A 45-year-old man with severe coronary heart disease s/p CABG but with an unprotected left main, presented to the emergency department for evaluation and suffered a ventricular fibrillation cardiac arrest. CPR and BVM ventilation was initiated immediately. The patient underwent an aggressive resuscitation effort with:

  • LUCAS CPR and ResQPod impedance threshold device
  • Multiple defibrillations
  • Amiodarone
  • Magnesium
  • Lidocaine
  • Esmolol

At this point the patient had received high-quality uninterrupted CPR, electrical defibrillations, inovasopressors, and antiarrhythmics. Despite this, the patient had persistent ventricular fibrillation. Intermittent cardiac ultrasound showed no cardiac activity. What options remain?


We decided to attempt high energy defibrillation. The use of a second defibrillator with separate pairs of electrodes allows 400 J of biphasic energy to be applied to depolarize a critical amount of myocardium. First described by in animal models by Geddes (4) in 1976, and then by Hoch (1) in 1994. He found that patients who developed refractory ventricular fibrillation during electrophysiology procedures had restoration of regular rhythm.

High energy defibrillation is performed by attaching a second set of pads attached to a second defibrillator, ensuring that a second vector is established through the heart. At the time of defibrillation, both shock buttons are depressed as near-simultaneously as possible.

While the high energy increases the likelihood of successful defibrillation, the severity of postresuscitation myocardial dysfunction increases with the magnitude of electrical energy delivered by the shock (2).

With all of these above eff