Energy Levels for Biphasic Defibrillation

An Advisory Statement from the

Australian Resuscitation Council

Ian Jacobs; James Tibballs; Peter Morley; Jennifer Dennett;

Jeff Wassertheil; Vic Callanan; John Hall:
ARC executive committee on behalf of the Australian Resuscitation Council*

Defibrillators which deliver biphasic waveforms are rapidly replacing defibrillators

which deliver monophasic waveforms. Lower energy biphasic shocks cause less
myocardial injury and subsequent post-resuscitation myocardial dysfunction thus
potential improving the likelihood of survival.(1-4) Recommendations of the
International Liaison Committee on Resuscitation (ILCOR) state that biphasic
energies less than or equal to 200 joules are as efficacious as escalating higher energy
monophasic shocks.(5) However, few clinical trials in adults and none in children
indicate the optimal dose of biphasic shock which would achieve maximum
defibrillation rate and minimum myocardial injury. Faced with the declining
availability of monophasic defibrillators and paucity of data in respect to biphasic
energy levels, the Australian Resuscitation Council (ARC) makes the following
recommendations.

Children
Although monophasic shocks have historically been well accepted for paediatric
defibrillation, the optimal dose has never been established. Instead, therapy has been
guided by a single study in which the recommended doses of monophasic shocks of 2
or 4 J/kg were studied. In 71 defibrillation attempts in 27 children, 91% of shocks
were successful within 10 watt-seconds (Joules) above or below an energy dose of 2
J/kg.(6) In every case, fibrillation was ultimately terminated by a shock of 4 J/kg or
less. To date, no systematic study of the efficacy of biphasic shock in children has
been published.

In the absence of any data it is difficult to specify the optimum dose of paediatric
biphasic shock. However, a randomised trial in adults using either 150J biphasic
shock or 200 to 360J monophasic shock delivered from automated external
defibrillators (AEDs), revealed that the lower dose of biphasic shock defibrillated at
higher rates than the higher monophasic shocks.(7) By extrapolation from this study,
it is suggested that the dose of biphasic shock for children should be 1 to 2 J/kg, ie
approximately half the monophasic dose, but that higher doses (up to 4J/kg) are not
likely to be harmful and are more efficacious than equivalent monophasic shocks.
This is supported by studies in ‘child’ and ‘infant’ animal models in which biphasic
shocks were more efficacious than the same dose of monophasic shocks(8) and may
be delivered in a fixed dose of 50J by an AED.(9)

The use of automated external defibrillators (AEDs) for out-of-hospital use are soon
to be recommended by the International Liaison Committee on Resuscitation

June 2003
(ILCOR) for children above one year of age provided that a ‘child’ dose is delivered
and that any device has been tested to ensure differentiation of ‘shockable’ from ‘non-
shockable’ rhythms.(10)

Recommendation
• Biphasic energy levels of 1-2 joules per kg should be used for defibrillating
ventricular fibrillation and pulseless ventricular tachycardia occurring in
children.

Adults
Monophasic energy levels of 200, 200 and 360 joules have been well accepted in
clinical practice and are currently recommended by the ARC and ILCOR when using
monophasic defibrillators.(5,11) As biphasic defibrillators produced by different
manufacturers recommend slightly different energy levels specific for their device,
increasing confusion amongst practitioners has resulted as to the appropriate energy
levels to be used.

To date there have been only two publications from one randomised controlled trial in
humans comparing monophasic and biphasic energy levels. (7,12) In this study
ventricular fibrillation occurring outside of hospital was treated using an AED. It
demonstrated that 150J biphasic shocks achieved higher rates of defibrillation and
return of spontaneous circulation than high energy (200J / 200J / 360J) escalating
monophasic shocks. No differences were observed in the proportion of patients
discharged from hospital.

Notwithstanding the limitations of this study (namely only out of hospital arrests
included, non-blinded and pseudo randomisation), best clinical evidence to date
would support the use of non-escalating 150J biphasic shocks in these patients. As
clinical superiority of one particular biphasic waveform over another has yet to be
demonstrated, it is appropriate to recommend a single energy level in order to achieve
a consistent approach, particularly when using manual biphasic defibrillators. Energy
levels for AEDs have been pre-set by the manufacturer, and as such do not require an
energy level to be set by the user.

Recommendation
• Biphasic energy levels of 150J should be used for defibrillating ventricular
fibrillation and pulseless ventricular tachycardia in adults.

June 2003
References

1. Jones JL, Jones RE. Decreased defibrillator-induced dysfunction with biphasic rectangular
waveforms. Am J Physiol 1984;247(pt 2)(2):792-796.
2. Tang W, Weil MH, Sun S, Yamaguchi H, Povoas HP, Pernat AM, et al. The effects of
biphasic and conventional monophasic defibrillation on postresuscitation myocardial function. Journal
of the American College of Cardiology. 1999;34(3):815-22.
3. Reddy RK, Gleva MJ, Gliner BE, Dolack GL, Kudenchuk PJ, Poole JE, et al. Biphasic
transthoracic defibrillation causes fewer ECG ST-segment changes after shock. Ann Emerg Med
1997;30(2):127-134.
4. Tang W, Weil MH, Sun S. Low-energy biphasic waveform defibrillation reduces the severity
of postresuscitation myocardial dysfunction. Crit Care Med 2000;28(suppl)(11):N222-N224.
5. American Heart Association in collaboration with International Liaison Committee on
Resuscitation. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care, Part 6: Advanced Cardiovascular Life Support: Section 2: Defibrillation. Circulation
2000;102(suppl)(8):I90-I94.
6. Gutgesell HP, Tacker WA, Geddes LA, Davis S, Lie JT, McNamara DG. Energy dose for
ventricular defibrillation of children. Pediatrics 1976;58(6):898-901.
7. Schneider T, Martens PR, Paschen H, Kuisma M, Wolcke B, Gliner BE, et al. Multicenter,
randomized, controlled trial of 150-J biphasic shocks compared with 200- to 360-J monophasic shocks
in the resuscitation of out-of-hospital cardiac arrest victims. Optimized Response to Cardiac Arrest
(ORCA) Investigators. Circulation 2000;102(15):1780-1787.
8. Clark CB, Zhang Y, Davies LR, Karlsson G, Kerber RE. Pediatric transthoracic defibrillation:
biphasic versus monophasic waveforms in an experimental model. Resuscitation 2001;51(2):159-63.
9. Tang W, Weil MH, Jorgenson D, Klouche K, Morgan C, Yu T, et al. Fixed-energy biphasic
waveform defibrillation in a pediatric model of cardiac arrest and resuscitation. Crit Care Med
2002;30(12):2736-41.
10. Samson R, Berg R, Bingham R and members of the PALS task force. Automated external
defibrillators for children: an update. An advisory statement by the pediatric advanced life support task
force of the International Liaison Committee on Resuscitation (ILCOR). In press.
11. Australian Resuscitation Council. Electrical Therapy for Adult Advanced Life Support. In:
Council GotAR, editor. Melbourne; 2002.
12. Martens PR, Russell JK, Wolcke B, Paschen H, Kuisma M, Gliner BE, et al. Optimal
Response to Cardiac Arrest study: defibrillation waveform effects. Resuscitation 2001;49(3):233-243.

*Member Organisations of the Australian Resuscitation Council (www.resus.org.au)

Australasian College for Emergency Medicine
Australian and New Zealand College of Anaesthetists
Australian and New Zealand Intensive Care Society
Australian College of Ambulance Professionals
Australian College of Critical Care Nurses Ltd
Australian Defence Force
Australian Red Cross
Cardiac Society of Australia and New Zealand
Convention of Ambulance Authorities
National Heart Foundation of Australia
Royal Australian College of General Practitioners
Royal Australasian College of Surgeons
Royal College of Nursing, Australia
Royal Life Saving Society - Australia
St John Ambulance Australia
Surf Life Saving Australia
Royal Australasian College of Physicians (Paediatrics and Child Health Division)
State Branches of the ARC.

June 2003