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Double defib for refractory v-fib

November 11, 2016

Short Attention Span Summary

Probably many of you have heard of double sequential external defibrillation (DSED).  I had never heard of it until a few months ago.  DSED consists of sticking two sets of pads on the patient, charging, and trying to deliver the shocks simultaneously.  This was a case report of a patient with shock-refractory v-fib (6 failed 200J shocks plus antiarrhythmic drugs) who was eventually diagnosed with long QT syndrome and had a good outcome after she finally converted to NSR using DSED.  DSED has been previously described in the EP lab, ED, and even prehospital setting, but this was the first report in the prehospital setting with a good neurological outcome.

Spoon Feed
Shock-refractory ventricular fibrillation is usually defined as failure after 5 shocks.  If you find your patient in this situation, try double sequential external defibrillation.


Prehosp Emerg Care. 2016 Sep-Oct;20(5):662-6. doi: 10.3109/10903127.2016.1168891. Epub 2016 Apr 14.

Double Sequential External Defibrillation and Survival from Out-of-Hospital Cardiac Arrest: A Case Report.

Johnston MCheskes SRoss GVerbeek PR.



Patients who present in ventricular fibrillation are typically treated with cardiopulmonary resuscitation (CPR), epinephrine, antiarrhythmic medications, and defibrillation. Although these therapies have shown to be effective, some patients remain in a shockable rhythm. Double sequential external defibrillation has been described as a viable option for patients in refractory ventricular fibrillation.


To describe the innovative use of two defibrillators used to deliver double sequential external defibrillation by paramedics in a case of refractory ventricular fibrillation resulting in prehospital return of spontaneous circulation and survival to hospital discharge with good neurologic function.


A 28-year-old female sustained a witnessed out-of-hospital cardiac arrest (OHCA). Bystander CPR was performed by her husband followed by paramedics providing high-quality CPR, antiarrhythmic medication, and 6 biphasic defibrillations using standard energy levels. Double sequential external defibrillation was applied and a return of spontaneous circulation was attained on scene and maintained through to arrival to the emergency department. Following admission to hospital the patient was diagnosed with long QT syndrome. An implantable cardioverter defibrillator was placed and the patient was discharged with a Cerebral Performance Category of 2 as well as a modified Rankin Scale of 2 after an 18-day hospital stay. The patient’s functional status continued to improve post discharge.


The addition of double sequential external defibrillation as part of a well-organized resuscitation effort may be a valid treatment option for OHCA patients who present in refractory ventricular fibrillation.

PMID: 27077941 [PubMed – in process]

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