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Double sequential external defibrillation for refractory ventricular fibrillation: The DOSE VF pilot randomized controlled trial

  • Sheldon Cheskes
    Correspondence
    Corresponding author at: Sunnybrook Centre for Prehospital Medicine, 77 Brown’s Line, Suite 100, Toronto, ON M8W 3S2, Canada.
    Affiliations
    Sunnybrook Centre for Prehospital Medicine, Toronto, Ontario, Canada

    Department of Family and Community Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada

    Li Ka Shing Knowledge Institute, St. Michaels Hospital, Toronto, Ontario, Canada
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  • Paul Dorian
    Affiliations
    St. Michaels Hospital, Toronto, Ontario, Canada
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  • Michael Feldman
    Affiliations
    Sunnybrook Centre for Prehospital Medicine, Toronto, Ontario, Canada

    Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
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  • Shelley McLeod
    Affiliations
    Department of Family and Community Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada

    Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
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  • Damon C. Scales
    Affiliations
    Li Ka Shing Knowledge Institute, St. Michaels Hospital, Toronto, Ontario, Canada

    Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada

    Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
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  • Ruxandra Pinto
    Affiliations
    Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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  • Linda Turner
    Affiliations
    Sunnybrook Centre for Prehospital Medicine, Toronto, Ontario, Canada
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  • Laurie J. Morrison
    Affiliations
    Li Ka Shing Knowledge Institute, St. Michaels Hospital, Toronto, Ontario, Canada

    Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
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  • Ian R. Drennan
    Affiliations
    Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada

    Sunnybrook Research Institute, Toronto, Ontario, Canada
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  • P. Richard Verbeek
    Affiliations
    Sunnybrook Centre for Prehospital Medicine, Toronto, Ontario, Canada

    Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
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      Abstract

      Objectives

      The primary objective was to determine the feasibility and safety of a cluster randomized controlled trial (RCT) with crossover comparing vector change defibrillation (VC) or double sequential external defibrillation (DSED) to standard defibrillation for patients experiencing refractory ventricular fibrillation (VF). Secondary objectives were to assess the rates of VF termination (VFT) and return of spontaneous circulation (ROSC).

      Methods

      We conducted a pilot cluster RCT with crossover in four Canadian paramedic services including all treated adult OHCA patients who presented in VF and received a minimum of three successive defibrillation attempts. Each EMS service was randomly assigned to provide standard defibrillation, VC or DSED. Agencies crossed over to an alternate defibrillation strategy after six months.

      Results

      152 patients were enrolled. With respect to feasibility, 89.5% of cases received the defibrillation strategy they were randomly allocated to, and 93.1% of cases received a VC or DSED shock prior to the sixth defibrillation attempt. There were no safety concerns reported. In the standard group, 66.6% of cases resulted in VFT, compared to 82.0% in VC and 76.3% in the DSED group. ROSC was achieved in 25.0%, 39.3% and 40.0% of standard, VC and DSED groups, respectively.

      Conclusions

      Our findings suggest the DOSE-VF protocol is feasible and safe. Rates of VFT and ROSC were higher in the VC and DSED than standard defibrillation. The results of this pilot trial will allow us to inform a multicenter cluster RCT with crossover to determine if alternate defibrillation strategies for refractory VF may impact clinical outcomes.

      Keywords

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