Double Sequence No-no???


    Double Sequence No-no???


    You are the leader of the code team.  Your patient is in refractory VF after multiple rounds of shocks and drugs.  You’ve tried repositioning the pads into an anterior-posterior position.  Looking around, you ask for suggestions.  Someone suggests double sequence defibrillation.  After all, what’s the harm?


    Sorry to take away one of your toys, cowboys, but, as it turns out, double sequence defibrillation may not be as magical as we thought.  Most of the evidence in favor of double sequence defibrillation comes from case reports.  No studies have demonstrated improved outcomes when compared to patients who received standard defibrillation, and the technique is still “off label” according to manufacturers.


    According to a recent study in Annals (see below), double sequence defibrillation may actually cause hidden damage to the machine and cause malfunctions, putting future patients at risk.  Furthermore, the machines are apparently not tested to withstand double sequence defibrillation, so it may void the warranty.


    So, next time you want to try double sequence defibrillation, stop and think about whether or not you have exhausted all other options.  And, if you are going to do it, make sure you know how to do it correctly.  Don’t just blindly try it because it’s cool.  There may be real harm associated.



    Need to brush up on cardiac arrests?  Click here:


    Want to read more about refractory VF?  Both of these links discuss how to perform double sequence defibrillation:





    External Defibrillator Damage Associated With Attempted Synchronized Dual-Dose Cardioversion. Gerstein NS, McLean AR, Stecker EC, Schulman PM. Ann Emerg Med. 2018 Jan;71(1):109-112. doi: 10.1016/j.annemergmed.2017.04.005. Epub 2017 May 27.

    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • Cervical Artery Dissection

      Cervical artery dissection (CAD) accounts for 1-2% of all ischemic strokes but 10-25% of strokes in younger individuals.  CAD includes extracranial carotid and vertebral artery dissections.  A review of the literature suggests that there mayRead more

    • Opioid Substitution Therapy

      ED physicians need to be comfortable with the various modalities of opioid substitution therapy (OST) and their associated complications.  We are all familiar with the patient who has missed a daily dose of methadone onRead more

    • Use the HEART Score

      There are approximately 8 million ED visits annually in the United States for chest pain. 10%-20% go on to receive an acute coronary syndrome diagnosis. The goal of the ED physician is to differentiate betweenRead more

    • Permissive Hypotension

      Resist the urge to administer a large crystalloid bolus in hypotensive trauma patients. Doing so worsens coagulopathy and acidosis. This practice should be abandoned. Normotensive trauma patients need no fluid resuscitation. The practice of permissiveRead more

    • PE Risk after Induced Abortion

      It’s well known that the risk of venous thromboembolism is increased during pregnancy.  It is thought to be two-to-six times higher than the risk in non-pregnant women.  However, these risk estimates are based on pregnantRead more

    • Bag Mask Ventilation During Intubation

      A few days ago NEJM published the results of an investigation with profound implications for our specialty.  A group of intensivists and anesthesiologists conducted a multicenter, randomized trial conducted in seven ICUs to study theRead more

    • Gastric Emptying for Acute Poisonings

      At the request of department leadership, we will be revisiting methods of gastric decontamination for today’s pearl.  Two methods in particular. Ipecac-induced emesis and gastric lavage are two procedures that we read about in medicalRead more

    • Pacemakers Review pt. 3

      Today we will review complications associated w/ implanted pacemakers that you may encounter in the ED and thus ought to be familiar with. Generally, complications can be divided into two categories: early vs. late EarlyRead more