(Circulation. 2000;102:1780.)
© 2000 American Heart Association, Inc.
Clinical Investigation and Reports |
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
From Johannes Gutenberg-Universitaet (T.S., B.W.), Mainz, Germany; St Jan Hospital (P.R.M.), Brugge, Belgium; Feuerwehr Hamburg (H.P.), Hamburg, Germany; Helsinki City EMS (M.K.), Helsinki, Finland; Agilent Technologies Heartstream Operation (B.E.G., J.K.R.), Seattle, Wash; Henry Ford Hospital (W.D.W.), Detroit, Mich; University Hospital (L.B.), Antwerp, Belgium; and University of Wales College of Medicine (D.C.), Cardiff, UK.
Correspondence to Benno Wolcke, MD, Clinic of Anaesthesiology, The Johannes Gutenberg-University Medical School, Langenbeckstr 1, D-55131 Mainz, Germany. E-mail wolcke{at}mail.Uni-Mainz.de
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Abstract |
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Background—In the present study, we compared an automatic external defibrillator (AED) that delivers 150-J biphasic shocks with traditional high-energy (200- to 360-J) monophasic AEDs.
Methods and Results—AEDs were prospectively randomized according to defibrillation waveform on a daily basis in 4 emergency medical services systems. Defibrillation efficacy, survival to hospital admission and discharge, return of spontaneous circulation, and neurological status at discharge (cerebral performance category) were compared. Of 338 patients with out-of-hospital cardiac arrest, 115 had a cardiac etiology, presented with ventricular fibrillation, and were shocked with an AED. The time from the emergency call to the first shock was 8.9±3.0 (mean±SD) minutes.
Conclusions—The 150-J biphasic waveform defibrillated at higher rates, resulting in more patients who achieved a return of spontaneous circulation. Although survival rates to hospital admission and discharge did not differ, discharged patients who had been resuscitated with biphasic shocks were more likely to have good cerebral performance.
Key Words: defibrillation • resuscitation • heart arrest • heart-arrest device
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Introduction |
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Sudden cardiac arrest associated with ventricular fibrillation (VF) remains a leading cause of unexpected death in the Western world.1 2 Rapid-response programs3 4 with automatic external defibrillators (AEDs) used as part of the "chain of survival"5 have achieved marked improvements in survival rates in selected localities. The European Resuscitation Council, the American Heart Association, and the International Liaison Committee on Resuscitation have advocated the widespread dissemination of AEDs.6 7 8
The success of widespread AED lifesaving programs depends on the development of therapeutic technology suitable for mass deployment with infrequent individual use. This will require great strides in defibrillator cost, size, and unattended reliability.
Traditional monophasic defibrillators deliver high and escalating energies, from 200 to 360 J. These waveforms and energy levels place fundamental limitations on device cost, weight, and volume reduction.9
Biphasic waveforms have replaced monophasic waveforms for implantable defibrillators because of proved advantages in energy requirements, size, and weight.10 11 12 The incorporation of low-energy impedance-compensating biphasic truncated exponential (ICBTE) waveforms into external defibrillators facilitates effective and automated application of the therapy to the general patient population. The safety and efficacy of these waveforms have been demonstrated under controlled laboratory and in-hospital conditions,13 14 15 and evidence that the use of lower energies and biphasic waveforms offers further benefit by reducing postshock myocardial dysfunction is mounting.16 17 18 19 20 21 22 23
Prospective, clinical studies to date have been conducted under highly controlled in-hospital conditions. Out-of-hospital cardiac arrest victims have more varied and longer arrest times. Data from out-of-hospital studies are needed to investigate the new role of low-energy biphasic waveforms in sudden cardiac arrest.24
Observational studies on patients with out-of-hospital cardiac arrest have previously demonstrated that a 150-J ICBTE AED terminated long-duration VF at high rates.25 26 27 We now present the results of the first prospective, randomized trial that compared a 150-J ICBTE AED with traditional, energy-escalating monophasic AEDs. The objective of this multicenter trial was to assess the effectiveness of the AEDs for victims of cardiac arrest in the out-of-hospital setting.
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Methods |
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Enrollment
On approval by each local ethics committee, all patients who weighed
36 kg, who had a known or suspected cardiac arrest, and who
were attended by the emergency medical services (EMS) system during the
study period were included. All devices used in the study were
CE (European Community)–marked and commercially available in
Europe, so informed consent was not required under the circumstances of
this study. Arrests witnessed by EMS personnel were excluded because
the response time from collapse was not representative
of out-of-hospital arrest. Patients with do-not-resuscitate
instructions, patients whose arrest resulted from a noncardiac cause
such as trauma or drowning, and patients who were not treated with AEDs
were also excluded.
Protocol
Patients were prospectively enrolled in 4 EMS systems
(Table 1
). First responders,
whether first or second tier, used either 150-J ICBTE AEDs or 200- to
360-J monophasic AEDs on victims of sudden collapse when defibrillator
application was indicated. All consecutive incidents were included in
the study in each area until the study was completed. Shocks were
delivered with self-adhesive defibrillation pads recommended by the
respective equipment manufacturers. Physicians also carried manual
defibrillators as backup and to address other electrotherapy and
monitoring needs (eg, synchronized cardioversion, external
pacing).
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If the responder suspected that the patient was in cardiac arrest, then the randomly preselected AED was immediately turned on. The patient was then positioned for cardiopulmonary resuscitation (CPR) and AED use. CPR was typically performed while the defibrillation pads were being attached to the patient. A sequence (200, 200, and 360 J for monophasic or 150,150, and 150 J for biphasic) of up to 3 defibrillation shocks was then delivered. If 3 consecutive shocks failed to defibrillate or if the AED did not advise that a shock be delivered, the local protocols according to European Resuscitation Council guidelines were followed.28 29
Randomization
A daily schedule of randomly selected AED types was distributed
on a quarterly basis. At the change of crew shifts in the morning, the
carrying case of the selected AED type was tagged, clearly indicating
which AED had to be used for the entire day. If the AED was being used
in a mission at the designated time, then randomization was delayed
until immediately after that mission was completed and the AED was
returned.
AED Descriptions
The biphasic AEDs (ForeRunner AED; Agilent
Technologies Heartstream Operation) delivered 150-J
impedance-compensated biphasic waveforms from a 100-µF capacitor.
This waveform adjusts the duration of each phase in response to patient
impedance measured during each shock, providing the desired total
waveform duration, tilt, and energy delivery.10 11 12 13 25
Monophasic waveforms were delivered by AEDs designed to conform to the defibrillation waveform requirements of AAMI/ANSI Standard DF-2.30 The monophasic AEDs delivered either monophasic truncated exponential (MTE) or monophasic damped sine (MDS) defibrillation waveforms, depending on the device model in use at each investigational site. MTE AEDs included Heartstart 3000 and Heartstart 911 (Laerdal Medical Corporation). MDS AEDs included Heartstart 2000 (Laerdal Medical Corporation) and LifePak 200 (Physio-Control).
End Points
The primary end point of the study was the percentage of
patients with VF as the initial monitored rhythm who were defibrillated
in the first series of 
3 shocks. Secondary end points included
defibrillation with 2 shocks, first-shock defibrillation, and
survival to hospital admission and discharge. Other predetermined
observations included return of spontaneous circulation (ROSC),
response times, and neurological status at discharge.
Sample Size
The sample size was based on historical data from the
investigators, which suggested that 70% of monophasic-waveform
patients would be defibrillated within 3 shocks. The detection of a
22% increase or a 28% decrease in the primary end point with 80%
power and a significance level of 0.05 would therefore require 48
patients per arm. With the estimation that VF would be the initial
monitored rhythm in 40% of the sudden cardiac arrest
victims,31 a total enrollment of 240 was anticipated.
Data Collection
ECG and shock data were obtained from the recording
systems within the AEDs. Patient data were collected from the incident
reports and follow-up reports. Neurological status was scored according
to the Glasgow-Pittsburgh Cerebral Performance Category (CPC)
and Overall Performance Category (OPC) by study investigators
at each site at patient discharge from the hospital.32
Rhythm Definitions
Postshock ECGs were classified by the investigator at each site
and reviewed by an independent Data and Safety Monitoring Board (DSMB).
VF was defined as a disorganized rhythm with a median
peak-to-peak amplitude of 100 µV. Any rhythm with an amplitude of
<100 µV was defined as asystole. An episode of VF was required to
persist 5 seconds before transition to a non-VF rhythm. The
subsequent recurrence of VF was considered a new episode.
Defibrillation was defined as the termination of VF for 5 seconds,
without regard to hemodynamic factors.33
By definition, rhythms that occurred after successful shocks included
supraventricular and paced rhythms, ventricular
standstill (asystole), bradycardia, and idioventricular
rhythms. Non-VF ventricular
tachyarrhythmias were defined as successful
defibrillation rhythms if they self-terminated within 30 seconds from
shock delivery.
Data and Safety Monitoring
Each case report form was sent independently from the centers to
the independent DSMB. Members of the DSMB (D.C., L.B., W.D.W.) reviewed
all case reports to ensure patient safety and integrity of the data
and selected source data (eg, original ECGs) as deemed
necessary to resolve apparent discrepancies, by judgment of the
chairman (D.C.). The DSMB conducted a separate analysis of the
major study end points. The data were formally analyzed after
the accumulation of the first 10% of the data and each successive
25% thereafter, based on the equivalent group sequential test for the
primary hypothesis. The board reviewed each case at the conclusion of
the study. Discrepancies were discussed until an agreement was reached
on all cases.
Statistical Analysis
Continuous variables are expressed as mean±SD and compared
with the use of t tests. Ordinal variables (discharge
destination, CPC, OPC) were compared by the Kruskal-Wallis rank sums
test. Discharge destination was assigned a rank of 1 for home, 2 for
rehabilitation facility, and 3 for extended care facility. Proportions
were compared by log-likelihood ratio 
2 tests
and include 
95% CIs of differences. Tests were 2-tailed and were
computed with the JMP software application developed by the SAS
Institute. A P value of 0.05 was considered statistically
significant.
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1References |
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Enrollment
The site in Mainz, Germany, enrolled 197 patients starting from December 1996; the site in Brugge, Belgium, enrolled 69 patients starting from September 1997; the site at Hamburg, Germany, enrolled 37 patients starting from November 1997; and the site at Helsinki, Finland, enrolled 35 patients starting from July 1998. By the conclusion of the study in December 1998, a total of 338 patients had been enrolled.
Of the 338 patients, 246 had an arrest of cardiac etiology that was not
witnessed by EMS personnel and were randomized to an AED. There were no
statistical differences between the monophasic and biphasic AED
patients in terms of age, sex, weight, primary structural heart
diseases, cause or location of arrest, bystanders who witnessed the
arrest or performed CPR, or the type of responder. Similarly, these
factors were not statistically different when only the 115 patients who
presented with VF as their initial monitored rhythm were
considered (Table 2). The patients who
presented with VF are the subjects of interest for this study
of AED efficacy. All analyses and discussions from this point
on focus exclusively on these patients.
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Response Time
The time from the emergency call to the first shock was 8.9±3.0
minutes overall and did not differ between treatments: 8.7±3.2 for
monophasic versus 9.2±2.9 for biphasic (P=0.51).
Resuscitation of VF Patients
The defibrillation efficacy of the 150-J biphasic waveform was
superior to that of the 200- to 360-J monophasic waveforms (Table 3, Figure 1). Four patients in the monophasic group
were not treated with the AED due to low-amplitude VF not being
detected by the AED. For the primary end point of defibrillation within
the first shock series, 53 of 54 (98%) VF patients were defibrillated
with 150-J biphasic shocks compared with 42 of 61 (69%) patients
defibrillated with 200- to 360-J monophasic shocks
(P<0.0001).
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More patients were defibrillated with the initial biphasic shock than with the initial monophasic shock (96% compared with 59%, P<0.0001), and ultimately all patients treated with biphasic AEDs were defibrillated while under EMS care, whereas this was not true for those treated with monophasic AEDs or a combination of monophasic AEDs and backup manual monophasic defibrillators (100% compared with 84%, P=0.003).
A higher percentage of patients (76%) achieved ROSC after 150-J
biphasic-waveform defibrillation compared with higher-energy
monophasic-waveform defibrillation (54%) (Figure 1
, P=0.01). Rates of survival to hospital admission and to
hospital discharge did not differ between the treatments.
Outcomes of Discharged Patients
Destination of discharge did not differ between the treatments
(Figure 2). CPC at hospital discharge
favored patients treated with 150-J biphasic shocks (Figure 2).
Among survivors to hospital discharge, 87% of patients resuscitated
with 150-J biphasic shocks had good cerebral status compared with only
53% after resuscitation with higher-energy monophasic shocks
(P=0.04, 95% CI 6% to 62%). OPC did not differ between
the treatments (Figure 2).
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1References |
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Improved Defibrillation Efficacy
The high defibrillation efficacy of the particular 150-J impedance-compensating biphasic waveform observed in the present study is consistent with previous reports but strengthens the finding by providing randomized data from out-of-hospital emergency care.26 27 The concurrent controls substantiate the magnitude of the improvement in defibrillation efficacy obtained with this biphasic waveform compared with conventional escalating-energy monophasic-waveform methods. In addition to the improved defibrillation rates of individual biphasic shocks or shock sequences, it is noted that all patients who received treatment with 150-J biphasic shocks were eventually defibrillated during the resuscitation attempt and without resort to backup manual defibrillators, which was not true for the higher-energy monophasic waveforms. Dynamic control of waveform parameters via impedance compensation with a 150-J biphasic shock provides consistently high defibrillation rates without the need for escalating energies. This finding is key to encouraging the further evolution of small, low cost, and widely available AED technology with dynamic waveform control techniques.
Impact on Patient Survival
Despite a statistically significant increase in ROSC after
defibrillation with 150-J biphasic shocks, no differences in survival
to admission to or discharge from hospital were established. The
present study was statistically powered to show differences in
defibrillation efficacy, not in patient survival. Our objective was to
assess the relative performances of the AEDs. The determination
of statistical differences in short- or long-term patient survival
would require a prohibitively large study to mitigate the uncontrolled
variables associated with EMS system influences and
postresuscitation treatment.
Impact on Patient Outcome
Although the rate of survival to discharge from hospital did not
differ between treatments, among patients who survived to be
discharged, those treated with the biphasic waveform were more likely
to be in good condition (eg, to have a CPC of "good") than were
those treated with monophasic waveforms. Discharge destinations and
OPCs were consistent with these findings in favoring biphasic
patients, although the differences were not statistically significant.
Improved neurological status has previously been associated with
shorter overall resuscitation times in the treatment of sudden cardiac
arrest victims34 but not with defibrillation energy or
waveform. It is our hypothesis that the superior neurological status
observed at hospital discharge after resuscitation with 150-J biphasic
defibrillation shocks is associated with shorter time to ROSC and
resultant better postresuscitation cardiac output during the critical
interval immediately after severe ischemic compromise. This
hypothesis is supported by the significantly higher rate of ROSC
obtained with the biphasic waveform. Furthermore, studies in animals
have demonstrated that both defibrillation waveform and energy dose
affect postresuscitation myocardial function.18 19 20 21 22 23 In
these studies, both stroke volume and ejection fraction were
significantly depressed for many hours after high-energy monophasic
shocks to a much greater degree than after 150-J biphasic shocks.
Increasing the number of neurologically intact survivors from
out-of-hospital sudden cardiac arrest may directly depend on reducing
the compromise of cardiac output associated with high-energy
defibrillation.
Study Limitations
Randomization of treatment was conducted on the basis of date
rather than on the basis of patient and responders were not blinded to
the AED type. The AEDs were all commercially available devices, with
each of the 5 models differing in its user interface, analysis
algorithm, and therapy waveform. The EMS personnel were familiar with
the monophasic devices at the outset of the study, whereas the biphasic
devices were newly introduced. These choices were made due to practical
and ethical considerations. The urgency of immediate intervention
precluded concealment. Training, budget, and regulatory constraints
precluded the development and use of novel devices solely for the
purposes of the study. Our method is, however, superior to the
alternative day technique used in other recent resuscitation
trials.35 36
In designing our nonblinded study, we considered that unintended randomization errors might favor one mode of defibrillation or the other. Bias in selection of the type of defibrillator used would then be difficult to disprove. It was for this reason that an intention-to-treat analysis was included in the protocol and in this report.
The control AEDs used in the present study deployed either MTE (79%) or MDS (21%) shocks, reflecting the distribution of AED types in service at the time of the study. There is some evidence that MTE waveforms have lower defibrillation rates than MDS waveforms.37 Thus, the observed defibrillation efficacy of the control group may depend in part on the distribution of monophasic AED types. However, a subset analysis that compared the efficacy of each waveform substantiates the benefits of the biphasic waveform over each of the monophasic waveforms (P. Martens, MD, unpublished data, 2000), as does a comparison of this biphasic AED with only MDS AEDs in a similar smaller study (K.-G. Kanz, unpublished data, 1999).
In summary, the results of the present study show that an appropriately dosed low-energy impedance-compensating biphasic-waveform strategy results in superior defibrillation performance in comparison with escalating, high-energy monophasic shocks in out-of hospital cardiac arrest. Moreover, the 150-J biphasic-waveform AED results in a higher rate of ROSC and better neurological status at the time of hospital discharge.
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Acknowledgments |
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This work was supported by a grant from Agilent Technologies Heartstream Operation. B. Gliner and Dr Russell were employees of and Dr Weaver was an advisor to Heartstream during the study. Prof Chamberlain’s Honorary Chair in Cardiff is supported (expenses only) by a grant from the Laerdal Foundation.
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Appendix 1 |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1References |
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Investigators and participating institutions are given in the order of the number of patients enrolled:
Thomas Schneider, MD; Benno Wolcke, MD; Gerhard Tauscher, Study Coordinator; Heinke Teichmann, Clinic of Anaesthesiology, The Johannes Gutenberg-University Medical School, Mainz, Germany; Patrick R. Martens, MD; Francis Cooman, MD; Martin De Meyer, RN, Emergency Medical Department, St Jan Hospital, Brugge, Belgium; Luc Charles, Project Coordinator, Fire Brigade, Brugge, Belgium; Hans-Richard Paschen, MD, EMS Medical Director, Hamburg Fire Brigade, Hamburg, Germany; and Markku Kuisma, MD, Janne Aaltonen, MD, Jouni Pousi, RN, Helsinki City EMS, Helsinki, Finland.
Received March 3, 2000; revision received May 15, 2000; accepted May 16, 2000.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1References |
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 L. Richardson, A. Dissanayake, and J. Dunning What cardioversion protocol for ventricular fibrillation should be followed for patients who arrest shortly post-cardiac surgery? Interactive CardioVascular and Thoracic Surgery, December 1, 2007; 6(6): 799 - 805. [Abstract] [Full Text] [PDF]
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I. G. Stiell, R. G. Walker, L. P. Nesbitt, F. W. Chapman, D. Cousineau, J. Christenson, P. Bradford, S. Sookram, R. Berringer, P. Lank, et al. BIPHASIC Trial: A Randomized Comparison of Fixed Lower Versus Escalating Higher Energy Levels for Defibrillation in Out-of-Hospital Cardiac Arrest Circulation, March 27, 2007; 115(12): 1511 - 1517. [Abstract] [Full Text] [PDF]
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P. J. Kudenchuk, L. A. Cobb, M. K. Copass, M. Olsufka, C. Maynard, and G. Nichol Transthoracic Incremental Monophasic Versus Biphasic Defibrillation by Emergency Responders (TIMBER): A Randomized Comparison of Monophasic With Biphasic Waveform Ascending Energy Defibrillation for the Resuscitation of Out-of-Hospital Cardiac Arrest due to Ventricular Fibrillation Circulation, November 7, 2006; 114(19): 2010 - 2018. [Abstract] [Full Text] [PDF]
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W. Tang, D. Snyder, J. Wang, L. Huang, Y.-T. Chang, S. Sun, and M. H. Weil One-Shock Versus Three-Shock Defibrillation Protocol Significantly Improves Outcome in a Porcine Model of Prolonged Ventricular Fibrillation Cardiac Arrest Circulation, June 13, 2006; 113(23): 2683 - 2689. [Abstract] [Full Text] [PDF]
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 American Heart Association 2005 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) of Pediatric and Neonatal Patients: Pediatric Advanced Life Support Pediatrics, May 1, 2006; 117(5): e1005 - e1028. [Full Text] [PDF]
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The International Liaison Committee on Resuscitati The International Liaison Committee on Resuscitation (ILCOR) Consensus on Science With Treatment Recommendations for Pediatric and Neonatal Patients: Pediatric Basic and Advanced Life Support Pediatrics, May 1, 2006; 117(5): e955 - e977. [Abstract] [Full Text] [PDF]
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Part 5: Electrical Therapies: Automated External Defibrillators, Defibrillation, Cardioversion, and Pacing Circulation, December 13, 2005; 112(24_suppl): IV-35 - IV-46. [Full Text] [PDF]
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Part 12: Pediatric Advanced Life Support Circulation, December 13, 2005; 112(24_suppl): IV-167 - IV-187. [Full Text] [PDF]
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Part 3: Defibrillation Circulation, November 29, 2005; 112(22_suppl): III-17 - III-24. [Full Text] [PDF]
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Part 6: Pediatric Basic and Advanced Life Support Circulation, November 29, 2005; 112(22_suppl): III-73 - III-90. [Full Text] [PDF]
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T. D. Valenzuela, K. B. Kern, L. L. Clark, R. A. Berg, M. D. Berg, D. D. Berg, R. W. Hilwig, C. W. Otto, D. Newburn, and G. A. Ewy Interruptions of Chest Compressions During Emergency Medical Systems Resuscitation Circulation, August 30, 2005; 112(9): 1259 - 1265. [Abstract] [Full Text] [PDF]
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 M. Kyller and D. Johnstone A 2-Tiered Approach to In-Hospital Defibrillation: Nurses Respond to a Trial of Using Automated External Defibrillators as Part of a Code-Team Protocol Crit. Care Nurse, August 1, 2005; 25(4): 25 - 33. [Full Text] [PDF]
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A A J Adgey, M S Spence, and S J Walsh Theory and practice of defibrillation: (2) defibrillation for ventricular fibrillation Heart, January 1, 2005; 91(1): 118 - 125. [Full Text] [PDF]
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C. R. Killingsworth, C.-C. Wei, L. J. Dell'Italia, J. L. Ardell, M. A. Kingsley, W. M. Smith, R. E. Ideker, and G. P. Walcott Short-Acting {beta}-Adrenergic Antagonist Esmolol Given at Reperfusion Improves Survival After Prolonged Ventricular Fibrillation Circulation, May 25, 2004; 109(20): 2469 - 2474. [Abstract] [Full Text] [PDF]
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W. Tang, M. H. Weil, S. Sun, D. Jorgenson, C. Morgan, K. Klouche, and D. Snyder The effects of biphasic waveform design on post-resuscitation myocardial function J. Am. Coll. Cardiol., April 7, 2004; 43(7): 1228 - 1235. [Abstract] [Full Text] [PDF]
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R. Torok and J. Till Biphasic or monophasic defibrillation for adult ventricular fibrillation Emerg. Med. J., September 1, 2003; 20(5): 464 - 465. [Abstract] [Full Text] [PDF]
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R. A. Samson, R. A. Berg, and R. Bingham Use of Automated External Defibrillators for Children: An Update--An Advisory Statement From the Pediatric Advanced Life Support Task Force, International Liaison Committee on Resuscitation Pediatrics, July 1, 2003; 112(1): 163 - 168. [Full Text] [PDF]
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R.A. Samson, R.A. Berg, R. Bingham, D. Biarent, A. Coovadia, M.F. Hazinski, R.W. Hickey, V. Nadkarni, G. Nichol, J. Tibballs, et al. Use of Automated External Defibrillators for Children: An Update: An Advisory Statement From the Pediatric Advanced Life Support Task Force, International Liaison Committee on Resuscitation Circulation, July 1, 2003; 107(25): 3250 - 3255. [Full Text] [PDF]
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A. Capucci, D. Aschieri, M. F. Piepoli, G. H. Bardy, E. Iconomu, and M. Arvedi Tripling Survival From Sudden Cardiac Arrest Via Early Defibrillation Without Traditional Education in Cardiopulmonary Resuscitation Circulation, August 27, 2002; 106(9): 1065 - 1070. [Abstract] [Full Text] [PDF]
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K. B. Kern, R. W. Hilwig, R. A. Berg, A. B. Sanders, and G. A. Ewy Importance of Continuous Chest Compressions During Cardiopulmonary Resuscitation: Improved Outcome During a Simulated Single Lay-Rescuer Scenario Circulation, February 5, 2002; 105(5): 645 - 649. [Abstract] [Full Text] [PDF]
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T. S. Takata, R. L. Page, and J. A. Joglar Automated External Defibrillators: Technical Considerations and Clinical Promise Ann Intern Med, December 4, 2001; 135(11): 990 - 998. [Abstract] [Full Text] [PDF]
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 H.-U. Strohmenger, T. Eftestol, K. Sunde, V. Wenzel, M. Mair, H. Ulmer, K. H. Lindner, and P. A. Steen The Predictive Value of Ventricular Fibrillation Electrocardiogram Signal Frequency and Amplitude Variables in Patients with Out-Of-Hospital Cardiac Arrest Anesth. Analg., December 1, 2001; 93(6): 1428 - 1433. [Abstract] [Full Text] [PDF]
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 S.G. Priori, E. Aliot, C. Blomstrom-Lundqvist, L. Bossaert, G. Breithardt, P. Brugada, A.J. Camm, R. Cappato, S.M. Cobbe, C. Di Mario, et al. Task Force on Sudden Cardiac Death of the European Society of Cardiology Eur. Heart J., August 2, 2001; 22(16): 1374 - 1450. [PDF]
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 N. Sotoodehnia, A. Zivin, G. H Bardy, and D. S Siscovick Reducing mortality from sudden cardiac death in the community: lessons from epidemiology and clinical applications research Cardiovasc Res, May 1, 2001; 50(2): 197 - 209. [Abstract] [Full Text] [PDF]
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