Dual sequential defibrillation

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StCEMT

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Skimming the protocols and got to thinking when I came across this part of it. My codes this year were all asystole/pea (peds or just definitely staying dead) so I never really gave it much thought. Who here has actually done this?

If the idea is to lower the threshold to convert the rhythm, would there be any benefit to some day just going straight to DSD with VF within the first or second shock instead of waiting until 4 or 5+ shocks?

I ask because this little nugget. Very small sample pool, but 30% ROSC out of 70% converted? I mean, none survived to discharge from this study, but that's already a decent possibility in these calls. Not really finding many great things written about it other than "its a thing, it works sometimes." So lets here those anecdotes.

https://www.ncbi.nlm.nih.gov/pubmed/25243771
 
StCEMT said:
If the idea is to lower the threshold to convert the rhythm, would there be any benefit to some day just going straight to DSD with VF within the first or second shock instead of waiting until 4 or 5+ shocks?

I ask because this little nugget. Very small sample pool, but 30% ROSC out of 70% converted? I mean, none survived to discharge from this study, but that's already a decent possibility in these calls. Not really finding many great things written about it other than "its a thing, it works sometimes." So lets here those anecdotes.
Click to expand...

I've never done it before, but the state of RI is implementing this on the first of the year. I'm curious to see the results. These results won't likely be sustainable, but could improve the already low number of ROSC patients. There's an article (can't post because I'm too new) that seems to suggest that Oregon is having some decent success, right around the same percentage (34% in this case), but again, a very small sample population.

I agree with wondering what would happen if the DSED happened earlier in these codes. There's one study that did it after 7 to 20 defibrillations, but I'm not seeing much in the way of initial attempts.
 
I've done it a few times. But we can only do it after 3 regular defibrillations at 360j (we skip the lower joule settings), so by that point they'd already been down for some time.
 
StCEMT said:
Skimming the protocols and got to thinking when I came across this part of it. My codes this year were all asystole/pea (peds or just definitely staying dead) so I never really gave it much thought. Who here has actually done this?

If the idea is to lower the threshold to convert the rhythm, would there be any benefit to some day just going straight to DSD with VF within the first or second shock instead of waiting until 4 or 5+ shocks?

I ask because this little nugget. Very small sample pool, but 30% ROSC out of 70% converted? I mean, none survived to discharge from this study, but that's already a decent possibility in these calls. Not really finding many great things written about it other than "its a thing, it works sometimes." So lets here those anecdotes.

https://www.ncbi.nlm.nih.gov/pubmed/25243771
Click to expand...

We can technically go to DSD as soon as refractory VF/VT is identified. So theoretically the second defibrillation in our code could be DSD if we have the second monitor. Generally it isn't...because the second monitor is coming with the Commander who generally arrives behind us by a little. Only time I could see it happening on the second shock would be with our one FD that is ALS and carries our same monitor.


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We do it.... then again, considering the study came out of my county, that isn't too surprising.....

It is interesting to note that it isn't used as a first defib, but only for persistent VF/VT, and even then it's an option, not a requirement. Then again, ambulances only have one lifepak, but every cardiac arrest gets two ALS ambulances, a District Chief and/or an APP (all of whom have lifepaks), so that second one is usually a couple minutes behind the first arriving ALS unit.

With a larger sample pool, as well as an analysis on comorbidity factors, could lead to a change in how initial defibrillation is delivered. After all, without ROSC, the chances the patient will walk out of the hospital are pretty damn slim
 
Why so many ALS resources? Can't one unit, fire and an APP or DC handle it?


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Handsome Robb said:
Why so many ALS resources? Can't one unit, fire and an APP or DC handle it?


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He is in NJ, fire doesnt generally play in EMS, and NEVER plays ALS. Some departments do first response (but NJ doesnt recognize anything below EMT)

Doc, you guys dont have 2 monitors up there?

We kept the LP12 when we got the 15s. We pull it out for the persistent VFVT from time to time. I shocked a patient 9 times last week with 720 before the LP12 died, then another 2 with the FDs semiauto AED, a Cardiac Science G3 with a little screen on it. Also did hands on defib at 720 much to the Er nurses shock and amazement
 
Bullets said:
He is in NJ, fire doesnt generally play in EMS, and NEVER plays ALS. Some departments do first response (but NJ doesnt recognize anything below EMT)

Doc, you guys dont have 2 monitors up there?

We kept the LP12 when we got the 15s. We pull it out for the persistent VFVT from time to time. I shocked a patient 9 times last week with 720 before the LP12 died, then another 2 with the FDs semiauto AED, a Cardiac Science G3 with a little screen on it. Also did hands on defib at 720 much to the Er nurses shock and amazement
Click to expand...

I don't think he's in NJ anymore...


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Handsome Robb said:
Why so many ALS resources? Can't one unit, fire and an APP or DC handle it?
Click to expand...
My assumption is (and the system existed before me, and will exist after me as well) they believe EMS is an EMS responsibility, and as a result, for a major incident, you should sent additional EMS resources. Its actually a great justification to have several off-the-ambulance supervisors, as well as justifies not always running at the bare minimum to answer the current call volume.

Further, despite having the APP and/or DC on the call, the first arriving paramedic is the "code commander" so they run the show, everyone else follows their direction and functions to support them. It's not like the DC pulls up and the paramedics says "here, the patient is all yours."

But to answer your question, I have handled many cardiac arrests with just a two person BLS crew and a two person ALS crew. So I wouldn't call it needed, but it's definitely awesome to have. But I also worked in a system where you worked on a two person ambulance crew, and depending on where in the county you were, you might get two or three first responders on an EMS call...... I'll gladly take the additional resources any day; a good incident commander can always find something for the people standing around to do
Bullets said:
He is in NJ, fire doesnt generally play in EMS, and NEVER plays ALS. Some departments do first response (but NJ doesnt recognize anything below EMT)

Doc, you guys dont have 2 monitors up there?

We kept the LP12 when we got the 15s. We pull it out for the persistent VFVT from time to time. I shocked a patient 9 times last week with 720 before the LP12 died, then another 2 with the FDs semiauto AED, a Cardiac Science G3 with a little screen on it. Also did hands on defib at 720 much to the Er nurses shock and amazement
Click to expand...
Bullet's, I'm not in NJ anymore, I left for NC two years ago due to the Governor's refusal to fund the pension system and a desire for cheaper taxes and nicer people. Best decision I ever made, but I do miss the pizza and bagels.

It's been a while since I was on the ambulance, but most have only one monitor, which makes sense because instead of being two medics on the truck (with two monitors in the ambulance as we had in NJ) it's usually one medic and 1 EMT. So if your monitor has an issue, you are OOS until you can either get a new one or get it fixed.

Which I think is the other reason they send so many resources. With every ambulance being an ALS ambulance, you get stuck dealing with a lot of BLS patients, or patients who just need an IV lock and a comfy ride to the hospital. Since you don't deal with as many sick patients (percentage wise), it's helpful for that solo medic to get another paramedic to bounce ideas off of, or to try to get the IV if it just isn't working that day.
 
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