Beyond Advanced Cardiac Life Support - Dual-Sequential Defibrillation for Refractory Ventricular Fibrillation after Witnessed Cardiac Arrest in the Emergency Department

Sep 23, 2026

Uploaded by Connor

Refractory ventricular fibrillation is a rare cause of cardiac arrest in both in-hospital and out-of-hospital settings. A 56-year-old male developed refractory ventricular fibrillation after an in-hospital arrest with multiple unsuccessful standard defibrillation attempts, and dualsequential defibrillation (DSD) successfully converted the rhythm to normal sinus rhythm. Advanced cardiac life support (ACLS) provides general guidance for cardiopulmonary emergencies but offers no specific recommendations for refractory ventricular fibrillation. This report supports DSD as a potential alternative when ACLS pathways fail.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages6

Reading Time15 min

AccessFree to download

Abstract

Introduction

Case Presentation

Initial presentation and assessment

Point-of-care ultrasound and resuscitation

ACLS course and decision for DSD

Post-stabilization evaluation and recurrence

Open Access Case Report DOI: 10.7759/cureus.3717 Received 11/21/2018 Review began 11/28/2018 Review ended 12/10/2018 Published 12/11/2018 © Copyright 2018 Frye et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Beyond Advanced Cardiac Life Support: Dualsequential Defibrillation for Refractory Ventricular Fibrillation after Witnessed Cardiac Arrest in the Emergency Department Kenneth L. Frye 1 , Ademola Adewale 2 , Elijah Kennedy 1 , Lisa O 'Grady 1 1. Emergency Medicine, Florida Hospital, Orlando, USA 2. Emergency Medicine, Florida Hospital, Orlando , USA Corresponding author: Kenneth L. Frye, [kenneth.frye@gmail.com](kenneth.frye@gmail.com) | Abstract
Refractory ventricular fibrillation is a rare condition seen in both in-hospital and out-of-hospital cardiac arrest. A 56-year-old male was identified to have refractory ventricular fibrillation after an in-hospital cardiac arrest with multiple unsuccessful standard defibrillation attempts that was converted with dualsequential defibrillation (DSD) to normal sinus rhythm. Advanced cardiac life support (ACLS) is the most widely used algorithmic treatment approach for various cardiopulmonary emergencies but has yet to provide recommendations for the treatment of refractory ventricular fibrillation. DSD may be a viable treatment strategy for refractory ventricular fibrillation when ACLS recommendations are ineffective. | | --- | | Categories: Cardiology, Emergency Medicine
Keywords: point-of-care ultrasound, dual sequential defibrillation, refractory ventricular fibrillation, emergency medicine, acls, resuscitation, cardiac arrest, pocus
Introduction
Cardiac arrest due to refractory ventricular fibrillation is a rare, life-threatening condition, seen in less than 10% of out-of-hospital cardiac arrests [1] . The term refractory ventricular fibrillation is used when there have been multiple failed attempts (two or more) at correcting ventricular fibrillation during cardiopulmonary resuscitation (CPR) [2] . Advanced cardiac life support (ACLS) guidelines help providers with clinical decisions while managing cardiac arrest patients but provide no recommendations for refractory ventricular fibrillation. Here we present a case detailing a potential treatment strategy for refractory ventricular fibrillation using dual-sequential defibrillation (DSD) once the ACLS algorithm pathways have been exhausted.
Case Presentation
A 56-year-old male presented to the emergency department (ED) with significant substernal chest pain starting 30 minutes prior to arrival. The patient was immediately brought back to an exam room after an electrocardiogram (ECG) was performed and was seen by a provider within 10 minutes of registration (Figure 1) . | |

FIGURE 1 : Electrocardiogram, atrial fibrillation.
Rate 147, atrial fibrillation, left axis deviation, QRS 84 ms, QTc 404, ST-segments with minimal depression in lateral leads. | How to cite this article Frye K L , Adewale A, Kennedy E , et al. (December 11 , 2018) Beyond Advanced Cardiac Life Support: Dual-sequential Defibrillation for Refractory Ventricular Fibrillation after Witnessed Cardiac Arrest in the Emergency Department. Cureus 10(12): e3717. DOI 10.7759/cureus.3717 The initial ECG revealed atrial fibrillation with a rapid ventricular response, rate of 147, with minimal ST depression within the lateral leads but was without apparent ST-segment elevation. On initial assessment, the patient had point-of-care labs immediately drawn (a basic metabolic panel and troponin), and a chest Xray performed to evaluate for a possible aortic dissection which revealed no gross abnormalities (Figure 2) . FIGURE 2: Chest X-ray. Portable chest X-ray, anterior-posterior orientation. With a non-diagnostic c

FAQs

What makes ventricular fibrillation “refractory” in this report?

The report uses refractory ventricular fibrillation to describe multiple failed attempts (two or more) to correct ventricular fibrillation during cardiopulmonary resuscitation.

How did dual-sequential defibrillation (DSD) change the outcome?

After standard ACLS efforts continued to fail, DSD was attempted by applying a second set of pads in anterior-posterior orientation, leading to successful conversion to normal sinus rhythm.

Why was point-of-care ultrasound (POCUS) important in the case?

POCUS was consulted to evaluate right heart strain related to suspected pulmonary embolism, and during the ultrasound the patient experienced ventricular fibrillation, prompting immediate CPR.

Sep 23, 2026

Uploaded by Connor