American Journal of Medical Case Reports
ISSN (Print): 2374-2151 ISSN (Online): 2374-216X Website: Editor-in-chief: Samy, I. McFarlane
Open Access
Journal Browser
American Journal of Medical Case Reports. 2019, 7(12), 325-328
DOI: 10.12691/ajmcr-7-12-6
Open AccessArticle

Beyond the Limit: Double Sequential Defibrillation as an Alternative Therapy for Refractory Ventricular Fibrillation

Dennis Miraglia1, , Lourdes A. Miguel1 and Wilfredo Alonso1

1Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, PR

Pub. Date: September 23, 2019

Cite this paper:
Dennis Miraglia, Lourdes A. Miguel and Wilfredo Alonso. Beyond the Limit: Double Sequential Defibrillation as an Alternative Therapy for Refractory Ventricular Fibrillation. American Journal of Medical Case Reports. 2019; 7(12):325-328. doi: 10.12691/ajmcr-7-12-6


The incidence of out-of-hospital cardiac arrest (OHCA) reported from the Resuscitation Outcomes Consortium (ROC) and the CARES registry in 2016 suggests that 110.8 individuals per 100,000 population or 347,000 adults annually suffer from OHCA in the United States (US); likewise, the incidence of in-hospital cardiac arrest (IHCA) reported by Get With The Guidelines-Resuscitation (GWTG-R) suggests that each year, 209,000 people are treated for IHCA. Double sequential defibrillation (DSD) has been proposed as an alternative treatment for refractory ventricular fibrillation (VF) as there appears to be a trend of promising outcomes, including termination of refractory VF, sustained ROSC, increased short term survival and favorable outcomes to hospital discharge. We report a case of prolonged resuscitation of an 72-year-old man who developed pulseless ventricular tachycardia (pVT) that progressed to refractory VF terminated by DSD. In addition, we provide a quick reference that summarizes the characteristics and resuscitative parameters of the reported case.

cardiac arrest double sequential defibrillation in-hospital cardiac arrest out-of-hospital cardiac arrest refractory ventricular fibrillation resuscitation

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit


[1]  Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation. 2017; 135: e146-e603.
[2]  Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2011 update: a report from the American Heart Association. Circulation. 2011; 123: e18-209.
[3]  Merchant RM, Yang L, Becker LB, et al. American Heart Association Get With the Guidelines–Resuscitation Investigators. Incidence of treated cardiac arrest in hospitalized patients in the United States. Crit Care Med. 2011; 39: 2401-6.
[4]  American Heart Association. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Part 6: advanced cardiovascular life support: section 3: adjuncts for oxygenation, ventilation and airway control. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Circulation 2000; 102(Suppl. 8): I95-I104.
[5]  Reynolds JC, Frisch A, Rittenberger JC, Callaway CW. Duration of resuscitation efforts and functional outcome after out-of-hospital cardiac arrest: when should we change to novel therapies? Circulation. 2013; 128: 2488-94.
[6]  Hasselqvist-Ax I, Riva G,Herlitz J, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med. 2015; 372: 2307-15.
[7]  Nademanee K, Taylor R, Bailey WE, Riders DE, Kosar EM. Treating electrical storm: sympathetic blockade versus advanced cardiac life support-guided therapy. Circulation. 2000; 102: 742-7.
[8]  Klouche K, Weil MH, Sun S, et al. Evolution of the stone heart after prolonged cardiac arrest. Chest. 2002; 122: 1006-11.
[9]  Hoch DH, Batsford WP, Greenberg SM, et al. Double sequential external shocks for refractory ventricular fibrillation. J Am Coll Cardiol. 1994; 23: 1141-5.
[10]  Cabañas JG, Myers JB, Williams JG, De Mario VJ, Bachman MW. Double sequential external defibrillation in out-of-hospital refractory ventricular fibrillation: a report of ten cases. Prehosp Emerg Care. 2015; 19: 126-30.
[11]  Merlin MA, Tagore A, Bauter R, Arshad FH. A case series of double sequence defibrillation. Prehosp Emerg Care. 2016; 20: 550-3.
[12]  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.
[13]  Ross EM, Redman TT, Harper SA, Mapp JG, Wampler DA, Miramontes DA. et al. Dual defibrillation in out-of-hospital cardiac arrest: a retrospective cohort analysis. Resuscitation. 2016; 106: 14-7.
[14]  Emmerson AC, Whitbread M, Fothergill RT. Double sequential defibrillation therapy for out-of-hospital cardiac arrests: The London experience. Resuscitation. 2017; 117: 97-101.
[15]  Cheskes S, Wudwud A, Turner L, McLeod S, Summers J, Morrison LJ, Verbeek PR. The impact of double sequential external defibrillation on termination of refractory ventricular fibrillation during out-of-hospital cardiac arrest. Resuscitation. 2019; 139: 275-281.
[16]  Leacock BW. Double simultaneous defibrillators for refractory ventricular fibrillation. J Emerg Med. 2014; 46: 472-4.
[17]  Gerstein NS, Shah MB, Jorgensen KM. Simultaneous use of two defibrillators for the conversion of refractory ventricular fibrillation. J Cardiothorac Vasc Anesth. 2015; 29: 421-4.
[18]  Lybeck AM, Moy HP, Tan DK. Double sequential defibrillation for refractory ventricular fibrillation: a case report. Prehosp Emerg Care. 2015; 19: 554-7.
[19]  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: 662-6.
[20]  Sena RC, Eldrich S, Pescatore RM, Mazzarelli A, Byrne RG. Refractory ventricular fibrillation successfully cardioverted with dual sequential defibrillation. J Emerg Med. 2016; 51: e37-40.
[21]  Boehm KM, Keyes DC, Mader LE, Moccia JM. First report of survival in refractory ventricular fibrillation after dual-axis defibrillation and esmolol administration. West J Emerg Med. 2016; 17: 762-5.
[22]  Bell CR, Szulewski A, Brooks SC. Make it two: a case report of dual sequential external defibrillation. CJEM. 2017; 20: 1-6.
[23]  Nikolla D. Dual Defibrillation: The Achilles' Heel of Refractory V-Fib? EM Resident. 2017.
[24]  El Tawil C, Mrad S, Khishfe BF. Double sequential defibrillation for refractory ventricular fibrillation. Am J Emerg Med. 2017; 35: 1985. e3-1985.e4.
[25]  Yannopoulos D, Bartos JA, Raveendran G, et al. Coronary artery disease in patients with out-of-hospital refractory ventricular fibrillation cardiac arrest. J Am Coll Cardiol. 2017; 70: 1109-17.
[26]  Camuglia AC, Randhawa VK, Lavi S, Walters DL. Cardiac catheterization is associated with superior outcomes for survivors of out of hospital cardiac arrest: review and meta-analysis. Resuscitation. 2014; 85: 1533-40.
[27]  Garcia S, Drexel T, Bekwelem W, et al. Early access to the cardiac catheterization laboratory for patients resuscitated from cardiac arrest due to a shockable rhythm: the Minnesota Resuscitation Consortium Twin Cities Unified Protocol. J Am Heart Assoc. 2016; 5: e002670.
[28]  Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2018; 138: e272-e391.