ventricular fibrillation, (2017), doi: 10.1016/ j.ajem.2017.09.009

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ACCEPTED MANUSCRIPT Title Page Title: Double Sequential Defibrillation for Refractory Ventricular Fibrillation Authors: Chady El Tawil M.D. Department of Emergency Medicine American University of Beirut - Medical Center

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Sandra Mrad M.D. Department of Emergency Medicine American University of Beirut - Medical Center

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Correspondent author and address for reprints: Basem F. Khishfe M.D. 5020 S LAKE SHORE DR (apt 2707) Chicago, Il 60615 [email protected]

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Basem F. Khishfe M.D. Department of Emergency Medicine American University of Beirut - Medical Center/ Mt Sinai Hospital

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Sources of support and disclaimers: None

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Keywords: Refractory, Ventricular Fibrillation, Double Sequential, Defibrillation, Resuscitation.

ACCEPTED MANUSCRIPT Double Sequential Defibrillation for Refractory Ventricular Fibrillation

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Abstract A 54-year-old suffered from an out-of-hospital cardiac arrest. Compressions were started within minutes

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and the patient was in refractory ventricular fibrillation despite multiple asynchronized shocks and

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maximal doses of antiarrhythmic agents. Double sequential defibrillation was attempted with successful Return Of Spontaneous Circulation (ROSC) after a total of 61 minutes of cardiac arrest. The patient was

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discharged home neurologically intact. Double sequential defibrillation could be a simple effective

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approach to patients with refractory ventricular fibrillation.

ACCEPTED MANUSCRIPT Introduction Out-of-hospital cardiac arrest remains a major cause of death worldwide accounting for around 0.5 to 1 deaths per 1000 population [1]. By-standers cardiopulmonary resuscitation (CPR) and early defibrillation have shown to have a major effect on mortality [2]; however, refractory ventricular fibrillation (VF)

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remains a challenge. We report a case of cardiac arrest for which dual simultaneous external defibrillation

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was performed for refractory VF. The patient was successfully resuscitated after 61 minutes with no

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neurological deficit.

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Case Presentation

A 54-year-old man with no significant past medical and surgical history was walking on the American

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University of Beirut (AUB) campus when he suddenly collapsed. Two medical students happened to be on scene and recognized the cardiac arrest immediately. They started resuscitating the patient with hands-

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only cardiopulmonary resuscitation (CPR) according to the 2015 BLS protocol. They applied the

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Automated External Defibrillator (AED) present on campus and activated the Campus Emergency Response Program (CERP) team. Upon arrival of the team, the hands-only CPR was still going

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uninterrupted and the AED had already delivered 1 shock. The CERP team continued the resuscitation while transferring to the emergency department (ED). The patient received a total of 3 additional shocks

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from the AED in route. Upon arrival to the ED, the patient was still in VF rhythm. He was shocked with 200 Joules using the defibrillator paddles. The resuscitation was continued according to the ACLS protocol. In total, the patient received 7 asynchronized shocks (including the AED shocks), multiple doses of intravenous (IV) Epinephrine (1:10000) 1 mg, Amiodarone 150 mg (IV), Lidocaine 250 mg (IV), Calcium Gluconate 2 g (IV), Magnesium Sulfate 2g (IV) and was still in refractory VF. The decision was made to try double sequential defibrillation. Two additional defibrillator patches were attached to the patient. It was ensured that the four patches are not making contact with each other. A

ACCEPTED MANUSCRIPT simultaneous shock was delivered from both defibrillators. CPR was resumed immediately, The patient received a total of 3 double sequential defibrillation shocks of 400 J each that resulted in Return Of Spontaneous Circulation (ROSC) after a total of 61 minutes of resuscitation. Hypothermia protocol was initiated and the patient was taken to the percutaneous catheter lab which showed total LAD occlusion.

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The patient was extubated the next day and was later discharged with no neurological deficits.

Discussion

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The field of resuscitation has been evolving for more than two centuries [3]. High quality CPR with

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limited interruption and early defibrillation for treatable arrhythmias remain the cornerstones of basic and advanced cardiac life support (ACLS). A single biphasic defibrillation remains the recommended

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treatment for VF or pulseless ventricular tachycardia (VT). Even though there isn't a large body of literature surrounding double sequential external defibrillation (DSED), it's been demonstrated successful

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in the electrophysiology lab, ED and prehospital settings. This has pushed several emergency medical

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services (EMS) systems to use DSED in their standing medical orders [4].

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The concept of DSED shocks was initially described in animal literature in the mid-1980s [5]. Using a canine model, investigators delivered single, double and triple exponential shocks to hearts in which VF

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and myocardial infarction had been induced. The researchers concluded that both sequential shocks and multiple vectors help to reduce the VF threshold and therefore terminate the arrhythmia [5]. The first mention of double sequential defibrillation in humans was in 1994 [6]. A case series described 5 patients with refractory VF that converted with DSED [6]. The reason for improved VF conversion may be due to several factors including additional defibrillation vectors, increased energy through the myocardium, and unknown other variables [7]. Kerber postulated that the first shock lowers the threshold for myocardial depolarization while the second successfully

ACCEPTED MANUSCRIPT depolarizes the already sensitized myocardial cells [8]. Another theory suggested by Ristagno is that the energy is increased to overcome limiting factors, such as poorly placed electrodes and the air in the lungs [9]. A retrospective case series by Cabanas et al. of 10 refractory VF cases (defined as VF that persisted after at least five shocks, epinephrine administration, and a dose of antiarrhythmic medication), were

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treated with DSED. Seven patients had successful cardioversion, and three had ROSC [10]. Also,

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Leacock et al. described a case of refractory VF that did not respond to standard defibrillation and

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medications but was successfully resuscitated with dual defibrillation [11].

In a retrospective cohort study, Ross et al found no association with neurologically intact survival rate

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between patients receiving DSED and standard defibrillation [12].

Conclusion

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This case demonstrates the applicability of dual simultaneous external defibrillation to the emergency

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department setting, providing a simple and potentially lifesaving approach to refractory ventricular fibrillation. Further cohort studies comparing the traditional external defibrillation and the dual

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simultaneous external defibrillation in refractory ventricular fibrillation are needed to implement this

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technique in the ACLS protocols.

ACCEPTED MANUSCRIPT References [1] Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics--2011 update: a report from the American Heart Association. Circulation. 2011;123(4):e18–e209. [2] Hasselqvist-Ax I, Riva G, Herlitz J, Rosenqvist M, Hollenberg J, Nordberg P, Ringh M, Jonsson M,

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Axelsson C, Lindqvist J, Karlsson T, Svensson L. Early cardiopulmonary resuscitation in out-of-hospital

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cardiac arrest. N Engl J Med.2015 Jun 11;372(24):2307-15.

[3] DeBard ML. The history of cardiopulmonary resuscitation. Ann Emerg Med 1980; 9:273.

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[4] Cortez E et al. Use of double sequential external defibrillation for refractory ventricular fibrillation

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during out-of-hospital cardiac arrest. Resuscitation 2016; 108:82-6.

[5] Chang MS, Inoue H, Kallok MJ, et al. Double and triple sequential shocks reduce ventricular

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defibrillation threshold in dogs with and without myocardial infarction. J Am Coll Cardiol. 1986;8(6):1393-1405.

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[6] Hoch DH, Batsford WP, Greenberg SM, et al. Double sequential external shocks for refractory

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ventricular fibrillation. J Am Coll Cardiol. 1994;23(5):1141-1145. [7] Merlin MA et al. A Case Series of Double Sequence Defibrillation. Prehospital Emergency Care. 2016

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Jan 29:1-4.

[8] Kerber RE. Indications and techniques of electrical defibrillation and cardioversion. In: Fuster V,

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Walsh R, Harrington RA, editor. Hurst's the heart. 13th ed. New York, New York: McGraw-Hill; 2011. [9] Ristagno G, Yu T, Quan W, Freeman G, Li Y. Comparison of defibrillation efficacy between two pads placements in a pediatric porcine model of cardiac arrest. Resuscitation 2012;83:755-9 [10] Cabanas JG, Myers JB, Williams JG et al. Double sequential external defibrillation in out-of-hospital refractory ventricular fibrillation: A report of ten cases. Prehosp Emerg Care. 2015;19(1):126-130. [11] Leacock BW. Double Simultaneous Defibrillators for Refractory Ventricular Fibrillation. JEM 2014; 46 (4): 472 – 74.

ACCEPTED MANUSCRIPT [12] Ross EM et al. Dual Defibrillation in Out-Of-hospital Cardiac Arrest: A Retrospective Cohort

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Analysis. Resuscitation 2016; 106:14-7.