# Double Sequential External Defibrillation



## Handsome Robb (Mar 10, 2011)

I was bored so I starting poking around and stumbled across this

http://www.wakegov.com/NR/rdonlyres...WakeCounty2010ClinicalOperatingGuidelines.pdf

Procedure 15 & Protocol 35b.

What is the thought process behind this? Couldn't the same thing be accomplished with a single monitor at a higher energy level? Seems pretty overkill, but I know that Wake County has great outcomes and is one of the more progressive systems in the country.


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## rhan101277 (Mar 10, 2011)

Yeah this was discussed at the gathering of the eagles conference in Dallas.

I think it works because when using two separate monitors to defibrillate, you get different vectors of electrical current moving across the heart instead of just one.  Also I think the electrical conduction of each dfib pad is different and this helps to.


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## HotelCo (Mar 10, 2011)

Where do the else second set of pads go? On the opposite sides of the chest?


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## abckidsmom (Mar 10, 2011)

HotelCo said:


> Where do the else second set of pads go? On the opposite sides of the chest?



Just talking here, but I'd guess the first set would be sternum/apex and the second set would be anterior/posterior or something of the like.

Learned something new today.


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## STXmedic (Mar 10, 2011)

I was actually just talking about this with my medical director last night. He was telling me that, though the additional vectors of the two sets of pads may play a role, the main benefit is the added joules. Apparently electrophysiologists have been doing this for years with great success (with only a single set of pads). They'll crank it up to 300-400j biphasic without batting an eye. How he explained it was, if 200j didn't work the first time, 200j didn't work the second time, why would 200j work the third time. Different people require different amounts of energy to be effective, due to differences in individual physiology and current pathologies. In the prehospital setting, we're of course limited to the capabilities of our monitors.

Sadly, he doesn't want us putting it in our protocols yet thanks to a high number of ALS providers who can hardly remember to tie their shoes, let alone be trusted to not go frying the first SVT they come across with 400j

Unfortunately, I didn't have the presence of mind to ask about pad placement...


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## mikie (Mar 10, 2011)

*In regards to placement*

According to Procedure 15: 



> 3. Apply a new set of external defibrillation pads *adjacent to*, but not touching the pad set currently in use.


I like the concept behind the AP placement + Traditional (more vectors) this just seems like more juice traveling across the same vector... Am I wrong?


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## byoung57 (Mar 10, 2011)

You are correct about the placement.  The effect of the double defibrillation on the vectors of energy have shown, in some studies, to be more effective in resolving VF.


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## Hockey (Mar 10, 2011)

So wait, 4 total pads?


Well I guess I can see that conccept?  Instead of "punching the heart " from each side once, do it from 4 different areas really "knocking it out" and letting it restart.  Maybe?


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## Handsome Robb (Mar 10, 2011)

So is it more an issue of a single monitor in the field not being able to generate the higher amounts of biphasic energy rather than having different vectors of energy delivery?


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## jjesusfreak01 (Mar 11, 2011)

mikie said:


> According to Procedure 15:
> 
> I like the concept behind the AP placement + Traditional (more vectors) this just seems like more juice traveling across the same vector... Am I wrong?



They actually just changed this. The newest guidance from our MD is that non-adjacent placement is fine (can even put one pad on the back) to create different vectors. 

The DSD protocol is only used to try and break persistent V-fib and V-tach. Its only used when they can't be broken by other means, since if its broken previously, then it probably isn't a problem with your electrical therapy.

PS: We use LP15s, which can give 360J biphasic, which is a good amount of energy to begin with. I'm a Wake County EMT.


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## goosecrane (Sep 29, 2013)

In my area this is probably going to be in future protocols, and is now being performed with medical direction. I have personally used it on a PT we just could not get out of Vtach with very positive results. I actually visited with my PT a few days later, he had no deficits, and set to be discharged later that day. We worked the PT a total of 48 mins with no neuro deficit!!!! I'm sold.


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## Christopher (Oct 3, 2013)

jjesusfreak01 said:


> They actually just changed this. The newest guidance from our MD is that non-adjacent placement is fine (can even put one pad on the back) to create different vectors.
> 
> The DSD protocol is only used to try and break persistent V-fib and V-tach. Its only used when they can't be broken by other means, since if its broken previously, then it probably isn't a problem with your electrical therapy.
> 
> PS: We use LP15s, which can give 360J biphasic, which is a good amount of energy to begin with. I'm a Wake County EMT.



I believe the latest protocols go to DSED for the 4th defib and beyond.


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