“Twice As Nice”: Dual Sequential Defibrillation



The Stats:

  • 350,000 out-of hospital cardiac arrests (OHCA)/209,000 in hospital cardiac arrests (IHCA) each year (2016)
  • Majority of cases have a primary cardiac etiology with vfib as presenting rhythm

So SHOCK IT!…..Survival Rate: OHCA 12%/IHCA 24.8

Enters Dual Sequential Defibrillation (DSD)

  • Research previously conducted in animals. In 1986 Chang et al showed that DSD resulted in lower peak voltages and lower energy required to terminate vfib, their findings indicated that increased body habitus required more energy to terminate vfib
  • Zhang et al (2002) also showed similar findings in pigs

Now onto the humans…

  • Merlin et al 2016 showed in a recent case series of 7 patients:
    • Mean time of resuscitation before DSD=34 minutes
    • Mean shocks delivered before DSD=5
    • Mean DSD shocks=2
    • Jules: monophasic 360J x2
    • 3/7 patients survived to discharge w/ ok neurologic outcome CPC scores ranged from 1-3 (1 being independent to 3 dependent)
    • Why it worked?
      • Increasing the number of vectors may capture more myocardium
      • Sequential shocks may result in longer duration of defibrillation
    • Next will look at this in 60 patients

Additional studies:

AuthorType of ResearchOutcomes
1. Lybeck et al. 2015Case ReportPt survived after DSD on 8th attempt
2. Cabanas et al. 2014Case SeriesROSC in 7 of 10 patients. No Survivors
3. Hoch et al. 1994Subgroup Analysis5 patients converted in EP lab after refractory VF. All survived
4. Leacock 20147Case ReportPt survived after DSD on 5th attempt (400J)
5. Gerstein et al. 2014Case ReportPt had ROSC after 400J with DSD and failed single multiple defibs. Pt did not survive



  1. Place 2nd set of pads in Anterolateral or Anteroposterior position, may be adjacent to first set of pads but not touching!
  2. Charge both monitors (360J for monophasic and 200J for biphasic)
  3. CLEAR!
  4. Simultaneously press both shock buttons
  5. Resume CPR



  1. DSD may work…
  2. Need 2 sets of pads! Place in AP or AL position
  3. Can use monophasic or biphasic defibrillators no proven standard of Jules
  4. May work because: (1) captures more of the myocardium with increase in vectors (2) delivers more energy through larger body habituses, (3) increased duration of defibrillation…but not certain
  5. We need more studies


Johnston et al 2016 Case Report: For the romantics

28yo F presents with out of hospital cardiac arrest as witnessed by husband. Husband calls 911 and begins CPR while awaiting for EMS. 6 minutes later EMS arrives and begins ACLS. Within first 15 minutes patient receives 6 shocks, Epi, Amio and then last but not least double sequential defibrillation and achieves ROSC 2 minutes later! EKG is STEMI negative. Patient taken to hospital later diagnosed with long QT syndrome, gets an ICD, and leaves hospital with significant level of independent function and able to return to her 16mo old daughter!! 

Shoutout to Doug for posting this topic for a previous TR Pearl and bringing it to my attention!

The sources:

The post “Twice As Nice”: Dual Sequential Defibrillation appeared first on FOAM EM RSS.

Source: http://www.foamem.com/

TPR Podcast Episode #12: 25 years of weird and wacky toxicology papers

25th Anniversary The Poison Review Podcast: Wild, Wacky and Weird Toxicology Articles From The Last Quarter-Century

“It is universally well known, that in ingesting our common food, there is created or produced in the bowels of human creatures, a great quantity of wind.”  Benjamin Franklin


Stool osmolar gap = 290 – 2*(stool Na + stool K)   [normal 50-100 mOsm/kg]

If stool osmolar gap < 50, diarrhea is secretory

If stool osmolar gap > 100, diarrhea is osmotic

Osmotic diarrhea will resolve with fasting; secretory diarrhea will not

Here is a link to a stool osmolar gap calculator


To read WebMD’s discussion of cases similar to that of the airline stewardess,

click here.


NOTE: As indicated above, current thinking is that a normal stool osmolar gap is

between 50 and 100 mOsm/kg. Interestingly, by that measure the stool

osmolar gap in this case of the air stewardess with puzzling diarrhea was

actually normal.


Other items discussed on the podcast:


Hennig Brand

Golden Fountain: The Complete Guide to Urine Therapy (book)

Your Own Perfect Medicine (book)


To read my “Toxicology Rounds” column on autourotherapy, click here



Quizzler (Podcast #11): In James Joyce’s novel Ulysses, Leopold Bloom’s father had committed suicide by self-poisoning. The Quizzler: what agent did Rudolph Bloom (né Rudolph Virág) use to kill himself? The answer: aconite. The winner, Dr. Richard Hamilton of Philadelphia, received a TPR t-shirt. Congratulations to Dr. Hamilton!


This episode’s Quizzler is at the end of the podcast. The winner will receive a $10 Amazon gift certificate as well as the TPR t-shirt. Our rules have changed slightly. Rather than awarding the prize to the first correct answer, we will take all correct answers submitted before the deadline and randomly select a winner. The deadline for submission is October 11, 2016, 6 pm (Chicago time.) Send submissions to: toxtrivia@gmail.com. Good luck!


Dr. Steve Aks with a Lava light

Dr. Steve Aks with a Lava light


Dr. Tim Erickson threatening to try autourotherapy

Dr. Tim Erickson threatening to try autourotherapy


Drs. Tim Erickson, Steve Aks, and Leon Gussow

Drs. Tim Erickson, Steve Aks, and Leon Gussow


The Poison Review newsletter, 1998

The Poison Review newsletter, 1998




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Source: http://www.foamem.com/

The Final X-Ray In Damage Control Surgery

Damage control surgery for trauma is over 20 years old, yet we continue to find ways to refine it and make it better. Many lives have been saved over the years, but we’ve also discovered new questions. How soon should the patient go back for definitive closure? What is the optimal closure technique? What if it still won’t close?

One other troublesome issue surfaced as well. We discovered that it is entirely possible to leave things behind. Retained foreign bodies are the bane of any surgeon, and many, many systems are in place to avoid them. However, many of these processes are not possible in emergent trauma surgery. Preop instrument counts cannot be done. Handfuls of uncounted sponges may be packed into the wound.

I was only able to find one paper describing how often things are left behind in damage control surgery (see reference below), and it was uncommon in this single center study (3 cases out of about 2500 patients). However, it can be catastrophic, causing sepsis, physical damage to adjacent organs, and the risk of performing an additional operation in a sick trauma patient.

So what can we do to reduce the risk, hopefully to zero? Here are my  recommendations:

  • For busy centers that do frequent laparotomy or thoracotomy for trauma and have packs open and ready, pre-count all instruments and document it
  • Pre-count a set number of laparotomy pads into the packs
  • Use only items that are radiopaque or have a marker embedded in them. This includes surgical towels, too!
  • Implement a damage control closure x-ray policy. When the patient returns to OR and the surgeons are ready to begin the final closure, obtain an x-ray of the entire area that was operated upon. This must be performed and read before the closure is complete so that any identified retained objects can be removed.

Tomorrow, a sample damage control closure x-ray.

Related post:

Reference: Retained foreign bodies after emergent trauma surgery: incidence after 2526 cavitary explorations. Am Surg 73(10):1031-1034, 2007.

Source: http://thetraumapro.com/2016/09/26/the-final-x-ray-in-damage-control-surgery/
Source: http://regionstraumapro.com/

CRACKCast E042 – Facial Trauma

This episode of CRACKCast covers Rosen’s Chapter 042, Facial Trauma. Continuing in our series on all things trauma, this episode tackles the issue of facial trauma and explores some of the nuances in the diagnosis and management of these patients. Shownotes – PDF Link   Rosen’s in Perspective mechanism of facial trauma varies significantly age highly associated with alcohol use 49% of maxillofacial trauma was ETOH related in one study (many from assaults) other …

The post CRACKCast E042 – Facial Trauma appeared first on CanadiEM and was written by Tristan Jones.

Source: http://canadiem.org/

AIR-Pro: Toxicology (Part 1)

Welcome to the Toxicology (Part 1) AIR-Pro Module. Below we have listed our selection of the 10 highest quality blog posts related to 5 advanced level questions on toxocology topics posed, curated, and approved for residency training by the AIR-Pro Series Board. The blogs relate to the following questions:

  1. Flumazenil in benzodiazepine overdose
  2. Acetaminophen – drawing and timing of levels
  3. Opioid overdoses
  4. Acetaminophen toxicity related to liver transplant
  5. Salicylates and hemodialysis

In this module, we have 6 AIR-Pro’s and 4 Honorable Mentions. To strive for comprehensiveness, we selected from a broad spectrum of blogs identified through FOAMSearch.net and FOAMSearcher.We have a brand new chief resident team and want to thank the out-going team for all of their support!

AIR-Pro Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR-Pro stamp of approval will only be given to posts scoring above a strict scoring cut-off of ≥28 points (out of 35 total), based on our AIR-Pro scoring instrument, which is slightly different from our original AIR Series scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR-Pro Board members as worthwhile, accurate, unbiased and useful to senior residents. Only the posts with the AIR-Pro stamp of approval will be part of the quiz needed to obtain III credit. To decrease the repetitive nature of posts relating to these advanced concepts, we did not always include every post found that met the score of ≥28 points.

Take the quiz at ALiEMU

ALiEMU AIR-Pro Toxicology block quiz
(You will need to create a one-time login account if you haven’t already.)

Toxocology Module (Part 1) 2016: Recommended III credit hours

3 hours (20 minutes per article, 30 minutes for articles with podcasts)


Article TitleAuthorsDateTitle
EMPharmD: Flumazenil: Friend or Foe?Nadia AwadNov 7, 2013AIR-PRO
ALiEM: Utility of Pre-4-Hour Acetaminophen Levels in Acute OverdoseBryan HayesAug 5, 2015AIR-PRO
StEmlyns: Opiate Overdose in the EDSimon CarleyFeb 27, 2015AIR-PRO
EMJClub: Treat and Release vs Observation After Naloxone for Opioid OverdoseEMJ ClubNov 24, 2014AIR-PRO
LIFTL: Liver Transplantation for Paracetamol ToxicityChris NicksonApril 30, 2016AIR-PRO
ALiEM: 5 Tips in Managing Acute Salicylate PoisoningKristin FontesNov 4, 2013AIR-PRO
LITFL: Paracetamol/Acetaminophen OverdoseChris NicksonSept 3, 2010Honorable Mention
ALiEM: Tricks of the Trade: Naloxone Dilution for Opioid OverdoseBryan HayesNov 17, 2014Honorable Mention
LITFL: ParacetamolChris Nickson2015Honorable Mention
EMDocs: Pearls and Pitfalls of Salicylate Toxicity in the EDSamantha Berman & Josh BucherOct 13, 2015Honorable Mention


Author information

Fareen Zaver, MD

Fareen Zaver, MD

Lead Editor/Co-Founder of ALiEM Approved Instructional Resources – Professional (AIR-Pro)
Emergency Physician
University of Calgary Emergency Department

The post AIR-Pro: Toxicology (Part 1) appeared first on ALiEM.

Source: http://www.aliem.com/

Sepsis-Associated AKI – Bellomo Kidney – Implications for Management

“Rather than love, than money, than fame, give me truth.” -Thoreau The Case A 56 year old man with non-ischemic cardiomyopathy [LVEF 40% and mitral regurgitation] is admitted with severe sepsis due to appendicitis.  One month prior to admission, his outpatient cardiologist saw him and noted a dry weight of 88 kg.  On admission to the [… read more]

The post Sepsis-Associated AKI – Bellomo Kidney – Implications for Management appeared first on PulmCCM.

Source: PulmCCM