Low-Energy Impedance-Compensating Biphasic Waveforms Terminate Ventricular Fibrillation at High Rates in Victims of Out-of-Hospital Cardiac Arrest
Corresponding Author
JEANNE E. POOLE M.D.
University of Washington, Seattle, Washington
Jeanne E. Poole, M.D., Division of Cardiology, Box 356422, University of Washington, 1959 N. E. Pacific St., Seattle, WA 98195. Fax: 206-616-6069; E-mail: [email protected]Search for more papers by this authorROGER D. WHITE M.D.
University of Washington, Seattle, Washington
Search for more papers by this authorKARL-GEORG KANZ M.D.
University of Washington, Seattle, Washington
Search for more papers by this authorFRIEDERIKE HENGSTENBERG M.D.
University of Washington, Seattle, Washington
Search for more papers by this authorG. TRUETT JARRARD M.D.
University of Washington, Seattle, Washington
Search for more papers by this authorVALERIE SANTANA R.N.
University of Washington, Seattle, Washington
Search for more papers by this authorDAVID K. McKENAS M.D.
University of Washington, Seattle, Washington
Search for more papers by this authorSTEVEN ROSAS M.D.
University of Washington, Seattle, Washington
Search for more papers by this authorLUKE MAGNOTTO M.D.
University of Washington, Seattle, Washington
Search for more papers by this authorJOHN V. GALLAGHER III, M.D.
University of Washington, Seattle, Washington
Search for more papers by this authorBRADFORD E. GLINER
University of Washington, Seattle, Washington
Search for more papers by this authorDAWN B. JORGENSON Ph.D.
University of Washington, Seattle, Washington
Search for more papers by this authorCARLTON B. MORGAN
University of Washington, Seattle, Washington
Search for more papers by this authorSTEPHEN M. DILLON Ph.D.
University of Washington, Seattle, Washington
Search for more papers by this authorRICHARD A. KRONMAL Ph.D.
University of Washington, Seattle, Washington
Search for more papers by this authorGUST H. BARDY M.D.
University of Washington, Seattle, Washington
Search for more papers by this authorfor the LIFE INVESTIGATORS
University of Washington, Seattle, Washington
Search for more papers by this authorCorresponding Author
JEANNE E. POOLE M.D.
University of Washington, Seattle, Washington
Jeanne E. Poole, M.D., Division of Cardiology, Box 356422, University of Washington, 1959 N. E. Pacific St., Seattle, WA 98195. Fax: 206-616-6069; E-mail: [email protected]Search for more papers by this authorROGER D. WHITE M.D.
University of Washington, Seattle, Washington
Search for more papers by this authorKARL-GEORG KANZ M.D.
University of Washington, Seattle, Washington
Search for more papers by this authorFRIEDERIKE HENGSTENBERG M.D.
University of Washington, Seattle, Washington
Search for more papers by this authorG. TRUETT JARRARD M.D.
University of Washington, Seattle, Washington
Search for more papers by this authorVALERIE SANTANA R.N.
University of Washington, Seattle, Washington
Search for more papers by this authorDAVID K. McKENAS M.D.
University of Washington, Seattle, Washington
Search for more papers by this authorSTEVEN ROSAS M.D.
University of Washington, Seattle, Washington
Search for more papers by this authorLUKE MAGNOTTO M.D.
University of Washington, Seattle, Washington
Search for more papers by this authorJOHN V. GALLAGHER III, M.D.
University of Washington, Seattle, Washington
Search for more papers by this authorBRADFORD E. GLINER
University of Washington, Seattle, Washington
Search for more papers by this authorDAWN B. JORGENSON Ph.D.
University of Washington, Seattle, Washington
Search for more papers by this authorCARLTON B. MORGAN
University of Washington, Seattle, Washington
Search for more papers by this authorSTEPHEN M. DILLON Ph.D.
University of Washington, Seattle, Washington
Search for more papers by this authorRICHARD A. KRONMAL Ph.D.
University of Washington, Seattle, Washington
Search for more papers by this authorGUST H. BARDY M.D.
University of Washington, Seattle, Washington
Search for more papers by this authorfor the LIFE INVESTIGATORS
University of Washington, Seattle, Washington
Search for more papers by this authorDr. Bardy serves as a consultant for Heartstream, Inc.
Abstract
Biphasic Waveform Defibrillation. Introduction: New automatic external defibrillators (AEDs), which are smaller, lighter, easier to use, and less costly make the goal of widespread AED deployment and early defibrillation for out-of-hospital cardiac arrest feasible. The objective of this study was to observe the performance of a low-energy impedance-compensating biphasic waveform in the out-of-hospital setting on 100 consecutive victims of sudden cardiac arrest.
Methods and Results: AEDs incorporating a 150-J impedance-compensating biphasic waveform were used by 12 EMS systems. Data were obtained from the AED PC card reporting system. Defibrillation was defined as conversion to an organized rhythm or to asystole. Endpoints included: defibrillation efficacy for ventricular fibrillation (VE); restoration of an organized rhythm at the time of patient transfer to an advanced life support (ALS) team or to the emergency department (ED); and time from AED power-on to first defibrillation. The AED correctly identified 44 of 100 patients presenting in VE as requiring a shock (100% sensitivity) and 56 of 100 patients not in VF as not requiring a shock (100% specificity). The time from 911 call to first shock delivery averaged 8.1 ± 3.0 minutes. A single 150-J biphasic shock defibrillated the initial VE episode in 39 of 44 (89%) patients. The average time from power-on to first defibrillation was 25 ± 17 seconds. At patient transfer to ALS or ED care, an organized rhythm was present in 34 of 44 (77%) patients presenting with VF. Asystole was present in 7 (16%) and VE in 3 (7%).
Conclusions: Low-energy impedance-compensating biphasic waveforms terminate long-duration VE at high rates in out-of-hospital cardiac arrest. Use of this waveform allows AED device characteristics consistent with widespread AED deployment and early defibrillation.
References
- 1 Ryan TJ, Anderson JL, Amman EM, et al: ACC/AHA guidelines for the management of patients with acute myocardial infarction: Executive summary. Circulation 1996; 94: 2341–2350.
- 2 Gillum RF: Sudden coronary death in the United States. Circulation 1989; 79: 756–765.
- 3 Bayes de Luna A, Coumel P, Leclercq JF: Ambulatory sudden cardiac death: Mechanisms of production of fatal arrhythmia on the basis of data from 157 cases. Am Heart J 1989: 117: 151–159.
- 4 Emergency Cardiac Care Committee and Subcommittees. American Heart Association: Guidelines for cardiopulmonary resuscitation and emergency cardiac care. IX: Ensuring effectiveness of communitywide emergency cardiac care, JAMA 1992; 268: 2289–2295.
- 5 Weaver WD, Copass MK, Bufi D, et al: Improved neurologic recovery and survival after early defibrillation. Circulation 1984: 69: 943–948.
- 6 Spaite DW, Hanlon T, Criss EA, et al: Prehospital cardiac arrest: The impact of witnessed collapse and bystander CPR in a metropolitan EMS system with short response times. Ann Emerg Med 1990; 19: 1264–1269.
- 7 Larsen MP, Eisenberg MS, Cummins RO, et al: Predicting survival from out-of-hospital cardiac arrest: A graphic model, Ann Emerg Med 1993: 22: 1652–1658.
- 8 Weaver WD, Cobb LA, Hallstrom AP, et al: Factors influencing survival after out-of-hospital cardiac arrest. J Am Coll Cardiol 1986; 7: 752–757.
- 9 Herlitz J. Ekström L, Wennerblom B. et al: Survival in patients found to have ventricular fibrillation after cardiac arrest witnessed outside hospital, Eur Heart J 1994; 15: 1628–1633.
- 10 Becker LB, Ostrander MP, Barrett J, et al: Outcome of CPR in a large metropolitan area—Where are the survivors Ann Emerg Med 1991: 20: 355–361.
- 11 Lombardi G, Gallagher EJ, Gennis P: Outcome of out-of- hospital cardiac arrest in New York City: The Pre-Hospital Arrest Survival Evaluation (PHASE) Study. JAMA 1994: 271: 678–683.
- 12 Eisenberg MS, Horwood BT, Cummins RO, et al: Cardiac arrest and resuscitation: A tale of 29 cities. Ann Emerg Med 1990; 19: 170–186.
- 13 White RD, Vukov LF, Bugliosi TF: Early defibrillation by police: Initial experience with measurement of critical time intervals and patient outcome. Ann Emerg Med 1994: 23: 1099–1113.
- 14 White RD, Asplin BR, Bugliosi TF, et al: High disc charge survival rate after out-of-hospital ventricular fibrillation with rapid defibrillation by police and paramedics. Ann Emerg Med 1996: 28: 480–485.
- 15 Weisfeldt ML, Kerber RE, McGoldrick RP, et al: American Heart Association Report on the Public Access Defibrillation Conference, December 8–10, 1994: Automatic External Defibrillation Task Force, Circulation 1995: 92: 2740–2747.
- 16 Winkle RA, Mead RH, Ruder MA, et al: Improved low energy defibrillation efficacy in man with the use of a biphasic truncated exponential waveform. Am Heart J 1989: 117: 122–127.
- 17 Bardy GH, Ivey TD, Allen MD, et al: A prospective, randomized evaluation of biphasic vs monophasic waveform pulses on defibrillation efficacy in humans. J Am Coll Cardiol 1989: 14: 728–733.
- 18
Swartz JF,
Fletcher RD,
Karasik PE: Optimization of biphasic waveforms for human nonthoracotomy defibrillation, Circulation
1993: 33: 2646–2654.
10.1161/01.CIR.88.6.2646 Google Scholar
- 19 Charbonnier FM: External defibrillators and emergency external pacemakers. Proc IEEE 1996: 84: 487–499.
- 20 Jones JL, Jones RE: Decreased defibrilliator-induced dysfunction with biphasic rectangular waveforms. Am J Physiol 1984; 247: H792–H796.
- 21 Jones JL, Jones RE, Balasky G: Improved defibrillator waveform safety factor with biphasic waveforms. Am J Physiol 1983: 245: H60–H65.
- 22 Osswald S, Trouton TG, O'Nunain SS, et al: Relation between shock-related myocardial injury and defibrillation efficacy of monophasic and biphasic shocks in a canine model. Circulation 1994: 90: 2501–2509.
- 23
Xie J,
Weil MH,
Sun S, et al: High-energy defibrillation increases the severity of postresuscitation myocardial dysfunction.
Circulation
1997: 96: 683–688.
10.1161/01.CIR.96.2.683 Google Scholar
- 24 Crampton R: Accepted, controversial, and speculative aspects of ventricular defibrillation. Prog Cardiovasc Dis 1980; 23: 167–186.
- 25 Kerber RE, Becker LB, Bourland JD, et al: Automatic external defibrillators for public access defibrillation. Recommendations for specifying and reporting arrhythmia analysis algorithm performance, incorporating new waveforms, and enhancing safety: A statement for health care professionals from the American Heart Association Task Force on Automatic External Defibrillation. Subcommittee on AED Safety and Efficacy. Circulation 1997: 95: 1677–1682.
- 26 Gliner BE, Lyster TE, Dillon SM, et al: Transthoracic defibrillation of swine with monophasic and biphasic waveforms. Circulation 1995: 92: 1634–1643.
- 27 Weaver WD, Cobb LA, Copass MK, et al: Ventricular defibrillation—A comparative trial using 175-J and 320-J shocks. N Engl J Med 1982: 307: 1101–1106.
- 28 Behr JC, Hartley LL, York DK, et al: Truncated exponential versus damped sinusoidal waveform shocks for transthoracic defibrillation. Am J Cardiol 1996; 78: 1242–1245.
- 29 Chen PS, Shibata N, Dixon EG, et al: Activation during ventricular defibrillation in open-chest dogs. J Clin Invest 1986: 77: 810–823.
- 30 Usui M, Callihan RL, Walker RG, et al: Epicardial sock mapping following monophasic and biphasic shock of equal voltage and an endocardial lead system. J Cardiovasc Electrophysiol 1996: 7: 322–334.
- 31 Cummins RO, Eisenberg MS, Litwin PE, et al: Automatic external defibrillators used by emergency medical technicians: A controlled clinical trial, JAMA 1987: 257: 1605–1610.
- 32 Weaver WD, Martin JS, Wirkus MJ, et al: Influence of external defibrillator electrode polarity on cardiac resuscitation. PACE 1993: 16: 285–290.
- 33 Cummins RO, Eisenberg MS, Hallstrom AP, et al: What is a “save”?: Outcome measures in clinical evaluations of automatic external defibrillators. Am Heart J 1985; 110: 1133–1138.
- 34 Kerber RE, Martins JB, Kelly KJ, et al: Self-adhesive preappllied electrode pads for defibrillation and cardioversion. J Am Coll Cardiol 1984: 3: 815–821.
- 35 Eisenberg MS, Horwood BT, Cummins RO, et al: Cardiac arrest and resuscitation: A tale of 29 cities. Ann Emerg Med 1990: 19: 179–186.
- 36 White RD: Early out-of-hospital experience with an impedance-compensating low-energy biphasic waveform automatic external defibrillator. J Interven Card Electrophysiol 1997; (In press).
- 37
Bardy GH,
Marchlinski FE,
Sharma AD, et al: Multicenter comparison of truncated biphasic shocks and standard damped sine wave monophasic shocks for transthoracic ventricular defibrillation.
Circulation
1996: 94: 2507–2514.
10.1161/01.CIR.94.10.2507 Google Scholar
- 38 Kerber RE, Martins JB, Kienzle MG, et al: Energy, current, and success in defibrillation and cardioversion: clinical studies using an automated impedance-based method of energy adjustment. Circulation 1988; 77: 1038–1046.
- 39 Gold JH, Schuder JC, Stoeckle H: Contour graph for relating per cent success in achieving ventricular defibrillation to duration, current, and energy content of shock. Am Heart J 1979: 98: 207–212.
- 40 Wharton JM, Wolf PD, Smith WM, et al: Cardiac potential and potential gradient fields generated by single, combined, and sequential shocks during ventricular defibrillation. Circulation 1992: 85: 1510–1523.
- 41 Yabe S, Smith WM, Daubert JP, et al: Conduction disturbances caused by high current density electric fields. Circ Res 1990; 66: 1190–1203.
- 42 Tovar OH, Jones JL: Cellular basis of type B defibrillation occurring at high shock intensity (Abstract). Circulation 1996: 94: 1–131.
- 43
Bardy GH,
Gliner BE,
Kudenchuk PJ, et al: Truncated biphasic pulses for transthoracic defibrillation.
Circulation
1995: 91: 1768–1774.
10.1592/phco.21.2.254.34110 Google Scholar
- 44 Kerber RE, Kouba CK, Martins J, et al: Advance prediction of transthoracic impedance in human defibrillation and cardioversion: Importance of impedance in determining the success of low-energy shocks. Circulation 1984; 70: 303–308.
- 45 Kroll MW: A minimal model of the monophasic defibrillation pulse. PACE 1993: 16: 769–777.
- 46 Geddes LA, Tacker WA, McFarlane J, et al: Strength duration curves for ventricular defibrillation in dogs. Circ Res 1970; 27: 551–560.
- 47 Schuder JC, Stoeckle H, West JA, et al: Transthoracic ventricular defibrillation in dogs with truncated and untruncated exponential stimuli. IEEE Trans Biomed Eng 1971: 18: 410–415.
- 48 Schuder JC, Rahmoeller GA, Stoekle H: Transthoracic ventricular defibrillation with triangular and trapezoidal waveforms. Circ Res 1966; 19: 689–694.
- 49 Jones JL, Jones, RE, Balasky G: Microlesion formation in myocardial cells by high-intensity electric field stimulation. Am J Physiol 1987; 253: H480–H486.
- 50 Trouton TG, Allen JD, Yong LK, et al: Metabolic changes and mitochondrial dysfunction early following transthoracic countershock in dogs. PACE 1989; 12: 1827–1834.
- 51 Reddy RK, Gleva MJ, Gliner BE, et al: Biphasic transthoracic defibrillation causes fewer BCG ST-segment changes after shock. Ann Emerg Med 1997: 30: 127–134.
- 52 Ujhelyi MR, Schur M, Frede T, et al: Differential effects of lidocaine on defibrillation threshold with monophasic versus biphasic shock waveforms. Circulation 1995; 92: 1644–1650.
- 53 Kopp D, Kall J, Kinder C, et al: Effect of amiodarone and left ventricular mass on defibrillation energy requirements: Monophasic vs. biphasic shocks (Abstract). PACE 1995: 18: 872.
- 54 Yee R, Jones DL, Jarvis H, et al: Changes in pacing threshold and R-wave amplitude after transvenous catheter countershock. J Am Coll Cardiol 1984: 4: 543–549.
- 55 Altamura G, Bianconi L, Bianco F, et al: Transthoracic DC shock may represent a serious hazard in pacemaker dependent patients. PACE 1995; 18: 194–198.
- 56 Kudenchuk PJ, Poole JE, Dolack GL, et al: Prospective evaluation of the effect of biphasic waveform defibrillation on ventricular pacing thresholds. J Cardiovasc Electrophysiol 1997; 8: 485–495.
- 57 Kerber RE, Sarnat W: Factors influencing the success of ventricular defibrillation in man. Circulation 1979: 60: 226–230.
- 58 Weaver WD, Cobb LA, Dennis D, et al: Amplitude of ventricular fibrillation waveform and outcome after cardiac arrest. Ann Intern Med 1985: 102: 53–55.
- 59 Echt DS, Barbey JT, Black JN: Influence of ventricular defibrillation duration on defibrillation energy in dogs using bidirectional pulse discharges. PACE 1988: 11: 1315–1323.
- 60 Jones JL, Swartz JF, Jones RE, et al: Increasing fibrillation duration enhances relative asymmetrical biphasic versus monophasic defibrillator waveform efficacy. Circ Res 1990; 67: 376–384.
- 61
Walcott GP,
Melnick SB,
Chapman FW, et al: Comparison of monophasic and biphasic waveforms for external defibrillation in an animal model of cardiac arrest and resuscitation (Abstract).
J Am Coll Cardiol
1995: 405A.
10.1016/0735-1097(95)93140-8 Google Scholar
- 62 Bardy GH, Gliner BE, White RD: Comparison of human defibrillation efficacy rates in short-duration and long-duration ventricular fibrillation using monophasic and biphasic transthoracic shocks (Abstract). Circulation 1997: (In press).
- 63 McCormack AP, Damon SK, Eisenberg MS: Disagreeable physical characteristics affecting bystander CPR, Ann Emerg Med 1989; 18: 283–285.
- 64 Ritter G, Wolfe RA, Goldstein S, et al: The effect of bystander CPR on survival of out-of-hospital cardiac arrest victims. Am Heart J 1985; 110: 932–937.