Cardiovascular Disease: Student/Resident Case Report Poster - Cardiovascular Disease II |

Why Stop at 360J for Refractory Ventricular Fibrillation? FREE TO VIEW

Habib Nazir, MD; Michael DiVita, MD; Naveen Tyagi, MD; Rory Spiegel, MD; Marc Cohen, MD; Mark Merlin, DO
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Internal Medicine, Newark Beth Israel Medical Center, Newark, NJ

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):101A. doi:10.1016/j.chest.2016.08.109
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SESSION TITLE: Student/Resident Case Report Poster - Cardiovascular Disease II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Double sequential defibrillation (DSD), although described as early as 1994, is a relatively new technique that can be utilized for refractory ventricular fibrillation (VF). We describe a case that lends credence to the use of DSD to convert refractory VF to a normal sinus rhythm (NSR).

CASE PRESENTATION: A 55 year-old caucasian male with left ventricular systolic dysfunction, diabetes mellitus, paroxysmal AFib, and morbid obesity (BMI 50.1) was admitted for AFib. During an elective TEE cardioversion, the patient went into VF. CPR was initiated per ACLS protocol and biphasic defib was attempted at 300J, with failure to convert to NSR. Two minutes later, a second defib shock at 360J was delivered along with IV amiodarone, however this too failed to convert VF. After two more minutes, IV lidocaine and a third 360J defib shock was administered; again failing to convert VF. The decision was made to attempt DSD. Using defib pads from defib #1 and paddles from defib #2, we delivered two nearly simultaneous electrical doses of 360J for a total electrical energy of 720J. Our patient's refractory VF immediately converted into a NSR. He immediately regained full consciousness, was following all commands, and was transferred to the cardiac critical care unit. He was discharged home seven days later without any evidence of neurological deficits.

DISCUSSION: The current guidelines for ACLS fail to provide guidance for cases of refractory VF beyond the use of anti-arrhythmics and continued defibrillation at 360J. Given that the ultimate outcome in refractory VF is death, it seems prudent to continue studying additional therapies. We postulate: correct amount of electrical energy may depend on the concept of transthoracic impedance (increase the amount of energy based on BMI) and energy vector delivery (delivering separate charges through the myocardium).

CONCLUSIONS: DSD offers another tool to physicians in the treatment of refractory VF and to prevent subsequent death. While there is data on the technique itself, we do not know the optimal electrical dose nor optimal pad placement to achieve maximal survival. Nor do we know the correct number of pads or best pad vector. The risk/benefit profile seems reasonable since all refractory VF leads to death. There is need for additional research.

Reference #1: Hoch DH, et al. Double Sequential External Shocks for Refractory Ventricular Fibrillation. Journal of the American College of Cardiology. 1994;23:1141-5.

Reference #2: Cabanas JG. Double Sequential External Defibrillation in Out-of-Hospital Refractory Ventricular Fibrillation: A Report of Ten Cases. Prehospital Emergency Care: Official Journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 2015;19:126-30.

Reference #3: Saliba W et al. Higher Energy Synchronized External Direct Current Cardioversion for Refractory Atrial Fibrillation. Journal of the American College of Cardiology. 1999;34:2031-4.

DISCLOSURE: The following authors have nothing to disclose: Habib Nazir, Michael DiVita, Naveen Tyagi, Rory Spiegel, Marc Cohen, Mark Merlin

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