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VF/VT-Pulseless (Shock Advised)

Date Last Search Run: Feb 01, 2022
Table last updated: Nov 27, 2021
Data last added: Nov 26, 2021

Recommendation RECOMMENDATION FOR INTERVENTION
STRENGTH OF EVIDENCE FOR INTERVENTION   SUPPORTIVE (Green) NEUTRAL (Yellow) AGAINST (Red) NOT YET GRADED (White)
1 (strong evidence exists)    
2 (fair evidence exists)    
3 (weak evidence exists)      


Interventions

Antiarrhythmic - Class I (Na+ channel blockers)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) ROSC Patient McLeod SL., Brignardello-Petersen R., Worster A., You J., Iansavichene A., Guyatt G., et al. Comparative effectiveness of antiarrhythmics for out-of-hospital cardiac arrest: A systematic review and network meta-analysis. Resuscitation 2017; 121:90-7. Medline
I Supportive (Green) Organized electrical rhythm Patient ED-MD Olson DW., Thompson BM., Darin JC., Milbrath MH. A randomized comparison study of bretylium tosylate and lidocaine in resuscitation of patients from out-of-hospital ventricular fibrillation in a paramedic system. Ann Emerg Med 1984; 13(9 Pt 2):807-10. Medline
I Neutral (Yellow) Survival to hospital discharge Patient Kudenchuk PJ., Brown SP., Daya M., et al. Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. N Engl J Med 2016; 374(18):1711-22. Medline
I Neutral (Yellow) Survival to discharge Patient Kudenchuk PJ., Leroux BG., Daya M., Rea T., Vaillancourt C., Morrison LJ., et al. Antiarrhythmic Drugs for Nonshockable-Turned-Shockable Out-of-Hospital Cardiac Arrest: The ALPS Study (Amiodarone, Lidocaine, or Placebo). Circulation 2017; 136(22):2119-31. Medline
I Neutral (Yellow) survival to hospital admission Patient PH-Paramedic Ong ME., Pellis T., Link MS. The use of antiarrhythmic drugs for adult cardiac arrest: a systematic review. Resuscitation 2011; 82(6):665-70. Medline
I Opposes (Red) Return of an organized rhythm Patient PH-Paramedic Haynes RE., Chinn TL., Copass MK., Cobb LA. Comparison of bretylium tosylate and lidocaine in management of out of hospital ventricular fibrillation: A randomized clinical trial. Am J Cardiol 1981; 48(2):353-6. Medline
II Supportive (Green) 1 month survival Patient Amino M, Inokuchi S, Yoshioka K, Nakagawa Y, Ikari Y, Funakoshi H, et al. Does Antiarrhythmic Drug During Cardiopulmonary Resuscitation Improve the One-month Survival: The SOS-KANTO 2012 Study. J Cardiovasc Pharmacol; 68(1):58-66. Medline
II Supportive (Green) 1-year mortality. Patient Huang CH., Yu PH., Tsai MS., Chuang PY., Wang TD., Chiang CY., et al. Acute hospital administration of amiodarone and/or lidocaine in shockable patients presenting with out-of-hospital cardiac arrest: A nationwide cohort study. Int J Cardiol 2017; 227:292-8. Medline
II Neutral (Yellow) Survival outcomes (ROSC and survival to discharge) Patient PH-Paramedic Huang Y., He Q., Yang M., Zhan L. Antiarrhythmia drugs for cardiac arrest: A systemic review and meta-analysis. Crit Care 2013; 17(4):R173. Medline
II Neutral (Yellow) Re-arrest Patient Salcido DD., Schmicker RH., Kime N., Buick JE., Cheskes S., Grunau B., et al. Effects of intra-resuscitation antiarrhythmic administration on rearrest occurrence and intra-resuscitation ECG characteristics in the ROC ALPS trial. Resuscitation 2018;129:6-12. Medline
II Neutral (Yellow) Survival at hospital admission Patient Sanfilippo F., Corredor C., Santonocito C., Panarello G., Arcadipane A., Ristagno G., et al. Amiodarone or lidocaine for cardiac arrest: A systematic review and meta-analysis. Resuscitation 2016; 107:31-7. Medline
II Neutral (Yellow) Increased hospital admission Patient ED-MD Tagami T., Matsui H., Ishinokami S., Oyanagi M., Kitahashi A., Fukuda R., et al. Amiodarone or nifekalant upon hospital arrival for refractory ventricular fibrillation after out-of-hospital cardiac arrest. Resuscitation 2016;109:127-32. Medline
III Neutral (Yellow) Feasibility Process PH-Paramedic & CCT Kovoor P., Love A., Hall J., Sadnick N., et al. Randomized double-blind trial of sotalol vs lignocaine in out-of-hospital refractory cardiac arrest due to ventricular tachyarrhythmia. Intern Med J 2005; 35(9):518-25. Medline
III Neutral (Yellow) Survival time Patient PH-Paramedic Wang HE., Min A., Hostler D., Chang CC., Callaway CW. Differential effects of out-of-hospital interventions on short- and long-term survival after cardiopulmonary arrest. Resuscitation 2005; 67(1):69-74. Medline

Antiarrhythmic - Class III (K+ channel blockers)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) ROSC Patient McLeod SL., Brignardello-Petersen R., Worster A., You J., Iansavichene A., Guyatt G., et al. Comparative effectiveness of antiarrhythmics for out-of-hospital cardiac arrest: A systematic review and network meta-analysis. Resuscitation 2017; 121:90-7. Medline
I Neutral (Yellow) Survival to hospital admission Process PH-Paramedic Dorian P., et al. Amiodarone as Compared With Lidocaine for Shock-Resistant Ventricular Fibrillation. N Engl J Med 2002; 346(12); 884-9. Medline
I Neutral (Yellow) Survival to hospital admission Patient PH-Paramedic Kudenchuk P., Cobb L., Copass M., et al. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med 1999; 234:871-8. Medline
I Neutral (Yellow) Survival to hospital discharge Patient Kudenchuk PJ., Brown SP., Daya M., et al. Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. N Engl J Med 2016; 374(18):1711-22. Medline
I Neutral (Yellow) Survival to hospital discharge Patient Kudenchuk PJ., Brown SP., Daya M., et al. Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. N Engl J Med 2016; 374(18):1711-22. Medline
I Neutral (Yellow) Survival to discharge Patient Kudenchuk PJ., Leroux BG., Daya M., Rea T., Vaillancourt C., Morrison LJ., et al. Antiarrhythmic Drugs for Nonshockable-Turned-Shockable Out-of-Hospital Cardiac Arrest: The ALPS Study (Amiodarone, Lidocaine, or Placebo). Circulation 2017; 136(22):2119-31. Medline
II Supportive (Green) 1 month survival Patient Amino M, Inokuchi S, Yoshioka K, Nakagawa Y, Ikari Y, Funakoshi H, et al. Does Antiarrhythmic Drug During Cardiopulmonary Resuscitation Improve the One-month Survival: The SOS-KANTO 2012 Study. J Cardiovasc Pharmacol; 68(1):58-66. Medline
II Supportive (Green) 1-year mortality. Patient Huang CH., Yu PH., Tsai MS., Chuang PY., Wang TD., Chiang CY., et al. Acute hospital administration of amiodarone and/or lidocaine in shockable patients presenting with out-of-hospital cardiac arrest: A nationwide cohort study. Int J Cardiol 2017; 227:292-8. Medline
II Supportive (Green) Increased hospital admission Process Tagami T., Matsui H., Ishinokami S., Oyanagi M., Kitahashi A., Fukuda R., et al. Amiodarone or nifekalant upon hospital arrival for refractory ventricular fibrillation after out-of-hospital cardiac arrest. Resuscitation 2016;109:127-32. Medline
II Supportive (Green) Defib rate, Rhythm conversion Process ED-MD Yoshioka K., Amino M., Morita S., et al. Can nifekalant hydrochloride be used as a first-line drug for cardiopulmonary arrest (CPA)? : Comparative study of out-of-hospital CPA with acidosis and in-hospital CPA without acidosis. Circ J 2006; 70(1):21-27. Medline
II Neutral (Yellow) Defib success Patient PH-Paramedic Amino M., Yoshioka K., Opthof T., et al. Comparative study of nifekalant versus amiodarone for shock-resistant ventricular fibrillation in out-of-hospital cardiopulmonary arrest patients. J Cardiovasc Pharmacol 2010; 55(4):391-8. Medline
II Neutral (Yellow) ROSC Process PH-Paramedic Harayama N., Nihei SI., Nagata K., et al. Comparison of nifekalant and amiodarone for resuscitation of out-of-hospital cardiopulmonary arrest resulting from shock-resistant ventricular fibrillation. J Anesth 2014; 28(4):587-92. Medline
II Neutral (Yellow) Survival outcomes (ROSC and survival to discharge) Patient PH-Paramedic Huang Y., He Q., Yang M., Zhan L. Antiarrhythmia drugs for cardiac arrest: A systemic review and meta-analysis. Crit Care 2013; 17(4):R173. Medline
II Neutral (Yellow) Re-arrest Patient Salcido DD., Schmicker RH., Kime N., Buick JE., Cheskes S., Grunau B., et al. Effects of intra-resuscitation antiarrhythmic administration on rearrest occurrence and intra-resuscitation ECG characteristics in the ROC ALPS trial. Resuscitation 2018;129:6-12. Medline
II Neutral (Yellow) Survival at hospital admission Patient Sanfilippo F., Corredor C., Santonocito C., Panarello G., Arcadipane A., Ristagno G., et al. Amiodarone or lidocaine for cardiac arrest: A systematic review and meta-analysis. Resuscitation 2016; 107:31-7. Medline
III Supportive (Green) Survival to hospital admission Patient PH-Paramedic Ong ME., Pellis T., Link MS. The use of antiarrhythmic drugs for adult cardiac arrest: a systematic review. Resuscitation 2011; 82(6):665-70. Medline
III Supportive (Green) Hemodynamic side effects Patient PH-Paramedic Skrifvars MB., Kuisma M., Boyd J., Maatta T., Repo J., Rosenberg PH., Castren M. The use of undiluted amiodarone in the mgt of out-of-hospital cardiac arrest. Acta Anaesth Scand 2004; 48:582-7. Medline
III Supportive (Green) Hemodynamic side effects Patient PH-Paramedic Skrifvars MB., Kuisma M., Boyd J., Maatta T., Repo J., Rosenberg PH., Castren M. The use of undiluted amiodarone in the mgt of out-of-hospital cardiac arrest. Acta Anaesth Scand 2004; 48:582-7. Medline
III Neutral (Yellow) Survival to DC Patient PH-Paramedic Olasveengen TM., Sunde K., Brunborg C., Thowsen J., Steen PA., Wik L. Intravenous drug administration during out-of-hospital cardiac arrest: A randomized trial. JAMA 2009; 302(20):2222-9. Medline
III Neutral (Yellow) Survival Patient ED-MD Pollak PT., Wee V., Al-Hazmi A., Martin J., Zarnke KB. The use of amiodarone for in-hospital cardiac arrest at two tertiary care centres. Can J Cardiol 2006; 22(3):199-202. Medline
III Neutral (Yellow) ROSC Process PH-Paramedic Yasuda S., Sawano H., Hazui H. Ukai I. et al. Report from J-PULSE Multicentre Registry of Patients With Shock-Resistant Out-of-Hospital Cardiac Arrest Treated with Nikekalant Hydrochloride. Japan Circ J 2010; 74(11):2308-13. Medline

Beta Blockers
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Sustained ROSC Patient Lee YH., Lee KJ., Min YH., Ahn HC., Sohn YD., Lee WW., et al. Refractory ventricular fibrillation treated with esmolol. Resuscitation 2016; 107:150-5. Medline

Biphasic Defibrillation
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Survival to discharge Patient PH-Paramedic Auble TE., Menegazzi JJ., Paris PM. Effect of out-of-hospital defibrillation by basic life support providers on cardiac arrest mortality: a meta-analysis. Ann Emerg Med 1995; 25(5):642-8. Medline
I Supportive (Green) First-shock efficacy rates Process ED-MD Bardy GH., Marchlinski FE., Sharma AD., et al. Multicenter comparison of truncated biphasic shocks and standard damped sine wave monophasic shocks for transthoracic ventricular defibrillation. Circulation 1996; 94(10):2507-14. Medline
I Supportive (Green) First Shock Success Patient OR Higgins SL., Herre JM., Epstein AE., et al. A comparison of biphasic and monophasic shocks for external defibrillation. Physio-Control Biphasic Investigators. Prehosp Emerg Care 2000; 4(4):305-13. Medline
I Supportive (Green) Return of organized rhythm Patient PH-Paramedic Koster RW., Walker RG., van Alem AP. Definition of successful defibrillation. Crit Care Med 2006; 34(12 Suppl):S423-6. Medline
I Supportive (Green) Survival to hospital Patient PH-Paramedic Kudenchuk PJ., Cobb LA., Copass MK., Olsufka M., Maynard C., Nichol G. Transthoracic incremental monophasic versus biphasic defibrillation by emergency responders (TIMBER): A randomized comparison of monophasic with biphasic waveform ascending energy defibrillation for the resuscitation of out-of-hospital cardiac arrest due to ventricular fibrillation. Circulation 2006; 114(19):2010-8. Medline
I Supportive (Green) Defibrillation efficacy Patient PH-Paramedic Martens P., Russell J., Wolcke B., Paschen H., Kuisma M., Gliner B., Weaver WD., Bossaert L., Chamberlain D., Schneider T. Optimal Response to Cardiac Arrest study: Defibrillation waveform effects. Resuscitation 2001; 49:233-43. Medline
I Supportive (Green) Conversion to organized rhythm at 5s after Patient PH-Paramedic Morrison LJ., Dorian P., Long J., et al. Out-of-hospital cardiac arrest rectilinear biphasic to monophasic damped sine defibrillation waveforms with advanced life support intervention trial (ORBIT). Resuscitation 2005; 66(2):149-57. Medline
I Supportive (Green) Termination of (VF) and (VT) Patient PH-Paramedic Morrison LJ., Henry RM., Ku V., Nolan JP., Morley P., Deakin CD. Single-shock defibrillation success in adult cardiac arrest: A systematic review. Resuscitation 2013; 84(11):1480-6. Medline
I Supportive (Green) Defibrillation efficacy Patient PH-Paramedic Schneider T., Martens PR., Paschen H., et al. Multicenter, randomized, controlled trial of 150-J biphasic shocks compared with 200- to 360-J monophasic shocks in the resuscitation of out-of-hospital cardiac arrest victims. Optimized Response to Cardiac Srrest (ORCA) investigators. Circulation 2000; 102(15):1780-7. Medline
I Supportive (Green) Survival Patient PH-Paramedic Watts DD. Defibrillation by basic emergency medical technicians: Effect on survival. Ann Emerg Med. 1995; 26(5):635-639. Medline
I Neutral (Yellow) Termination of VF, Return of organized rhythm post first shock, ROSC, Survival to DC. Patient PH-Paramedic Wang CH., Huang CH., Chang WT., et al. Biphasic versus monophasic defibrillation in out-of-hospital cardiac arrest: A systematic review and meta-analysis. Am J Emerg Med 2013; 31(10):1472-1478. Medline
II Supportive (Green) ROSC Process PH-Paramedic Freeman K., Hendey GW., Shalit M., Stroh G. Biphasic defibrillation does not improve outcomes compared to monophasic defibrillation in out-of-hospital cardiac arrest. Prehosp Emerg Care 2008; 12(2):152-6. Medline
II Supportive (Green) Neurologically favorable 30 day survival Patient PH-Paramedic Kajino K., Iwami T., Berg RA., et al. Comparison of neurological outcomes following witnessed out-of-hospital ventricular fibrillation defibrillated with either biphasic or monophasic automated external defibrillators. Emerg Med J 2009; 26(7):492-6. Medline
II Supportive (Green) Survival to hospital discharge. Patient PH-Paramedic Nichol G., Stiell IG., Laupacis A., Pham B., De Maio VJ., Wells GA. A cumulative meta-analysis of the effectiveness of defibrillator-capable emergency medical services for victims of out-of-hospital cardiac arrest. Ann Emerg Med 1999; 34(4 Pt 1):517-25. Medline
II Supportive (Green) Termination of VF. Patient PH-Paramedic Stothert JC., Hatcher TS., Gupton CL., Love JE., Brewer JE. Rectilinear biphasic waveform defibrillation of out-of-hospital cardiac arrest. Prehosp Emerg Care 2004; 8(4):388-392. Medline
II Supportive (Green) Survival at 1 month Patient PH-Paramedic Tanabe S., Yasunaga H., Ogawa T., et al. Comparison of outcomes after use of biphasic or monophasic defibrillators among out-of-hospital cardiac arrest patients: A nationwide population-based observational study. Circ Cardiovasc Qual Outcomes 2012; 5(5):689-696. Medline
II Neutral (Yellow) Survival to hospital discharge Patient PH-Paramedic Sweeney TA., Runge JW., Gibbs MA., et al. EMT defibrillation does not increase survival from sudden cardiac death in a two-tiered urban-suburban EMS system. Ann Emerg Med 1998; 31(2):234-240. Medline
III Supportive (Green) Percent efficacy Process OR Bardy GH., Gliner BE., Kudenchuk PJ., et al. Truncated biphasic pulses for transthoracic defibrillation. Circulation 1995; 91(6):1768-74. Medline
III Supportive (Green) Detection ventricular vf/vt-pulseless (shock advised) Process SIM Leng CT., Paradis NA., Calkins H., et al. Resuscitation after prolonged ventricular fibrillation with use of monophasic and biphasic waveform pulses for external defibrillation. Circulation 2000; 101(25):2968-74. Medline
III Supportive (Green) Delayed onset of asystole/PEA Patient Scheatzle MD., Menegazzi JJ., Allen TL., et al. Evaluation of biphasic transthoracic defibrillation in an animal model of prolonged ventricular fibrillation. Acad Emerg Med 1999; 6(9):880-6. Medline
III Supportive (Green) Successful defibrillation Patient OR Szili-Torok T., Theuns D., Verblaauw T., et al. Transthoracic defibrillation of short-lasting ventricular fibrillation: A randomised trial for comparison of the efficacy of low-energy biphasic rectilinear and monophasic damped sine shocks. Acta Cardiol 2002; 57(5):329-334. Medline
III Supportive (Green) Survival to Discharge Patient PH-Paramedic White RD., Asplin BR., Bugliosi TF., Hankins DG. High discharge survival rate after out-of-hospital ventricular fibrillation with rapid defibrillation by police and paramedics. Ann Emerg Med 1996; 28(5):480-485. Medline

CPR before defibrillation
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Time to intubation Process SIM Baker P., Conway J., Cotton C., Ashby D., Smyth J., Woodman J., Grantham H. Defibrillation versus Cardiopulmonary Resuscitation first for patients with Out-Of-Hospital Cardiac Arrests found by Paramedics to be in Ventricular Fibrillation. Resus 2008; 79:424-31. Medline
I Neutral (Yellow) Survival to discharge Patient PH-Paramedic Freese JP., Jorgenson DB., Liu PY., et al. Waveform analysis-guided treatment versus a standard shock-first protocol for the treatment of out-of-hospital cardiac arrest presenting in ventricular fibrillation: Results of an international randomized, controlled trial. Circulation 2013; 128(9):995-1002. Medline
I Neutral (Yellow) Survival to hospital d/c Patient PH-Paramedic Jacobs IG., Finn JC., Oxer HF., Jelinek GA. CPR before defibrillation in OOHCA: an RCT. Emerg Med Australas 2005; 17(1):39-45. Medline
I Neutral (Yellow) Survival to hospital admission Patient PH-Paramedic Jost D., Degrange H., Verret C., Hersan O., et al. DEFI 2005: A randomized controlled trial of the effect of automated external defibrillator cardiopulmonary resuscitation protocol on outcome from out-of-hospital cardiac arrest. Circ 2010; 121(14)1614-22. Medline
I Neutral (Yellow) Sustained ROSC Patient PH-Paramedic Ma MH., Chiang WC., Ko PC., et al. A randomized trial of compression first or analyze first strategies in patients with out-of-hospital cardiac arrest: Results from an asian community. Resuscitation 2012; 83(7):806-12. Medline
I Neutral (Yellow) Survival Patient PH-Paramedic Meier P., et al. Chest Compressions before Defibrillation for Out-of-Hospital Cardiac Arrest: A meta-Analysis of Randomized Controlled Trials. BMC 2010; 8:52-65. Medline
I Neutral (Yellow) survival to hospital discharge Patient PH-Paramedic Simpson P., et al. Delayed Versus Immediate Defibrillation for Out-of-Hospital Cardiac Arrest due to Ventricular Fibrillation: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Resus 2010; 81:925-931. Medline
I Neutral (Yellow) Survival to discharge with satisfactory functional status Patient PH-Paramedic Stiell IG., Nichol G., Leroux BG., et al. Early versus later rhythm analysis in patients with out-of-hospital cardiac arrest. N Engl J Med 2011; 365(9):787-797. Medline
I Neutral (Yellow) Survival to discharge Patient PH-Paramedic Wik L., Hansen T., Fylling F., Steen T., Vaagenes P., Auestad B., Steen P. Delaying Defibrillation to Give Basic Cardiopulmonary Resuscitation to Patients With Out-of-hospital Ventricular Fibrillation A Randomized Trail. JAMA 2003; 289(11):1389-1395. Medline
II Supportive (Green) Survival and neurologic status at hospital discharge Patient PH-Paramedic Cobb LA., Fahrenbruch CE., Walsh TR., et al. Influence of CPR prior to defibrillation in patients with OOH VF. JAMA 1999; 281:1182-8. Medline
II Supportive (Green) One- month survival Patient PH-Paramedic Koike S., Tanabe S., Ogawa T., et al. Immediate defibrillation or defibrillation after cardiopulmonary resuscitation. Prehosp Emerg Care 2011; 15(3):393-400. Medline
II Neutral (Yellow) Defibrillation success Process PH-Paramedic Eftestol T., Wik L., Sunde K., Steen PA. Effects of CPR on predictors of VF defibrillation during OOHCA. Circulation 2004; 110:10-5. Medline

Defibrillation
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Survival to discharge Patient PH-Paramedic Eisenberg MS., Hallstrom AP., Copass MK., Bergner L., Short F., Pierce J. Treatment of ventricular fibrillation. Emergency medical technician defibrillation and paramedic services. JAMA 1984; 251(13):1723-6. Medline
I Supportive (Green) Ventricular fibrillation conversion Patient PH-Paramedic Stiell IG., et al. A randomized comparison of fixed lower vs escalating higher energy levels for defibrillation in OOHCA. Circulation 2007; 115:1511-7. Medline
II Supportive (Green) Good neurological recovery Patient PH-Paramedic Lee SGW, Park JH, Ro YS, Hong KJ, Song KJ, Shin SD. Time to first defibrillation and survival outcomes of out-of-hospital cardiac arrest with refractory ventricular fibrillation. Am J Emerg Med 2021; 40:96-102. Medline
II Supportive (Green) Survival to hospital discharge Patient Nehme Z., Andrew E., Nair R., Bernard S., Smith K. Manual Versus Semiautomatic Rhythm Analysis and Defibrillation for Out-of-Hospital Cardiac Arrest. Circulation Cardiovascular Quality and Outcomes 2017; 10(7). Medline
II Supportive (Green) Survival to hospital discharge Patient PH-Paramedic Stiell IG., Wells GA., Field BJ., et al. Improved out-of-hospital cardiac arrest survival through the inexpensive optimization of an existing defibrillation program: OPALS study phase II. Ontario prehospital advanced life support. JAMA 1999; 281(13):1175-1181. Medline
II Supportive (Green) Quality of life Patient PH-Paramedic van Alem AP., Waalewijn RA., Koster RW., de Vos R. Assessment of quality of life and cognitive function after out-of-hospital cardiac arrest with successful resuscitation. Am J Cardiol 2004; 93(2):131-135. Medline
II Neutral (Yellow) Survival to 1 month post discharge Patient PH-Paramedic Sekimoto M., Rahman M., Noguchi Y., Hira K., Shimbo T., Fukui T. The defibrillation system of basic emergency medical technicians in japan: A comparison with other systems from a 14-year review of out-of-hospital cardiac arrest reports. J Epidemiol 2001; 11(1):29-40. Medline
III Supportive (Green) Interval to first shock Process SIM Verbeek PR., Turner D., Lane CJ., Carter CC. A comparison of two automated external defibrillator algorithms. Acad Emerg Med 1999; 6(6):631-6. Medline
III Neutral (Yellow) Detection pinion vf/vt-pulseless (shock advised) Process Nolan JP., Soar J. Defibrillation in clinical practice. Curr Opinion Crit Care 2009; 15:1070. Medline
III Neutral (Yellow) Survival time Patient PH-Paramedic Wang HE., Min A., Hostler D., Chang CC., Callaway CW. Differential effects of out-of-hospital interventions on short- and long-term survival after cardiopulmonary arrest. Resuscitation 2005; 67(1):69-74. Medline
III Neutral (Yellow) Difference in mean transthoracic impedance Patient PH-Paramedic White RD., Blackwell TH., Russell JK., Snyder DE., Jorgenson DB. Transthoracic impedance does not affect defibrillation... Resus 2005; 64:63-9. Medline

Double Sequential Defibrillation
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Survival Patient ED-Paramedic & MD Miraglia D, Miguel LA, Alonso W. Double Defibrillation for Refractory In- and Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. J of Emerg Med (0736-4679) 2020; 59(4):521-41. Medline
II Supportive (Green) ROSC Patient Emmerson AC., Whitbread M., Fothergill RT. Double sequential defibrillation therapy for out-of-hospital cardiac arrests: The London experience. Resuscitation 2017; 117:97-101. Medline
II Supportive (Green) Neurologically intact survival to hospital discharge. Patient Ross EM., Redman TT., Harper SA., Mapp JG., Wampler DA., Miramontes DA. Dual defibrillation in out-of-hospital cardiac arrest: A retrospective cohort analysis. Resuscitation 2016; 106:14-7. Medline
II Neutral (Yellow) Termination of VF Process PH-Paramedic Cheskes S., Wudwud A., Turner L., McLeod S., Summers J., Morrison LJ., et al. The impact of double sequential external defibrillation on termination of refractory ventricular fibrillation during out-of-hospital cardiac arrest. Resuscitation 2019; 139:275-81. Medline
II Neutral (Yellow) Survival to hospital admission Patient Mapp JG, Hans AJ, Darrington AM, Ross EM, Ho CC. Prehospital Double Sequential Defibrillation: A Matched Case-Control Study. Acad Emerg Med. 2018. [Epub ahead of print] Medline
III Supportive (Green) ROSC Patient PH-Paramedic Choi HJ, Noh H. Successful defibrillation using double sequence defibrillation: Case reports. Medicine (Baltimore) 2021; 100(10):e24992. Medline
III Supportive (Green) Survival neurologically intact Patient El Tawil C., Mrad S., Khishfe BF. Double sequential defibrillation for refractory ventricular fibrillation. Am J Emerg Med 2017; 35(12):1985.e3-4. Medline
III Supportive (Green) - Patient Johnston M., Cheskes S., Ross G., Verbeek PR.. Double Sequential External Defibrillation and Survival from Out-of-Hospital Cardiac Arrest: A Case Report. Prehosp Emerg Care 2016; 20(5):662-6. Medline
III Supportive (Green) ROSC Patient Lybeck AM., Moy HP., Tan DK. Double Sequential Defibrillation for Refractory Ventricular Fibrillation: A Case Report. Prehosp Emerg Care 2015; 19(4):554-7. Medline
III Supportive (Green) Conversion Patient Merlin MA., Tagore A., Bauter R., Arshad FH. A Case Series of Double Sequence Defibrillation. Prehosp Emerg Care 2016; 20(4):550-3. Medline
III Neutral (Yellow) Termination of shock-resistant VF Patient Bell CR., Szulewski A., Brooks SC. Make it two: A case report of dual sequential external defibrillation. CJEM 2017:1-6. Medline
III Neutral (Yellow) Termination of refractory VF Patient Cabanas JG., Myers JB., Williams JG., De Maio VJ., Bachman MW. Double Sequential External Defibrillation in Out-of-Hospital Refractory Ventricular Fibrillation: A Report of Ten Cases. Prehosp Emerg Care 2015; 19(1):126-30. Medline
III Neutral (Yellow) ROSC Patient Cortez E., Krebs W., Davis J., Keseg DP., Panchal AR. Use of double sequential external defibrillation for refractory ventricular fibrillation during out-of-hospital cardiac arrest. Resuscitation 2016; 108:82-6. Medline
III Neutral (Yellow) Survival to discharge Patient PH-Paramedic Miraglia D, Alonso W. A review of pre-hospital case series among those with time to double external defibrillation and neurologic outcomes. Am J Emerg Med 2020. Medline

Hands-on defib
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Detection of shock. Process Wampler D., Kharod C., Bolleter S., Burkett A., Gabehart C., Manifold C. A randomized control hands-on defibrillation study-Barrier use evaluation. Resuscitation 2016; 103:37-40. Medline

Magnesium
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) ROSC Patient PH-Paramedic Allegra J., Lavery R., Cody R., Birnbaum G., Brennan J., Hartman A., Horowitz M., Nashed A., Yablonski M. Magnesium sulfate in the treatment of refractory ventricular fibrillation in the prehospital setting. Resuscitation 2001; 49:245-9. Medline
I Neutral (Yellow) ROSC at scene Patient PH-Paramedic Hassan TB., Jagger C., Barnett DB. A randomised trial to investigate the efficacy of magnesium sulphate for refractory ventricular fibrillation. Emerg Med J 2002; 19:57-62. Medline
I Neutral (Yellow) Feasibility, safety and efficacy Patient PH-Paramedic Longstreth WT Jr., Fahrenbruch CE., Olsufka M., Walsh TR., Copass MK., Cobb LA. Randomized clinical trial of magnesium, diazepam, or both after out-of-hospital cardiac arrest. Neurology 2002; 59(4):506-14. Medline
I Neutral (Yellow) ROSC Patient ED-MD Thel MC., et al. Randomized trial of magnesium in in-hospital cardiac arrest. Lancet 1997; 305:1272-75. Medline
II Neutral (Yellow) Survival outcomes (ROSC and survival to discharge) Patient PH-Paramedic Huang Y., He Q., Yang M., Zhan L. Antiarrhythmia drugs for cardiac arrest: A systemic review and meta-analysis. Crit Care 2013; 17(4):R173. Medline
III Neutral (Yellow) Rhythm post drug administration Process ED-MD Fatovich DM., Prentice DA., Dobb GJ. Magnesium in cardiac arrest (the magic trial). Resuscitation 1997; 35(3):237-41. Medline


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