720 j defibrillation

[Underoath87]

So I finally got to attempt defibrillation with 720 j during a cardiac arrest the other day. Unfortunately, it didn't work, but the pt was an elderly male and had been down for 15-30 minutes. He had an AICD/pacemaker and kept alternating between (paced) asystole (PEA?) and V-Fib. You just use two monitors and place one set of pads normally, and the other in an anterior-posterior configuration. Then charge both and have one person press the shock buttons simultaneously.

My understanding is that this is a fairly rare procedure, but our medical director (2 med directors ago) was really aggressive and the subsequent ones haven't seen reason to remove it from the protocols. Our first shock is to be at 360 j, then all subsequent ones at 720 j if possible.

Thoughts? Experiences with it?

 

[STXmedic]

Yeah, refractory, sustained VF isn't all that common. I think I've done it twice now. One converted, on didn't. The theory behind it seems logical.

 

[FiremanMike]

It's led to a discussion here locally as to whether we should tear down the 360J cap and start delivering weight based energy.

A department nearby has had double sequential for about a year now and with an n=12 have had 3 surive to discharge, 2 with a CPC of 1..

N=12 is an extremely small sample, but still interesting to say the least.

 

[chaz90]

I've only had a couple of cases of refractory VF. I would desperately love to have a protocol for double sequential defibrillation, but my medical director shot it down.

 

[FiremanMike]

Our medical director wants us to change vectors to anterior/posterior instead..

 

[Underoath87]

Our medical director wants us to change vectors to anterior/posterior instead..

When using a single monitor?
It was a pain getting the second set of pads on in anterior/posterior, since we had to interrupt compressions and roll the patient on his side.

 

[FiremanMike]

When using a single monitor?
It was a pain getting the second set of pads on in anterior/posterior, since we had to interrupt compressions and roll the patient on his side.

Yep, and to be honest I hadn't thought of that..

 

[Chewy20]

Have only seen one patient juiced up by double sequential. I'm for it, with my limited experience, it seems like a last ditch effort. What's it gonna hurt?

 

[CANMAN]

Yep, and to be honest I hadn't thought of that..

Takes like 10 seconds in between switching compressors, you don't have to be gentle with it.....

 

[johnrsemt]

So; first of all you will have to carry 2 monitors (you don't always 2nd a 2nd ALS unit); and pressing the buttons at the same time doesn't mean that it will shock at the same time. You may have a slight delay between one button to the next or one finger to the next

 

[Underoath87]

So; first of all you will have to carry 2 monitors (you don't always 2nd a 2nd ALS unit); and pressing the buttons at the same time doesn't mean that it will shock at the same time. You may have a slight delay between one button to the next or one finger to the next

How often do you work a cardiac arrest for very long with only 1 unit?
We have an ALS Fire unit as first response on nearly all calls, so when we show up (and they're in a shockable rhythm), the second set of pads goes on.

The shocks are within a few milliseconds unless you're really uncoordinated. And even then, it probably doesn't matter much, since other places are purposely staggering them slightly (hence the term "double sequential").