UMEM Educational Pearls

Title: Go Big or Go Home -- an Escalating Energy Strategy for OHCA VF Requiring Repeated Defibrillation

Keywords: OHCA, shockable rhythms, VF, ventricular fibrillation, defibrillation, AED, energy (PubMed Search)

Posted: 6/4/2025 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

A recent retrospective cohort study out of China investigated an escalating energy (200 > 300 > 360J) versus fixed energy (200 > 200 > 200 J) defibrillation strategy in OHCA with ventricular fibrillation requiring repeated defibrillations.

Notes:

342 adult patients with OHCA receiving prehospital defibrillation from 2017-2023
- *Cheskes et al.'s DOSE-VF for refractory VT/VF published in November 2022
Defibrillation energy strategy dependent on which biphasic AED was used prehospital; ultimately 64% escalating, 36% fixed low-energy.
Total 782 defibrillations, mean age 58 years, 80% male

Results:

Equivalent outcomes after 1st shock in both groups (which makes sense as both groups started with 200J defibrillations)
More patients in the escalating energy group with VF termination (93% vs 75%, p<0.001) and change to an organized rhythm (64% vs 47%, p<0.001)
In the refractory VF population (required >2 shocks), more organized rhythms after 360J than the 3rd 200J defibrillation (35% s 18%, p=0.003).

Caveats:

Retrospective
No assessment of possible shock-related myocardial injury differences between groups
No commentary on other OHCA management (like anti-arrhythmics)

Bottom Line: For patients with OHCA VF, if the first shock does not succeed, try try again – at a higher dose.

References

Cheskes S, Verbeek PR, Drennan IR, McLeod SL, Turner L, Pinto R, Feldman M, Davis M, Vaillancourt C, Morrison LJ, Dorian P, Scales DC. Defibrillation Strategies for Refractory Ventricular Fibrillation. N Engl J Med. 2022 Nov 24;387(21):1947-1956. doi: 10.1056/NEJMoa2207304.
Tang H, Wu R, Yin L, et al. Escalating vs Fixed Energy Defibrillation in Out-of-Hospital Cardiac Arrest Ventricular Fibrillation. JAMA Netw Open. 2025 Apr 1;8(4):e257411. doi: 10.1001/jamanetworkopen.2025.7411.