Double simultaneous external defibrillation


  • In patients suffering from non-traumatic cardiac arrest who exhibit ventricular fibrillation refractory to standard defibrillation, two simultaneous shocks may be considered. This is termed double sequential external defibrillation (DSED) and has been shown to have some effect in terminating VF[1][2], though existing data on neurologic outcomes conflict. Several large EMS systems currently use DSED in their standing medical orders[3].



  • Spontaneous circulation
  • Inability to apply two sets of defibrillation pads without overlapping

Equipment Needed

  • Two monitors capable of manual defibrillation (both biphasic or both monophasic)
  • Pre-hospital or hospital provider credentialed to perform defibrillation
  • Two sets of defibrillation pads


  1. Apply second set of defibrillation pads (configurations vary). Generally pads are applied in the same configuration as the existing pads but in adjacent placement. Pads should not be applied on top of one another
  2. Charge both monitors to maximum energy level (200J for biphasic, 360J for monophasic)
  3. After ensuring providers are not in contact with the patient, charge and simultaneously activate the defibrillation/shock button on each monitor
  4. Resume chest compressions
  5. May consider esmolol bolus (0.5 mg/kg) followed by infusion (0.1 mg/kg) for subsequent DSED attempts[4] or hold epinephrine dosing for a round of CPR to limit cardiac excitation.


  • Generally none

See Also


  1. Hoch DH, et al. Double sequential external shocks for refractory ventricular fibrillation. J Am Coll Cardiol. 1994; 23(5):1141-5.
  2. Cabanas JG, et al. Double Sequential External Defibrillation in Out-of-Hospital Refractory Ventricular Fibrillation: A Report of Ten Cases. Prehosp Emerg Care. 2015; 19(1):126-130.
  3. Cortez E et al. Use of double sequential external defibrillation for refractory ventricular fibrillation during out-of-hospital cardiac arrest. Resuscitation 2016; 108:82-6.
  4. Driver BE, Debaty G, Plummer DW, et al. Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with ventricular fibrillation. Resuscitation. 2014; 85(10):1337-1341.