RESUSCITATION 150 (2020) 178 184

Available online at www.sciencedirect.com

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

Clinical paper

Double sequential external defibrillation for

refractory ventricular fibrillation: The DOSE
VF pilot randomized controlled trial

Sheldon Cheskes a,b,c, *, Paul Dorian d , Michael Feldman a,e , Shelley McLeod b,f ,
Damon C. Scales c,e,f, Ruxandra Pinto g , Linda Turner a , Laurie J. Morrison c,e ,
Ian R. Drennan h,i , P. Richard Verbeek a,e
a
Sunnybrook Centre for Prehospital Medicine, Toronto, Ontario, Canada
b
Department of Family and Community Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
c
Li Ka Shing Knowledge Institute, St. Michaels Hospital, Toronto, Ontario, Canada
d
St. Michaels Hospital, Toronto, Ontario, Canada
e
Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
f
Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
g
Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
h
Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
i
Sunnybrook Research Institute, Toronto, Ontario, Canada

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: Cardiopulmonary resuscitation, Heart arrest, Resuscitation, Defibrillation, Double sequential external defibrillation, Prehospital care

* Corresponding author at: Sunnybrook Centre for Prehospital Medicine, 77 Brown’s Line, Suite 100, Toronto, ON M8W 3S2, Canada.
E-mail address: Sheldon.Cheskes@sunnybrook.ca (S. Cheskes).
https://doi.org/10.1016/j.resuscitation.2020.02.010
Received 9 December 2019; Received in revised form 26 January 2020; Accepted 12 February 2020
0300-9572/© 2020 Elsevier B.V. All rights reserved.
 RESUSCITATION 150 (2020) 178
Introduction
Out-of-hospital cardiac arrest (OHCA) accounts for over
350,000 unexpected deaths each year in North America; and nearly
100,000 of these are attributed to ventricular fibrillation or pulseless
ventricular tachycardia (VF/VT).1 Patients presenting in VF/VT
continue to represent the subgroup of patients for whom survival
remains the greatest. However, despite significant advances in
resuscitation care, some patients remain in VF/VT after multiple
standard defibrillation attempts, termed “refractory VF/VT”.2,3 Survival
to hospital discharge for patients who remain in refractory VF/VT is
reported between 4.9% to 12.7%, much lower compared to survival in
recurrent VF/VT which range from 21.4% to 29.3%.4 7
Double sequential external defibrillation (DSED), the technique
of providing rapid sequential defibrillatory shocks via two
defibrillators with defibrillation pads placed in two different planes
(usually anterior-lateral and anterior-posterior) has been studied
for decades in the electrophysiology lab for patients in both
refractory atrial fibrillation and refractory VF.8 15 From an
electrophysiology perspective, Ideker et al. have demonstrated
that when defibrillation fails to terminate VF, fibrillation resumes in
the region of lowest voltage and current gradient in the
myocardium.16 Considering the anatomical location of the left
ventricle, a posterior structure, this region is furthest from the
direct line between the standard anterolateral electrode pads.
Vector change defibrillation (VC) (the technique of switching
defibrillation pads from anterior-lateral to anterior posterior after
failed defibrillation attempts) may result in a higher voltage
gradient in the posterior part of the ventricle, where fibrillation is
most likely to restart or fail to terminate after standard pad
positions. With DSED, there is the additional influence of
increased voltage and energy delivered by the second shock.
Immediately after initial unsuccessful defibrillation, the instanta-
neous wave fronts are not the same as they were during VF and
may be more vulnerable to successful defibrillation than if the first
“conditioning shock” had not occurred. Therefore, it is important to
evaluate both VC defibrillation and DSED strategies separately to
determine if either, or both, are superior to standard care.
In the prehospital setting, VC and DSED, have been described in
case reports, case series, and observational studies. These reports
have generally employed DSED as a “last-resort” therapeutic option
for patients who remain in refractory VF.17 28 As such, the results of
these studies may have been confounded by the late application of a
defibrillation strategy in a subset of patients for whom a positive
outcome is unlikely. A recently published study suggested that early
application of DSED (shocks 4 8 of the resuscitation) may be
associated with improved VF termination and return of spontaneous
circulation (ROSC) when compared to standard defibrillation.29 To
date, no high quality evidence in the form of a randomized controlled
trial (RCT) exists to dispute or support the efficacy of VC or DSED
compared to standard defibrillation for refractory VF.
The goal of this pilot study was to examine trial logistics such as
recruitment, intervention delivery and adherence, with the aim of
enhancing the efficiency and internal validity of the main trial.30,31 The
primary objective of the DOSE VF internal pilot RCT was to determine
the feasibility and safety for a full-scale RCT of alternative defibrillation
strategies in refractory VF. Secondary objectives were to evaluate
the effect of the interventions on the outcomes of VF termination and
ROSC.
184 179
Methods
Setting and design
This three-arm, pilot cluster RCT with crossover was conducted in four
paramedic services located in Ontario, Canada from March 8, 2018 to
September 9, 2019. The services (Peel Regional Paramedic Service,
Halton Region Paramedic Service, Simcoe Paramedic Service and
Toronto Paramedic Service) provide emergency care and transport to
a population of 4.8 million people in both urban and rural settings within
a geographic area of 7680 km2. Paramedics in these regions treat over
4000 OHCA per year. Prehospital medical care is provided by
advanced care paramedics full advanced life support skills and
primary care paramedics basic life support skills with the addition of a
small number of medications and manual defibrillation). As part of the
cluster randomization strategy, each of two treatment strategies (VC
and DSED) were compared against a common control group
(standard defibrillation). This approach was chosen to maximize
efficiency, allowing comparison of two new treatments to standard
care in a single three-armed randomized trial.32,33 The clusters were
defined by the paramedic service in each of the four regions with each
cluster crossing over at least once during the pilot study to receive one
of three treatment approaches (standard care, VC or DSED) for six
months followed by a different treatment approach. Depending on the
start of enrollment in each service, crossover could occur more than
once in a particular service, but a minimum of one crossover for each
service had to occur during the pilot study. Computer-generated
random assignment of treatment sequence was performed by the
coordinating center prior to the start of the study. Agencies were
informed of their randomization assignment one month prior to trial
launch or crossover, to allow time for appropriate preparations to start
the trial or crossover to another defibrillation strategy. The DOSE VF
pilot RCT protocol was approved by the Sunnybrook Health Sciences
Centre Research Ethics Board and registered with clinicaltrials.gov
(NCT03249948). The study was conducted under waiver of informed
consent.
All adult (18 years) patients remaining in refractory VF during
non-traumatic OHCA of presumed cardiac etiology were eligible for
study inclusion. Patients suffering a traumatic cardiac arrest, patients
with pre-existing do not resuscitate medical directives, and those
suffering cardiac arrest secondary to drowning, hypothermia, hanging
or suspected drug overdose were excluded. Patients presenting in
pulseless VT were also excluded.
Study protocol
All paramedics followed a provincial protocol (consistent with
American Heart Association guidelines) for treatment of patients in
VF.34 Cardiopulmonary resuscitation (CPR) was performed prior to
defibrillator pad application. Each rhythm analysis occurred at
standard two-minute intervals. VF was determined by paramedic
manual defibrillator rhythm analysis, after which defibrillation was
provided. For all patients, the first three defibrillation attempts
occurred with defibrillation pads placed in the anterior-lateral position
(standard defibrillation). Eligible patients remaining in VF after three
consecutive shocks (following two minute CPR intervals) delivered by
paramedics (defibrillation shocks provided by bystander and/or fire
services prior to paramedic arrival were not counted), received one of
three defibrillation strategies:
180 RESUSCITATION 150 (2020) 178
Strategy 1 (standard defibrillation)
All subsequent defibrillation attempts occurred with the defibrillation
pads placed in an anterior-lateral configuration.
Strategy 2 (VC defibrillation)
All subsequent shocks were delivered using anterior posterior pad
placement. Transfer of pads to the anterior posterior position from
the initial standard anterior-lateral configuration occurred as soon as
possible during the two-minute cycle of CPR following the third
defibrillation attempt with minimal interruptions in CPR.
Strategy 3 (DSED)
Paramedics applied a second set of defibrillation pads after the first
three shocks (via a second EMS or fire defibrillator) in the anterior
posterior position. Application of defibrillation pads for the second
defibrillator occurred as soon as possible during the two-minute cycle
of CPR following the third shock with minimal interruptions in CPR. All
subsequent defibrillation attempts were carried out using sequential
defibrillation shocks provided by two defibrillators. To ensure shocks
were not applied at the exact same moment, we employed a short
delay to provision of the second defibrillator shock through a single
paramedic pressing the “shock button” on each defibrillator in rapid
sequence as opposed to simultaneously to avoid possible defibrillator
damage previously reported with simultaneous DSED.35 Dispatch
deployment strategies ensured two defibrillators were available as
frequently as possible for all cardiac arrests when paramedic services
were randomized to the DSED arm of the study.
The paramedic services of the City of Toronto, Regions of Peel and
Halton employed Zoll X series defibrillators (Zoll Medical Chelmsford,
Massachusetts) during the study. County of Simcoe paramedic
services employed Lifepak15 defibrillators (Stryker Corporation,
Seattle, Washington) during the study. Energy provided by Zoll
defibrillators was 120 J, 150 and 200 J for shocks 1 3 respectively.
Energy provided by Lifepack 15 defibrillators was 200, 300, 360 J for
shocks 1 3 respectively. All vector change shocks or DSED shocks
were provided at 200 J for Zoll defibrillators and 360 J for Lifepack
defibrillators. All anterior-lateral and anterior posterior pad positions
were as per manufacturer specifications.
Paramedic training and oversight
In conjunction with the paramedic services, Sunnybrook Centre for
Prehospital Medicine provided training to over 2500 paramedics in the
four participating services. Prior to the launch of the trial, paramedics
received standardized in-person training in the techniques of VC and
DSED defibrillation using a combination of didactic one hour, video
and simulated scenarios two hours. During the trial, each medical
director provided continuous feedback regarding study protocol
performance and compliance. Monthly study updates were provided
by the investigators to all participating services on paramedic study
performance.
Measurement and study definitions
For the purpose of our study, refractory VF was defined as patients
who presented in VF, had three successive standard defibrillation
attempts and remained in VF at the time of the fourth rhythm
analysis. VF termination was defined as the absence of VF at the
subsequent rhythm check following defibrillation and two minutes
of CPR.
184
Using a computerized structured data abstraction form, trained
research personnel reviewed the ambulance call reports (ACR) and
extracted patient data. ACRs were reviewed to collect data on Utstein
variables, event characteristics and treatment received. CPR quality
and defibrillation data were abstracted from the compression
acceleration signal and impedance channel measurements recorded
by the defibrillator. Data for all defibrillations during each resuscitation
were abstracted up to the point of first ROSC or transfer of care at the
receiving emergency department. ROSC was defined as the
restoration of an organized rhythm noted on the defibrillator files with
a corresponding documentation of ROSC or a blood pressure noted
on the paramedic ambulance call report.
Feasibility targets and outcomes
Avery et al.31 has outlined the potential advantages of internal pilot
study data, which include piloting key study logistics such as
recruitment, intervention delivery and adherence. The authors
suggest the pilot phase may form the first part of the main trial and
the outcome data generated may contribute to the final analyses. For
internal pilot studies, it is recommended that prespecified ‘progres-
sion’ or ‘decision’ criteria are used to indicate whether targets have
been met during the internal pilot phase and the main trial should
proceed.31
We a-priori defined our first feasibility target as the successful
delivery of the allocated intervention in 80% of eligible patients. We
believed this would account for the pragmatic reality that a second
defibrillator (for DSED) would not always be guaranteed during each
resuscitation. Our second feasibility target was for 80% of enrolled
patients to receive an intervention shock (VC or DSED) prior to the
sixth shock, consistent with our previously published work suggesting
improved rates of VF termination and ROSC with earlier as opposed to
later DSED.29
We did not pre-specify a patient recruitment target, but rather
estimated monthly trial recruitment for each paramedic service. Based
on historic rates of refractory VF seen in our previous research29 we
estimated a minimum of 110 patients would be enrolled in the pilot trial.
To account for differences in the start date of each service, enrollment
was continued beyond our initial calculation to ensure each service
underwent a minimum of one crossover while spending a minimum of
three months in a second arm of the study (minimum time of 9 months
in the pilot) to maximize information related to study feasibility and
enrollment rate.
With respect to safety, we assessed ACR and service reports for
any mention of defibrillator damage following DSED, as well as
complaints of chest burns and concerns from paramedics, emergency
department staff, patients or their families. Lastly, regarding
obtainment of outcome data, we evaluated the effect of standard
defibrillation, VC and DSED on the outcomes of VF termination and
ROSC to help inform the sample size of the main RCT.
The unit of analysis for the feasibility comparisons was the
individual patient. All patients were analyzed according to random-
ized treatment assignment (intention-to-treat analysis); while
analyses were also performed according to the treatment received
by each patient, the treatment received by all correctly randomized
patients and the treatment received by all correctly randomized
patients who received optimal VC or DSED shock timing (shock 4).
Descriptive statistics were summarized using means and standard
deviations (SD), medians with interquartile range (IQR), where
appropriate.
 RESUSCITATION 150 (2020) 178 184 181

Table 1 – Demographic characteristics of included population.

Variable Standard (n = 36) Vector change (n = 61) DSED (n = 55)
Mean (SD) age 64.4 (14.9) 63.6 (13.0) 64.4 (14.4)
Male 28 (77.8%) 56 (91.8%) 49 (89.1%)
Bystander witnessed 23 (63.9%) 44 (72.1%) 38 (69.1%)
Bystander CPR 21 (58.3%) 32 (52.5%) 33 (60.0%)
Public location 12 (33.3%) 21 (34.4%) 18 (32.7%)
Median (IQR) response time (minutes)a 7.5 (4.0) 7.2 (3.3) 7.6 (3.5)

Where: DSED = double sequential external defibrillation, SD = standard deviation; IQR = interquartile range; CPR = cardiopulmonary resuscitation.
a
911 call to arrive scene (excludes fire first response).

In total, 93% of patients received an intervention shock prior to the

Results
During the study period, 152 patients were enrolled. Table 1
describes the demographic characteristics of the study population
by intervention allocation. The three arms of the trial were well
matched with respect to Utstein variables, with high rates of
bystander witnessed and bystander CPR. Table 2 displays the
resuscitation characteristics and treatment provided by intervention
allocation. The three intervention arms were similar with respect to
system response times and treatment characteristics, however
there was a slightly lower rate of intubation in the standard arm. CPR
quality provided by paramedics during the resuscitation was
compliant with the current guidelines.36,37 The number of shocks
provided was greatest in the standard arm and lowest in the
DSED arm of the trial, while time to first ROSC was similar in all
three arms.
With regards to feasibility, 89.5% patients received the defibrilla-
tion strategy they were randomized, demonstrating good compliance
overall. Specifically, for those randomized to VC and DSED, 89.1%
and 83.6% respectively received the defibrillation strategy they were
allocated to. All cases randomized to standard defibrillation received
there allocated therapy.
sixth defibrillation attempt (Fig. 1). Of note, 77% of patients received
an intervention shock at shock 4, which was the earliest time an
intervention shock could have been provided according to the study
protocol. Five patients received an intervention shock prior to
defibrillation attempt 4 due to inadvertent inclusion of prior shocks
from a fire service. These patients remained in the primary analysis
according to the intention to treat principle.
Overall, 12.6 patients were enrolled per month in the pilot study
(Fig. 2). With regards to safety, there were no reported cases of
defibrillator malfunction, skin burns, difficulty with pad placement or
concerns expressed by paramedics, patients, families, or emergency
department staff about the trial.
In the standard defibrillation group, there was VF termination in
66.6% of cases, compared to 82.0% in the VC group and 76.3% in
the DSED group (Fig. 3). ROSC was achieved in 25.0%, 39.3% and
40.0% of standard, VC and DSED groups, respectively. The rate of
ROSC at ED arrival was higher in the VC (24.6%) and DSED
(32.7%) groups, compared to the standard defibrillation group
(19.4%). VF was terminated at the 4th standard shock or first
intervention shock in 22.2% of standard cases, 37.7% of VC cases,
and 34.5% of DSED cases. Similar results were noted in the per
treatment analysis, per randomization analysis and per

Table 2 – Event characteristics.

Variable Standard (n = 36) Vector change (n = 61) DSED (n = 55)

Median (IQR) time from initial call to first shock 11.1 (6.2) 11.0 (4.4) 10.7 (4.2)
Prehospital intubation 14 (38.9%) 35 (57.4%) 30 (54.5%)
Median (IQR) pre-shock pause (seconds) 5.2 (6.7) 4.8 (5.9) 5.8 (6.5)
Median (IQR) post-shock pause (seconds) 4.0 (1.1) 4.4 (4.2) 4.3 (2.3)
Mean (SD) compression rate 111.3 (6.8) 112.6 (7.7) 112.4 (7.2)
Mean (SD) compression depth 6.1 (1.2) 5.9 (1.1) 5.7 (1.0)
Mean (SD) chest compression fraction 83.0 (6.2) 80.4 (10.4) 81.5 (6.0)
Mean (SD) number of standard shocks 6.8 (2.1) NA NA
Mean (SD) number of vector change shocks NA 3.3 (2.7) NA
Mean (SD) number of DSED shocks NA NA 2.8 (2.2)
Amiodarone given 29 (80.6%) 45 (73.8%) 42 (76.4%)
Mean (SD) amiodarone dose (mg) 413.8 (65.3) 403.3 (77.2) 385.7 (75.1)
Epinephrine given 34 (94.4%) 60 (98.4%) 49 (89.1%)
Mean (SD) epinephrine dose (mg) 4.2 (2.0) 4.4 (2.0) 4.1 (3.0)
Median (IQR) time to first ROSC 15.0 (11.0) 13.5 (7.0) 15.0 (11.3)
Mean (SD) number of shocks to first ROSC 5.6 (1.6) 5.1 (2.1) 5.9 (2.2)

DSED = double sequential external defibrillation; IQR = interquartile range; SD = standard deviation; ROSC = return of spontaneous circulation.
182 RESUSCITATION 150 (2020) 178
Fig. 1 – Feasibility objective of percent of patients
receiving an intervention shock prior to the sixth
defibrillation attempt.
Fig. 2 – Monthly enrollment per site during the study
period.
randomization with optimal intervention shock analysis, as depicted
in Supplementary Figs. 1 3.
Discussion
We conducted the first pilot RCT assessing the feasibility and impact
of the alternative defibrillation strategies of VC and DSED compared to
Fig. 3 – Flow chart of enrolled patients (intention to treat analysis).
184
standard defibrillation for the treatment of refractory VF. We have
described our findings in a manner consistent with the CONSORT
2010 extension to randomised pilot and feasibility trials.38 With
respect to protocol adherence, our results suggest the DOSE-VF
protocol is feasible and can be appropriately applied in a “real world”
environment. 89.5% of patients received the allocated defibrillation
strategy according to the randomization schedule. The most common
cause for VC randomized patients to receive standard care was VF
termination after the fourth standard shock while paramedics
prepared to perform a VC defibrillation. For DSED randomized
patients, an inability to have a second defibrillator available was the
most common cause for protocol non-compliance. Our inability to
achieve perfect compliance with the protocol reflects the reality in
which paramedics practice. Although there were situations when a
second defibrillator was not available and times when paramedics
were not able to provide an intervention defibrillation at the earliest
time (shock 4), it is remarkable that 77% of patients received an
intervention shock at the fourth defibrillation attempt, with a further
12% of patients receiving an intervention defibrillation one shock later.
There were no reported cases of defibrillator malfunction, skin burns,
difficulty with pad placement or concerns expressed by paramedics,
patients, families, or emergency department staff about the trial. The
pilot feasibility was stopped on September 9, 2019 as all feasibility
objectives were met.
In our intention to treat analysis, as well as three supplementary
analyses, both VC defibrillation and DSED appeared to improve VF
termination and ROSC compared to standard defibrillation for
refractory VF. Our findings contrast with previous observational
studies18,19,25,26 which suggest that DSED is inferior to standard
defibrillation for refractory VF, yet they are consistent with our
previously published research suggesting earlier DSED may be
superior to standard defibrillation in this cohort of patients.29 It is
important to note that our current pilot RCT was performed in a manner
that differed from previous research in this area. We employed cluster
crossover randomization in multiple paramedic services in both rural
and urban communities and achieved consistent results in all
analyses performed. We controlled for timing of intervention shocks
while maintaining high quality CPR, two metrics which are rarely
described in previous studies. As well, our high level of medical
 RESUSCITATION 150 (2020) 178
oversight and paramedic feedback ensured high compliance with the
study protocol.
Our three arm approach to the study of alternative strategies to
defibrillation in refractory VF was meant to provide insight into the still
widely debated topic of whether energy or vector play a predominant
role in the potential benefit of DSED.8,9,10,12,16,27 Our preliminary data
suggests the vector or plane of defibrillation may have a role in
terminating VF when a previous vector is unsuccessful. This finding
may have significant therapeutic implications for the future treatment
of refractory VF, particularly in rural communities where the availability
of two defibrillators to perform DSED may be limited.
One of the benefits of our internal pilot design is the opportunity to
make minor operational modifications to the main trial based on
information gleaned from the pilot work.31
During the course of the pilot study, it became apparent that minor
modifications may strengthen the conduct of the main RCT. The most
critical of these modifications involves the inclusion of fire department
first responder shocks in cases randomized to VC defibrillation and
DSED. The pilot trial protocol did not include these shocks which were
provided in 28% of enrolled cases, which resulted in later “intervention
shocks” delivered to the patient. The exclusion of fire shocks may have
underestimated the potential benefit of VC and DSED to improve VF
termination and ROSC. The main DOSE VF RCT (clinicaltrials.gov
NCT04080986) was subsequently launched following minor
modifications gleaned from the pilot RCT and the recommendations
of the Data and Safety Monitoring Board.
Our pilot study is not without limitations. Enrollment in the standard
arm was lower than either intervention arm due to cluster
randomization, with the largest enrolling site not being randomized
to standard care during the pilot study. Ideally, cluster randomization
should balance all three arms as each agency spends the same
amount of time in each arm of the study. However, this was an internal
pilot study designed to achieve feasibility objectives, not a desired
sample size with equal numbers of patients in all arms of the trial. It is
worth noting the ROSC rate in the standard arm of our pilot study is
consistent with our historic findings in this cohort of patients.29
Although the study included both urban and rural settings, the majority
of patients were enrolled in the urban setting where a second
defibrillator is more often available. Finally, our study took place with a
high degree of medical oversight and paramedic feedback, which may
not be possible in all EMS services.
Conclusions
Findings from our pilot RCT 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 patient-
centered, clinical outcomes.
Conflict of interest statement
Dr. Cheskes has received speaking honorarium for educational events
on CPR quality from Zoll Medical and Stryker Corporation. Dr. Cheskes
has received grant funding from the Laerdal Foundation for the DOSE
VF pilot RCT. Dr. Cheskes has received grant funding from HSF
Canada for the DOSE VF RCT. Dr. Cheskes has received grant funding
184 183
from Zoll Medical for AED on the Fly, Community Responder Program
for Peel Region and Monitoring Ventilation during OHCA research
studies. Dr. Cheskes sits on the Advisory Board of Drone Delivery
Canada. Dr. Morrison is the Robert and Dorothy Pitts Chair in Acute
Care and Emergency Medicine funded by St Michael’s Foundation and
the University of Toronto for which she receives salary support. No other
authors have any conflicts of interest to declare.
Acknowledgements
We would like to acknowledge the hard work and dedication of all
paramedics in the Regions of Peel, Halton, Simcoe and the City of
Toronto, Ontario, Canada during the DOSE VF pilot RCT. Research in
the prehospital setting would not be possible without their tireless
efforts.
Appendix A. Supplementary data
Supplementary material related to this article can be found, in the online
version, at doi:https://doi.org/10.1016/j.resuscitation.2020.02.010.
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