3 shocks, now what?

Early defibrillation is one of the most important predictors of survival after out-of-hospital cardiac arrest (OHCA).1 Accordingly, many strategies to provide early defibrillation have been implemented across communities including deployment of automated external defibrillators (AEDs) to facilitate defibrillation by bystanders or alerted volunteer responders, dispatch of professional first-responders (firefighters or police) or even drone delivered AEDs. However, despite these efforts, many patients require several defibrillation attempts to terminate ventricular fibrillation (VF).2 The phenomenon referred to as ‘refractory VF’ is typically defined as patients who have received at least three consecutive defibrillation attempts without achieving an organized rhythm, though the exact definition in guidelines is unclear.3 Furthermore, sparse evidence is available to guide treatment for these patients and current guidelines only state that after 3 shocks, alternative treatments such as intravenous drugs, transport to percutaneous coronary intervention or extracorporeal membrane oxygenation may be considere