Episode 5 - Offload - Defibrillation & Resuscitation w/Dr. Sheldon Cheskes

Episode Show Notes: Rethinking the VF Paradigm with Dr. Sheldon Cheskes

Episode Summary

In this special "Offload" episode of the podcast, we sit down with out-of-hospital cardiac arrest (OHCA) and resuscitation expert Dr. Sheldon Cheskes. We look back at the landmark DOSE-VF trial that changed ALS protocols in Ontario, dive into the secondary analyses that emerged from the data, and tackle the heated debate between refractory and recurrent ventricular fibrillation. Dr. Cheskes also gives us a sneak peek into the future of resuscitation science, from frontloading Double Sequential External Defibrillation (DSED) to rethinking epinephrine dosing and tidal volumes.

Guest Bio Dr. Sheldon Cheskes is a Professor with the Division of Emergency Medicine at the University of Toronto and a scientist at the Li Ka Shing Knowledge Institute at St. Michael's Hospital. He serves as the Medical Director for the regions of Halton and Peel with the Sunnybrook Centre for Pre-Hospital Medicine. An international leader in CPR quality and resuscitation, he is the principal investigator of the practice-changing DOSE-VF trial.

Key Takeaways & Discussion Points

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  The DOSE-VF Trial Recap: A review of the three-arm cluster-randomized trial that compared standard defibrillation to vector change (VC) and double sequential external defibrillation (DSED) for refractory VF.

   

   

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  A Massive Jump in Survival: DSED more than doubled the rate of survival to hospital discharge (30.4%) when compared to standard AL defibrillation (13.3%).

   

   

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  The Pad Placement Debate: Research shows that anterior-posterior (AP) pad placement yields about twice the odds of ROSC compared to anterior-lateral (AL) placement, independent of the current delivered.

   

   

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  Speed Does Not Equal Efficacy: Taking an extra few seconds to correctly place pads in the AP position is highly recommended over rushing to place them in the AL position.

   

   

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  Refractory vs. Recurrent VF: Addressing the Amsterdam UMC study, Dr. Cheskes notes that whether a patient is in true refractory VF or recurrent VF, DSED still proves to be a superior clinical strategy compared to standard defibrillation.

   

   

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  Frontloading DSED: Several ongoing European trials are currently investigating the efficacy of deploying DSED much earlier in the arrest, such as after a single failed shock or as the very first shock.

   

   

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  Rethinking the 2-Minute CPR Cycle: While see-through CPR technology is advancing and could eventually replace fixed 2-minute cycles, deep compressions can still create artifacts that mimic VF, making the technology imperfect.

   

   

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  The EpiDose Trial: An upcoming trial will explore whether a 2mg maximum dose of epinephrine provides a "sweet spot" for neurologically intact survival compared to standard dosing.

   

   

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  The OptiVol Trial: Investigating optimal tidal volumes during cardiac arrest by comparing 300-400 mL against the standard 500-600 mL using advanced ventilation feedback devices.

   

   

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  The Power of Feedback: Just as CPR feedback devices revolutionized compression quality a decade ago, real-time ventilation feedback is exposing widespread hypoventilation and driving the next wave of clinical improvement.

   

  References:

• DOSE-VF trial
• Defibrillation and Refractory VF UMC Trial
• The impact of defibrillation current and pad position on return of spontaneous circulation during refractory ventricular fibrillation