Survival in relation to number of defibrillation attempts in out-of-hospital cardiac arrest.

Introduction/aim: Out-of-hospital cardiac arrest (OHCA) with shockable pulseless ventricular tachycardia or fibrillation not responding to defibrillation is a medical challenge. Novel treatment strategies have emerged for so-called refractory ventricular fibrillation not responding to three or more defibrillations but the evidence for optimal timing for these strategies is sparse. The primary aim of this observational study was to assess survival in relation to total numbers of defibrillations in OHCA.

Methods: This is a registry-based retrospective cohort study based on data reported by the emergency medical services to the Swedish Registry of Cardiopulmonary Resuscitation and the National Patient Registry. All OHCA patients aged 18 years or older with an initial shockable rhythm in Sweden from January 1, 2010 and December 31, 2020 were included. Exposure was total number of defibrillations, and primary outcome was survival to 30 days. Logistic regression was used to adjust for patient and resuscitation characteristics.

Results: Over the study period a total of 10,549 patients were included. Among them, 3,006 (28.5%) received only one shock, 1,665 (15.8%) two shocks, 1,336 (12.9%) three shocks, 1,064 (10.1%) four shocks and 3,478 (33.0%) five or more shocks. In the adjusted analysis an exponential decrease in the 30-day survival was found for each additional defibrillation. For patients receiving one, two, three and four defibrillations, the adjusted probability of survival was 42%, 36%, 30% and 25% respectively.

Conclusions: In this registry-based retrospective cohort study, additional defibrillations were associated with a lower survival. This association persisted after adjustments for patient and resuscitation characteristics.