Dual Sequential Defibriliation

Achilles

Achilles

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Michigan recently re vamped many of their protocols including AED placement and dual sequential shocking. I did a search and found some older threads on the topic, but I'm interested to see if anyone else's MCA has adopted it, in addition to that, they also want anterior posterior placement for pads. Have those that have had MCA opt in for it, have you found it to be effective? Our protocols want it done, but then contradict themselves to say "follow Manufacturer's recommendation on pad placement"
The dual sequential is after an AED has shocked 3 times, so rare, albeit could happen i suppose.
Two questions in one, sorry for the sloppiness in paragraph structure.
 
Several years ago we switched to the AP placement for the defibrillation pads so that is our go to. If we have done multiple defibrillations with success in converting then we will do a vector change and place another set of pads in the “traditional” location and attempt further defibrillations.

We one medic attempt a double sequential defibrillation however it was unsuccessful and both the medic and the base hospital physician got in some trouble for doing it.
 
We have it in our guidelines for use after three consecutive unsuccessful shocks. We are supposed to do AP pad placement on the first set but that has been difficult to get buy in on. Agencies that use the Zoll X have really struggled as you have to remove the CPR puck and people don’t do that. We also don’t use amiodarone or lidocaine in our system in cardiac arrest so take that for what it’s worth.

I did it once seven years ago when our wildman medical director wanted us “to be the first.” And it worked great!
 
We have talked about it at my PT job; thought and talked a lot about doing it on a patient in and out of Cardiac arrest back in January: 135 mile transport, in and out 7 times. We we decided to do it the next time he coded, (we were 35 miles into the transport: no cell or radio service) he stopped coding and the rest of the transport was boring except bagging him.
We had 2 monitors, so we could have done it, and probably wouldn't have gotten in trouble, but I think trying to hit both buttons at the exact same time would be hard
 
johnrsemt said:
We have talked about it at my PT job; thought and talked a lot about doing it on a patient in and out of Cardiac arrest back in January: 135 mile transport, in and out 7 times. We we decided to do it the next time he coded, (we were 35 miles into the transport: no cell or radio service) he stopped coding and the rest of the transport was boring except bagging him.
We had 2 monitors, so we could have done it, and probably wouldn't have gotten in trouble, but I think trying to hit both buttons at the exact same time would be hard
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it depends entirely on the protocol, but you can do them 1 right after the other or at the same time.
 
Most of the stuff I've seen about dual sequential defibrillation has been regarding serial defibrillations, immediately one then the other. This is different than dual simultaneous defibrillation. From what I've read, both approaches work. The idea is to depolarize as much of the myocardium as possible and utilizing different electrical pathways across the heart could get other portions of the myocardium to depolarize if it hadn't done so on the first shock.

I just hope we don't go so far as to attempt quintuple simultaneous defibrillations at 360J in the very refractory cases...
 
Akulahawk said:
I just hope we don't go so far as to attempt quintuple simultaneous defibrillations at 360J in the very refractory cases...
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I was thinking maybe continuous defibrillation using a car battery and jumper cables.
 
Akulahawk said:
Most of the stuff I've seen about dual sequential defibrillation has been regarding serial defibrillations, immediately one then the other. This is different than dual simultaneous defibrillation. From what I've read, both approaches work. The idea is to depolarize as much of the myocardium as possible and utilizing different electrical pathways across the heart could get other portions of the myocardium to depolarize if it hadn't done so on the first shock.

I just hope we don't go so far as to attempt quintuple simultaneous defibrillations at 360J in the very refractory cases...
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I don’t know that there will ever be enough data to truly evaluate the efficacy of DSD.. Persistent ventricular rhythms are so few and far between..
 
Akulahawk said:
I just hope we don't go so far as to attempt quintuple simultaneous defibrillations at 360J in the very refractory cases...
Click to expand...
Let's just transcutaneously pace at 15A ;)
 
I work in a rural agency in Colorado and we utilize Denver Metro Protocols. Our protocols do not specifically allow for dual sequential defibrillation, however with shock refractory V-tach or V-Fib our protocol suggests attempting a vector change. My agency recently acquired Life Pak 35's and our Stryker rep. told us that dual sequential d-fib is not a labeled use of the new Life Pak and suggested that there was a small chance of damage to the monitor with dual sequential. We work closely with a multitude of air medical resources who's protocols vary from ours and allow for dual sequential defibrillation. In a recent cardiac arrest I was on we had an individual who was in shock refractory v-fib and was also refractory to multiple doses of amiodarone. The air medical resource on scene of this call suggested attempting dual sequential defibrillation we attempted dual sequential using the new LifePak and the Zoll monitor that the flight service had without success. We attempted multiple dual sequential shocks and the patient was shocked probably a total of 10 times. Eventually the patient's rhythm degenerated to asystole resulting in termination of resuscitation.

I am curious how agencies are approaching dual sequential defibrillation. How do these agencies get multiple monitors to the scene? How do they approach the risk of possible damage to expensive monitors? How do agency protocols approach dual sequential defibration?
 
MountainMedic4263 said:
I work in a rural agency in Colorado and we utilize Denver Metro Protocols. Our protocols do not specifically allow for dual sequential defibrillation, however with shock refractory V-tach or V-Fib our protocol suggests attempting a vector change. My agency recently acquired Life Pak 35's and our Stryker rep. told us that dual sequential d-fib is not a labeled use of the new Life Pak and suggested that there was a small chance of damage to the monitor with dual sequential. We work closely with a multitude of air medical resources who's protocols vary from ours and allow for dual sequential defibrillation. In a recent cardiac arrest I was on we had an individual who was in shock refractory v-fib and was also refractory to multiple doses of amiodarone. The air medical resource on scene of this call suggested attempting dual sequential defibrillation we attempted dual sequential using the new LifePak and the Zoll monitor that the flight service had without success. We attempted multiple dual sequential shocks and the patient was shocked probably a total of 10 times. Eventually the patient's rhythm degenerated to asystole resulting in termination of resuscitation.

I am curious how agencies are approaching dual sequential defibrillation. How do these agencies get multiple monitors to the scene? How do they approach the risk of possible damage to expensive monitors? How do agency protocols approach dual sequential defibration?
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In a decent number of systems in the US there are paramedics on both the ambulance and fire engine that respond to medical calls so there would be 2 full sets of ALS gears. In some systems there would be a paramedic on the ambulance and then a paramedic supervisor in another response vehicle.

While it is not current being utilized in my system, I have not seen any case reports or actually heard stories from Zoll or LP about monitors actually receiving damage from doing it. There are many areas where DSD is in the protocols with more getting it added everyday. I would imagine if there was actually monitor damage occurring, Zoll and LP would put out memos.
 
FiremanMike said:
I don’t know that there will ever be enough data to truly evaluate the efficacy of DSD.. Persistent ventricular rhythms are so few and far between..
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going out on a limb here but I suspect that with the management of CAD and ischemic cardiomyopathy becoming more sophisticated beyond surgery (CA stenting/drugs/electrophysiologic intervention) it will become more and a more of a thing going forward. Sicker and sicker people are living longer and longer. We see people in the OR for elective stuff that no one would have touched with a 10 foot pole even 30 years ago and they do really well. Get ready...it's getting harder and harder to die...
 
E tank said:
going out on a limb here but I suspect that with the management of CAD and ischemic cardiomyopathy becoming more sophisticated beyond surgery (CA stenting/drugs/electrophysiologic intervention) it will become more and a more of a thing going forward. Sicker and sicker people are living longer and longer. We see people in the OR for elective stuff that no one would have touched with a 10 foot pole even 30 years ago and they do really well. Get ready...it's getting harder and harder to die...
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You may be right there, time will tell.

Local major city (30+ ALS transport units, 30+ ALS engine companies, over 120k ems runs annual) did a DSD trial a few years ago. Numbers are fuzzy, but I believe it was something like 30 cases over 2 years with no appreciable improvement in outcome - abandoned the study. Now, we all know with a sample size of 30 it's incredibly difficult to get meaningful data, but the bigger takeaway is that with that run volume, they only had 30 cases that met criteria.

Big picture - when your heart stops, there is an 89% chance you are just dead and only a 7% chance you'll leave the hospital with any meaningful existence, numbers that are essentially unchanged for many years.
 
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