• Sheldon Cheskes, P Richard Verbeek, Ian R Drennan, Shelley L McLeod, Linda Turner, Ruxandra Pinto, Michael Feldman, Matthew Davis, Christian Vaillancourt, Laurie J Morrison, Paul Dorian, and Damon C Scales.
• From the Division of Emergency Medicine, Department of Family and Community Medicine (S.C., I.R.D., S.L.M.), the Division of Emergency Medicine, Department of Medicine, (P.R.V., L.J.M.), the Interdepartmental Division of Critical Care Medicine (R.P., D.C.S.), and the Department of Medicine (R.P., P.D., D.C.S.), Temerty Faculty of Medicine, University of Toronto, the Sunnybrook Centre for Prehospital Medicine (S.C., P.R.V., L.T., M.F.), the Departments of Emergency Services (I.R.D., L.J.M.) and Critical Care Medicine (R.P., D.C.S.), Sunnybrook Health Sciences Centre, the Schwartz/Reisman Emergency Medicine Institute, Sinai Health (S.L.M.), and the Division of Cardiology, Unity Health Toronto (P.D.), Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Medicine, University of Western Ontario, London (M.D.), and the Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa (C.V.) - all in Canada.
• N. Engl. J. Med. 2022 Nov 24; 387 (21): 194719561947-1956.

BackgroundDespite advances in defibrillation technology, shock-refractory ventricular fibrillation remains common during out-of-hospital cardiac arrest. Double sequential external defibrillation (DSED; rapid sequential shocks from two defibrillators) and vector-change (VC) defibrillation (switching defibrillation pads to an anterior-posterior position) have been proposed as defibrillation strategies to improve outcomes in patients with refractory ventricular fibrillation.MethodsWe conducted a cluster-randomized trial with crossover among six Canadian paramedic services to evaluate DSED and VC defibrillation as compared with standard defibrillation in adult patients with refractory ventricular fibrillation during out-of-hospital cardiac arrest. Patients were treated with one of these three techniques according to the strategy that was randomly assigned to the paramedic service. The primary outcome was survival to hospital discharge. Secondary outcomes included termination of ventricular fibrillation, return of spontaneous circulation, and a good neurologic outcome, defined as a modified Rankin scale score of 2 or lower (indicating no symptoms to slight disability) at hospital discharge.ResultsA total of 405 patients were enrolled before the data and safety monitoring board stopped the trial because of the coronavirus disease 2019 pandemic. A total of 136 patients (33.6%) were assigned to receive standard defibrillation, 144 (35.6%) to receive VC defibrillation, and 125 (30.9%) to receive DSED. Survival to hospital discharge was more common in the DSED group than in the standard group (30.4% vs. 13.3%; relative risk, 2.21; 95% confidence interval [CI], 1.33 to 3.67) and more common in the VC group than in the standard group (21.7% vs. 13.3%; relative risk, 1.71; 95% CI, 1.01 to 2.88). DSED but not VC defibrillation was associated with a higher percentage of patients having a good neurologic outcome than standard defibrillation (relative risk, 2.21 [95% CI, 1.26 to 3.88] and 1.48 [95% CI, 0.81 to 2.71], respectively).ConclusionsAmong patients with refractory ventricular fibrillation, survival to hospital discharge occurred more frequently among those who received DSED or VC defibrillation than among those who received standard defibrillation. (Funded by the Heart and Stroke Foundation of Canada; DOSE VF ClinicalTrials.gov number, NCT04080986.).Copyright © 2022 Massachusetts Medical Society.

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