B51-05 Dual Sequential Defibrillation for Refractory Pulseless Ventricular Tachycardia in the Hospital Setting

Abstract Introduction Dual sequential defibrillation (DSD), serial delivery of two sequential electric shocks from 2 separate defibrillators, is a management option for refractory ventricular fibrillation (VF). This has been variably defined in existing, largely pre-hospital literature as an initial presenting rhythm of either solely VF or both VF and pulseless ventricular tachycardia (VT) persisting despite 3 standard defibrillations and rhythm analyses separated by 2-minute CPR intervals. While prior studies of DSD in this population have demonstrated benefit over standard defibrillation (SD) for out-of-hospital cardiac arrest, its utility in the general hospital setting has not been well-characterized. Description of Case A 43-year-old male with a history of type B aortic dissection, asthma, and stroke complicated by prolonged intubation, tracheal stenosis, tracheomalacia and tracheostomy placement (2022) presented with 2 days of worsening dyspnea and subjective upper airway tightness. He was admitted to the general hospital floor and received racemic epinephrine, steroids, and nebulized airway clearance for 4 days with only mild symptomatic improvement. Rapid response was called on hospital day 5 for hypoxia and visibly poor air movement despite noninvasive therapies, prompting rapid transition to Code Airway and ultimately Code Blue. The initial rhythm was PEA. Multiple rounds of compressions and doses of epinephrine were provided without return of spontaneous circulation (ROSC), though bag-valve mask ventilation corrected the initial hypoxia. Despite use of a pediatric fiberoptic laryngoscope, a definitive airway could not be established due to profound tracheal stenosis and tortuosity proximal and distal to the stoma. The patient was found to be in VT during the next 3 pulse checks and ROSC was initially achieved after SD x 3. The patient then quickly re-arrested and pulseless VT persisted despite lidocaine 1 mg/kg x 1, epinephrine 1 mg x 2, and 3 further SD. The patient was deemed to be in refractory VT and DSD was administered followed by sustained ROSC at the next pulse check, allowing time for the patient to be transported to the surgical ICU. The patient ultimately underwent emergent mediastinal tracheostomy placement and is currently following verbal commands in the ICU. Discussion In this case, DSD was utilized on the general hospital floor to terminate pulseless VT refractory to multiple rounds of antiarrhythmic medication and SD attempts, enabling the patient to be bridged to definitive airway management. Further high-quality investigation into in-hospital DSD usage may be worthwhile to affirm the generalizability of positive pre-hospital findings. This abstract is funded by: None