Resuscitation 59 (2003) 181
/188

www.elsevier.com/locate/resuscitation

VF recurrence: characteristics and patient outcome in out-of-hospital

cardiac arrest
Anouk P. van Alem a,*, Jelle Post a, Rudolph W. Koster b
a
Department of Cardiology, Academic Medical Centre, room B2-239, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
b
Department of Cardiology, Academic Medical Centre, room B2-238, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands

Received 11 February 2003; received in revised form 2 May 2003; accepted 9 May 2003

Abstract

Background: Refibrillation after successful defibrillation in out-of-hospital cardiac arrest is a frequent event. Little is known of
factors that predispose to the occurrence of refibrillation. The effect of recurrence of ventricular fibrillation (VF) on survival is not
known. Methods: Data of patients in out-of-hospital cardiac arrest were collected in a combined first responder and paramedic
programme in Amsterdam, the Netherlands. Continuous recorded rhythm data of 322 patients covering the entire out-of-hospital
resuscitation attempt was included in the analysis. Recurrence of VF was recorded, the patient and process characteristics were
analysed in relation to the occurrence of refibrillation. The number of refibrillations was related to survival. Results and conclusion:
Of the studied patients 79% had at least one recurrence of VF, and a median number of two times 25
/75%; one to four times). The
median time from successful first shock to VF recurrence was 45 s (25
/75%: 23
/115 s). A significant inverse relation was found
between the number of refibrillations and survival of out-of-hospital cardiac arrest. The recurrence of VF was independent of the
underlying cardiac disorder, the time to defibrillation, the defibrillation waveform and other characteristics of the patient and the
process. Anti-arrhythmics should be considered in all patients found in VF to reduce the number of recurrences.
# 2003 Elsevier Ireland Ltd. All rights reserved.

Keywords: Ventricular fibrillation; Defibrillation; Out-of-hospital CPR

Resumo

Contexto: A recorrencia da fibrilhacao ventricular (FV) na paragem cardaca extra-hospitalar, apos desfibrilhacao bem sucedida,
e um acontecimento frequente. Os factores predisponentes ao seu aparecimento sao pouco conhecidos. As consequencias da
recorrencia da FV na sobrevida ainda nao e conhecida. Metodos: Foram analisados dados de doentes em paragem cardaca
ocorrida fora do hospital a partir de um projecto de first responder e paramedicos, em Amesterdao, na Holanda. O estudo
analtico incluiu os registos electrocardiograficos contnuos de 322 doentes, cuja reanimacao ocorreu fora do hospital. Registaram-
se as situacoes de recorrencia de FV, foram analisados os processos e as caractersticas dos doentes em relacao a` recorrencia da FV.
Esta recorrencia foi relacionada com a sobrevida. Resultados e conclusao: Dentro dos doentes estudados a recorrencia da FV
ocorreu uma vez em cerca de 79% casos e em media duas vezes em 25-75% casos. O tempo medio entre o primeiro choque e a
recorrencia de FV foi de 45 s (25-75%: 23-115 s). Foi verificada uma relacao inversa entre o n8 de refibrilhacoes e a sobrevida da
PCR fora do hospital. A recorrencia da FV foi independente da doenca cardaca de base, do tempo de desfibrilhacao, da curva de
desfibrilhacao e de outras caractersticas do doente e do processo. Os antiarrtmicos deverao ser considerados em todos os doentes
encontrados em FV, para reduzir o n8 de recorrencias.
# 2003 Elsevier Ireland Ltd. All rights reserved.

Palavras chave: Fibrilhacao ventricular; Desfibrilhacao reanimacao fora do hospital

* Corresponding author. Tel.: /31-20-566-7644; fax: /31-20-566-6809.

E-mail address: a.p.vanalem@amc.uva.nl (A.P. van Alem).

0300-9572/03/$ - see front matter # 2003 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/S0300-9572(03)00208-9
182 A.P. van Alem et al. / Resuscitation 59 (2003) 181
/188

Resumen

Antecedentes : La refibrilacion despues de una desfibrilacion exitosa en paro cardaco extrahospitalario es un evento frecuente. No
se conoce el efecto de la recurrencia de la fibrilacion ventricular (VF) sobre la sobrevida. Metodos : Se recogieron los datos de los
pacientes de paro cardaco extrahospitalario en un programa de respuesta combinada de paramedicos y primeros respondedores en
A msterdam, en los pases bajos. Se incluyeron en el analisis los registros continuos de ritmo de 322 pacientes, cubriendo todo el
intento de reanimacion extrahospitalaria. Se registro la recurrencia de la VF, se analizaron las caractersticas del paciente y del
procedimiento en relacion con la ocurrencia de la refibrilacion. El numero de refibrilaciones se relaciono con sobrevida. Resultados y
conclusiones : El 79% de los pacientes estudiados presentaron al menos una recurrencia de VF, con una mediana de dos veces 25-
75%, una a cuatro veces).La mediana de tiempo desde la primera descarga desfibriladora a la recurrencia de VF fue de 45 s (25-75%:
23-115 s). Se encontro una relacion inversa significativa entre el numero de refibrilaciones y la sobrevida al paro cardaco
extrahospitalario. La recurrencia de la VF fue independiente de la alteracion cardaca subyacente, tiempo hasta la desfibrilacion,
forma de onda de la descarga y de otras caractersticas del paciente y del procedimiento. Deben considerarse los antiarrtmicos en
todos los pacientes encontrados en VF para reducir el numero de recurrencias.
# 2003 Elsevier Ireland Ltd. All rights reserved.

Palabras clave: Fibrilacion ventricular; Desfibrilacion; Reanimacion cardiopulmonar (RCP) extrahospitalaria

1. Introduction 2.2. EMS

Refibrillation after successful defibrillation in out-of-
hospital cardiac arrest is a frequent event but its cause,
consequence and management have not been clarified
[1
/3]. Recently in an observational study of out-of-
hospital cardiac arrest the occurrence and frequency of
refibrillation has not been found to affect survival [2].
The effect of the waveform of defibrillation on the
occurrence of refibrillation is unknown.
This observational study examines the characteristics
of VF recurrence in out-of-hospital cardiac arrest
patients, patient characteristics and process character-
istics on VF recurrence, and the relation between VF
recurrence and survival of out-of-hospital cardiac arrest.
Moreover, this study describes the recognition of
refibrillation by the automated external defibrillator
(AED) and paramedics using manual defibrillators.
2. Material and methods
2.1. Study design
The EMS consisted of police and fire fighter first
responders, equipped with an AED and ambulances
equipped with a manual defibrillator and manned with a
team qualified to perform advanced cardiopulmonary
life support (ACLS). The first responders and ambu-
lances were equipped with both biphasic (biphasic
truncated exponential) waveform and monophasic
(monophasic damped sine) waveform defibrillators
(LIFEPAK 500 and LIFEPAK 12 (Medtronic Physio-
Control, Redmond, WA, USA), respectively). When the
first responders arrived first at the scene they used the
AED. The AED was programmed to analyse the rhythm
60 s after one or more shocks and 180 s after the initial
analysis indicated a non-shockable rhythm or when, in a
subsequent analysis, no shock was advised. When the
ambulance arrived, the paramedics took over the
resuscitation and used their own manual device. The
energy protocol for all defibrillators was 200, 200 and
360 J thereafter as needed for defibrillation.
In the beginning of the study the first choice of anti-
arrhythmic treatment in persistent VF was lidocaine.
During the study the new guidelines were introduced
and amiodarone was used. No standard protocol existed
for recurrent VF.

Between January 2000 and June 2002 data of all
patients in cardiac arrest, identified by the emergency
medical system (EMS) dispatch centre, were collected
prospectively. For the purpose of this analysis, patients
with VF as initial rhythm in whom resuscitation was
attempted were included. Patients below the age of 18
years were excluded.
The study area included the city of Amsterdam and
urban and rural surrounding areas, including 1.6 million
inhabitants and covering 885 sq. km.
2.3. Data collection
Data collection took place on scene by dedicated data
collectors. Data were obtained on the circumstances of
the arrest, the complaints of the patient prior to
collapse, the estimated time of collapse, witnesses,
bystander cardiopulmonary resuscitation, sequence of
events, and relevant time points and time intervals, by
directly interviewing all persons involved. The contin-
uous rhythm data from the AEDs and manual defi-
 A.P. van Alem et al. / Resuscitation 59 (2003) 181
/188 183

brillators were downloaded into a laptop computer at statistics were performed in SPSS 10.0 for the Apple
the scene. Deviations of internal clocks were corrected Macintosh.
by comparison with radio-controlled wristwatches. Date
of death or discharge was obtained from hospital
records. Medical history was obtained from the charts 3. Results
of the patient admitted to the ICU.

2.4. Rhythm and data analysis 3.1. Inclusion

The rhythm data extended from connection of the
electrodes to the arrival at the hospital. The rhythm data
was analysed independently by a researcher and a
physician, both experienced in rhythm analysis. If
necessary, agreement was sought. All rhythm analysis
was constrained to the first eight shocks. Rhythms were
categorised as VF (a disorganised rhythm, with a
median amplitude of
/100 mV), asystole ( B/100 mV)
or organised rhythm (one or more QRS complexes).
Shock success was defined as the termination of VF at 5
s after the shock. Persistent VF was defined as VF at 5 s
after the shock. Refibrillation was defined as the
recurrence of VF after a successful shock. The rhythm
before each shock, the time of each shock delivery,
rhythm at 5 s after each shock, the occurrence of VF
recurrence, the rhythm before VF recurrence and the
time of VF recurrence were recorded.
Return of spontaneous circulation (ROSC) was
defined as the return of palpable pulse for at least
15 s. Patients were classified as having a history of
ischaemic heart disease when their medical history
included angina pectoris, myocardial infarction, coron-
ary bypass surgery or angioplasty. Based on complaints
prior to the collapse and the ECG or laboratory findings
during admission, patients were classified as having
signs of acute ischaemia prior to collapse. This could not
be determined in patients in whom the complaints prior
to the collapse were unknown and who died before
hospital admission.
In the study-period 682 cardiac arrests were directly
identified by the EMS dispatch centre. VF was the initial
rhythm of 380 patients (56%). Of these, 322 patients
could be included in the analysis (Fig. 1). The median
duration of the continuously recorded rhythm data was
35 min (25
/75%; 27
/42 min).
3.2. VF recurrence
VF recurrence occurred at least once in 79% of the
patients. The characteristics of the VF recurrence are
shown in Table 1. In general, the incidence of subse-
quent recurrence after a successful shock was 69% (810/
1170). Fig. 2 shows in a cumulative graph the time
interval from the successful first shock to VF recurrence.
The patient and process characteristics and outcome,
stratified for VF recurrence, are shown in Table 2. None
of the variables was significantly different in the group
with or without VF recurrence except the time to ROSC,
which was of significantly longer duration in patients
with at least one VF recurrence.
The percentage of VF recurrence was 78% after the
successful first shock by first responders and 75% after
the successful first shock by the paramedics (ns).

2.5. Ethics

Medical ethics committees from participating hospi-

tals and EMS approved the study. Authorisation for
study of patient data was obtained from patients or
family members post resuscitation, and all consented to
provide access to their medical records.

2.6. Statistical methods

Time intervals are expressed in medians and 25
/75%

percentiles. Significance was tested by calculating the
Chi-square statistic for proportions and the Mann
/
Whitney U -test for continuous variables. Significance
was accepted when a two-sided P -value was B/0.05 or
the confidence interval did not include unity. Trends
were tested with the Chi square test for trends. All Fig. 1. Flowchart showing the patients in and excluded in the analysis.
184 A.P. van Alem et al. / Resuscitation 59 (2003) 181
/188
Table 1
Descriptive of VF recurrence
Description of VF recurrencea
Total amount of shocks for VF
Total amount of successful shocks
Total amount of VF recurrences
Termination of VF with first shock
VF recurrence after successful first shock
Patient with a least once VF recurrence after a
successful shock
Frequency of VF recurrence per patient, median
(25
/75%)
Time to VF recurrence after successful first shockb 45 (23
/115)
Time to 2nd
/8th VF recurrence after a successful shock 52 (22
/122)
Rhythm before VF recurrence
Asystole
Organised rhythm
a
All analyses concern the first eight shocks.
b
All time intervals are in seconds, median (25
/75%).
3.3. Waveform
The biphasic waveform defibrillator had a higher
success percentage in terminating VF with a single
shock: 91% for a biphasic shock and 75% for a
monophasic shock, P /0.001. The rate of refibrillation
was 79% after a successful monophasic shock and 74%
after a successful biphasic shock (ns). The median time
interval from successful shock to refibrillation was 49 s
(25
/75%: 27
/119 s) after a monophasic shock and 36 s
(25
/75%: 17
/77 s) after a biphasic shock (ns).
Fig. 2. Cumulative graph showing the time interval from the successful first shock to the recurrence of VF, n/197. The median time was 45 s (25
/
75%: 23
/115).
3.4. VF recurrence and survival
n/322
Fig. 3 shows the relation between the number of VF
recurrences during the resuscitation attempt and survi-
1453 val to hospital discharge. There is a trend to decreased
1170
survival with increasing recurrence of VF. The linear
810
257/322 association of this trend is significant (P /0.005).
(80%)
197/257
(77%)
254/322 3.5. Recognition of VF recurrence
(79%)
2 (1
/4) Time to delivery of the second shock for recurrent VF
is shown in Fig. 4. This cumulative curve shows that the
median time from recurrence to next shock when using
an AED was a median 75 s (25
/75%: 58
/87 s). When a
94 (48%) manual defibrillator, operated by the paramedics was
103 (52%) used the time from VF recurrence to consecutive shock
was a median of 43 s (25
/75%: 22
/110 s).
4. Discussion
Time to first defibrillation has been established as the
most critical intervention for survival of cardiac arrest
[4,5]. Survival also depends on many other patient and
process characteristics and on the further treatment.
This study found the number of refibrillations to be
another factor determining survival of out-of-hospital
cardiac arrest. In this study the recurrence of VF was
independent of the underlying cardiac disorder, the time
to defibrillation, the defibrillation waveform and other
characteristics of the patient and the process.
 A.P. van Alem et al. / Resuscitation 59 (2003) 181
/188 185

Table 2
Univariate analysis of occurrence of VF recurrence after a successful shock

No VF recurrencea, n /68 ]/One time VF recurrence, n /254 P -value

Age, years9/S.D. 669/13 659/13 0.6

Gender
Female 22% (15) 17% (43) 0.3
Male 78% (53) 83% (211) 0.3
Weight, kg9/S.D. 829/15 849/15 0.4
History of ischaemiab 65% (24/37) 74% (125/168) 0.3
Acute ischemiac 47% (27/58) 57% (116/204) 0.2
Witnessed arrest 91% (62) 94% (240) 0.4
Bystander CPR 59% (40) 52% (131) 0.2
Time to CPRd 240 (60
/433) 240 (60
/540) 0.9
Time to first shockd 658 (550
/759) 672 (546
/900) 0.5
Time to ACLSd 810 (658
/975) 840 (660
/1020) 0.2
ROSC 62% (42) 66% (168) 0.5
Shocks to ROSC, median (25
/75%) 1 (1
/1) 5 (2
/7) B/0.001
Time to first ROSCd 870 (648
/1185) 1350 (931
/1881) B/0.001
Admission 54% (37) 66% (168) 0.5
Survival to hospital discharge 24% (16) 20% (50) 0.5

CPR denotes cardiopulmonary resuscitation, ACLS denotes advanced cardiopulmonary life support, and ROSC denotes return of spontaneous
circulation.
a
All analyses concern first eight shocks.
b
Patients history was only registered for the patients admitted to a hospital.
c
In these patient there were signs of acute ischaemia based on complaints prior to collapse, on ECG or laboratory findings. In 60 patients there
was not enough information available.
d
Time intervals are measured from the moment of the collapse. The moment of collapse could only be estimated in patients with a witnessed
cardiac arrest. Time intervals are in seconds, median (25
/75%).

shock refractory VF [8,9]. We defined persistent VF as

VF present at 5 s after the shock and a successful shock
as termination of VF at 5 s. This definition of shock
success is recommended by others [1,10], and can be
judged with confidence when baseline drift and artefacts
after a shock have disappeared but may occasionally
misclassify recurrence as persistence of VF. Our ob-
served rate of VF recurrence after a successful shock
(69%) is comparable with the study of Weaver et al. who
observed 68% refibrillation after a successful shock [11].
Our observed percentage of patients with VF recurrence
(79%) was higher than in the study of White et al. who
observed VF recurrence in 64% of patients [2].

4.2. Effect of recurrence on survival

Fig. 3. Bar graph illustrates the frequency of VF recurrence in relation
to survival to hospital discharge. The linear association is significant
(P/0.005). The numbers in the base of the bars represent the number
of patients included in the group.
4.1. Occurrence of refibrillation
It is important to make a distinction between persis-
tent VF and VF recurrence, since the mechanisms of
failure to defibrillate and refibrillation are considered to
be different [1,6,7]. This distinction is not simply made
during resuscitation but may be relevant for adminis-
tration and understanding the mechanism of action of
anti-arrhythmics, such as amiodarone, indicated for
We found an inverse relation between the number of
VF recurrences and survival. Obviously, when recurrent
VF occurs, more shocks were needed to achieve ROSC
and the time to ROSC was significantly longer. Longer
or repeated circulatory arrest could explain this inverse
relation. Another explanation could be the damaging
effect on the myocardium when more defibrillation
shocks and higher cumulative energy was needed. It is
also possible that recurrence is promoted by more
extensive myocardial ischaemia with more extensive
pump failure and failure to achieve ROSC.
Weaver described an inverse relation between the
number of shocks a patient received and the chance of
186 A.P. van Alem et al. / Resuscitation 59 (2003) 181
/188

Fig. 4. Cumulative graph showing the time interval in seconds from VF recurrence to the subsequent shock from the AED operated by first
responders and the manual defibrillator operated by the paramedics. The paramedics rapidly shocked over 60% of the patients with refibrillation
within 1 min, but after 3 min they only had shocked 85% of the patients. In contrast, the AED only shocked 30% of the recurrences in 1 min but after
4 min all patient with VF recurrence were shocked.

survival, but they did not make the distinction between
shocks delivered for persistent VF and recurrent VF.
White et al. [2] in a recent study, could not demonstrate
a relation between the occurrence and frequency of
refibrillation and survival. In their analysis, with a
limited number of patients, only the occurrence and
frequency of refibrillation during first responder defi-
brillation were included while it is to be expected that
many recurrences took place during subsequent para-
medic care.
4.3. Treatment of refibrillation
First responders with AEDs and paramedics with
manual defibrillators acted differently when defibrilla-
tion occurred. The paramedics recognised VF recur-
rence quickly in most cases and delivered a second shock
rapidly (over 60% of recurrences were shocked within 1
min) but after 5 min they only had shocked about 85%
of the recurrences. It is possible that this delay was
caused by other activities by paramedics, such as ACLS
measures including intubation and administering med-
ication, competing for their attention and not giving
priority to defibrillation. The AED shocked only 30% of
the recurrences within 1 min but after 3.5 min all
patients with recurrence received a shock. The AED
was programmed to perform an automated rhythm
analysis 60 s after the first shock. When no VF was
present at the time of this analysis the next rhythm
analysis was performed 3 min later. So all recurrences
occurring in the 1st min after the shock were recognised
at 1 min and defibrillated 20 s later. When the time to
VF recurrence was more then 1 min this was recognised
in the second analysis, 3 min later.
4.4. Waveform
The biphasic waveform is superior to the monophasic
waveform in efficacy and safety in termination of VF
[12
/17]. In animal laboratory studies, the depression of
myocardial function was less after biphasic waveform
defibrillation than after monophasic waveform defibril-
lation. In agreement with these previous studies we
observed a significant better defibrillation rate with
biphasic defibrillators, but no relation was found
between the defibrillation waveform after the successful
first shock and the occurrence of refibrillation or time to
refibrillation, consistent with the study of Gliner et al.
[1].
4.5. Ischaemia
In animal and in vitro studies [7,18,19], VF recurrence
is recorded as partly attributable to ischaemia. In several
clinical studies it is assumed that refibrillation is
attributable to the underlying disease [1,2], but in our
study we could not demonstrate a clear difference in the
occurrence of VF recurrence in patients with signs of
acute ischaemia or with a history of ischaemic heart
disease. This can be explained by the fact that VF in
itself leads to myocardial ischaemia and, therefore,
could have obscured the distinction between ischaemia
as cause or as subsequence.
 A.P. van Alem et al. / Resuscitation 59 (2003) 181
/188
4.6. How to respond to recurrent VF?
We observed a relation between recurrence of VF and
survival, but our study was not designed to prove a
causal relation. However, with the observed high rate of
VF recurrence (79%) aggressive anti-arrhythmic treat-
ment after defibrillation should be considered. The
distinction between persistence (for which amiodarone
is indicated [8,9]) and immediate recurrence (for which
lidocaine is probably effective [20,21]) is difficult. But
for reasons of simplicity amiodarone may be the first
choice, to be given immediately after the first VF
episode has terminated. Ideally such a new protocol
should be tested in randomised studies.
4.7. Limitations
The analysis was confined to the 322 patients with
complete rhythm data of VF cardiac arrests. In 43
patients rhythm data was missing, caused by practical
factors (i.e. lost files, no continuous data, transmission
errors) but there was no indication that selection bias
had occurred.
The analysis of the waveform of defibrillation was
confined to the first shock, because of the mixture of
biphasic and monophasic waveform defibrillators (both
AEDs and manual defibrillators), which could be used
in an individual patient. Outcomes of the two groups
reported beyond the first shock would reflect this mixed
monophasic and biphasic therapy.
5. Conclusions
Refibrillation occurs in the majority of cases during
out-of-hospital cardiac arrest and is negatively asso-
ciated with survival. Refibrillation was neither asso-
ciated with the type of shock waveform nor with patient-
or process characteristics.
Anti-arrhythmics should be considered after defibril-
lation in all patients found in VF and not only for
persistent VF.
Acknowledgements
This study was supported by a grant from The
Netherlands Heart Foundation (grant 98.179) and an
unrestricted grant from Medtronic Physio-Control,
Redmond, WA, USA.
187
References
[1] Gliner BE, White RD. Electrocardiographic evaluation of defi-
brillation shocks delivered to out-of-hospital sudden cardiac
arrest patients. Resuscitation 1999;41:133
/44.
[2] White RD, Russell JK. Refibrillation, resuscitation and survival
in out-of-hospital sudden cardiac arrest victims treated with
biphasic automated external defibrillators. Resuscitation
2002;55:17
/23.
[3] Blouin D, Topping C, Moore S, Stiell I, Afilalo M. Out-of-
hospital defibrillation with automated external defibrillators:
postshock analysis should be delayed. Ann Emerg Med
2001;38(3):256
/61.
[4] Eisenberg M, Bergner L, Hallstrom A. Out-of-hospital cardiac
arrest: improved survival with paramedic services. Lancet
1980;1:812
/5.
[5] Waalewijn RA, de Vos R, Koster RW. Out-of-hospital cardiac
arrests in Amsterdam and its surrounding areas: results from the
Amsterdam resuscitation study (ARREST) in Utstein style.
Resuscitation 1998;38:157
/67.
[6] Li H, Jones D, Yee R, Klein G. Defibrillation shocks produce
different effects on Purkinje fibers and ventricular muscle:
implications for successful defibrillation, refibrillation and post-
shock arrhythmia. J Am Coll Cardiol 1993;22:607
/14.
[7] Qin H, Walcott GP, Killingsworth CR, Rollins DL, Smith WM,
Ideker RE. Impact of myocardial ischemia and reperfusion on
ventricular defibrillation patterns, energy requirements, and
detection of recovery. Circulation 2002;105:2537
/42.
[8] Kudenchuk PJ, Cobb LA, Copass MK, et al. Amiodarone for
resuscitation after out-of-hospital cardiac arrest due to ventricular
fibrillation. New Engl J Med 1999;341:871
/8.
[9] Dorian P, Cass D, Schwartz B, Cooper R, Gelaznikas R, Barr A.
Amiodarone as compared with lidocaine for shock-resistant
ventricular fibrillation. New Engl J Med 2002;346:884
/90.
[10] Poole J, White R, Kanz K, et al. Low-energy impedance-
compensating biphasic waveforms terminate ventricular
fibrillation at high rates in victims of out-of-hospital cardiac
arrest. LIFE Investigators. J Cardiovasc Electrophysiol
1997;8:1373
/85.
[11] Weaver W, Cobb L, Copass M, Hallstrom A. Ventricular
defibrillation */a comparative trial using 175-J and 320-J shocks.
New Engl J Med 1982;307:1101
/6.
[12] Gliner BE, Lyster TE, Dillion SM, Bardy GH. Transthoracic
defibrillation of swine with monophasic and biphasic waveforms.
Circulation 1995;92:1634
/43.
[13] Bardy GH, Ivey TD, Allen MD, Johnson G, Mehra R, Greene
HL. A prospective randomized evaluation of biphasic versus
monophasic waveform pulses on defibrillation efficacy in humans.
J Am Coll Cardiol 1989;14:728
/33.
[14] Bardy GH, Marchlinski FE, Sharma AD, et al. Multicenter
comparison of truncated biphasic shocks and standard damped
sine wave monophasic shocks for transthoracic ventricular
defibrillation. Circulation 1996;94:2507
/14.
[15] Tang W, Weil MH, Sun S, et al. The effects of biphasic and
conventional monophasic defibrillation on postresuscitation myo-
cardial function. J Am Coll Cardiol 1999;34:815
/22.
[16] Tang W, Weil MH, Sun S, et al. A comparison of biphasic and
monophasic waveform defibrillation after prolonged ventricular
fibrillation. Chest 2001;120:948
/54.
[17] Higgins SL, Herre JM, Epstein AE, et al. A comparison of
biphasic and monophasic shocks for external defibrillation.
Prehosp Emerg Care 2000;4:305
/13.
[18] Axelrod P, Verrier R, Lown B. Vulnerability to ventricular
fibrillation during acute coronary arterial occlusion and release.
Am J Cardiol 1975;36:776
/82.
188 A.P. van Alem et al. / Resuscitation 59 (2003) 181
/188

[19] Zaugg CE, Wu ST, Barbosa V, et al. Ventricular fibrillation-
induced intracellular Ca2 overload causes failed electrical defi-
brillation and post-shock reinitiation of fibrillation. J Mol Cell
Cardiol 1998;30:2183
/92.
[20] Lie KI, Wellens HJ, van Capelle FJ, Durrer D. Lidocaine in the
prevention of primary ventricular fibrillation. A double-blind,
randomized study of 212 consecutive patients. New Engl J Med
1974;291:1324
/6.
[21] Koster RW, Dunning AJ. Intramuscular lidocaine for prevention
of lethal arrhythmias in the prehospitalization phase of acute
myocardial infarction. New Engl J Med 1985;313:1105
/10.