Survival with good neurological outcome – Modified Rankin Score ≤2.Primary outcome: Survival to hospital discharge.The 1st 3 defibrillation attempts occurred with the pads in standard anterior–lateral position.Resuscitation followed standard AHA guidelines.136 patients assigned to standard defibrillation.All defibrillation attempts occurred in standard anterior–lateral position.16 patients received standard defibrillation. Single operator pressed shock button on anterior-lateral followed immediately (<1sec) by anterior-posterior defibrillation 2nd defibrillator attached in AP position.All subsequent shocks performed using DSED.Double Sequential External Defibrillation (DSED).31 patients received standard defibrillation.113 patients received VC defibrillation.144 patients assigned to VC defibrillation.All subsequent defibrillations performed with Anterior-Posterior pad placement.Anti-arrhythmic dose administered: 81% vs.Pre-hospital intubation: 38% vs 50% vs 42%.Median time from initial call to 1st shock: 10 vs.Bystander witnessed cardiac arrest: 60% vs.Comparing baseline characteristics of standard vs.Patients initially treated by non-participating fire or EMS agencies.Traumatic cardiac arrest, drowning, hypothermia, hanging, or suspected drug overdose.Defined as initial presenting rhythm of VF/VT that was still present after 3 consecutive rhythm checks and standard defibrillations.Out-of-hospital-VF arrest of presumed cardiac cause.Study paused April – September 2020 due to COVID pandemic.Pilot trial: March 2018 – September 2019 (n=152) – results also included in this analysis.6 paramedic services, Ontario, Canada, included ~4000 paramedics.Outcomes assessed until hospital discharge.Treatment received analysis also reported.Intention to treat analysis used for primary analysis.Trial terminated early by data and safety monitoring board due to paramedic staffing shortages affecting timely delivery of assigned defibrillation strategy.Power calculation: 930 patients would provide 80% power to detect an 8% absolute improvement in the primary outcome from a baseline of 12%, with a false positive rate of 5%.Random treatment sequences were computer-generated.Randomisation performed at level of paramedic service.Each cluster crossed over every 6 months.3 group cluster randomisation with cross-over.These strategies may enable a greater or different part of the ventricle to be defibrillated Case series have suggested a potential benefit with the use of Double Sequential External Defibrillation or Vector-change defibrillation to treat patients with refractory VF.However the ALPS study reported no significant improvement in survival to discharge or good neurological outcome with the use of either amiodarone or lignocaine
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