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(Circulation. 2007;115:1511-1517.)
© 2007 American Heart Association, Inc.

Arrhythmia/Electrophysiology

BIPHASIC Trial

A Randomized Comparison of Fixed Lower Versus Escalating Higher Energy Levels for Defibrillation in Out-of-Hospital Cardiac Arrest

Ian G. Stiell, MD, MSc, FRCPC; Robert G. Walker, BA; Lisa P. Nesbitt, MHA; Fred W. Chapman, PhD; Donna Cousineau, RN, MSN; James Christenson, MD; Paul Bradford, MD; Sunil Sookram, MD; Ross Berringer, MD; Paula Lank, RN, BSN; George A. Wells, PhD

From the Department of Emergency Medicine (I.G.S.), Department of Epidemiology and Community Medicine (G.A.W.), and Clinical Epidemiology Program (L.P.N., D.C.), Ottawa Health Research Institute, University of Ottawa, Ottawa, Canada; Medtronic Emergency Response Systems (R.G.W., F.W.C., P.L.), Redmond, Wash; University of British Columbia and British Columbia Ambulance Service (J.C.) and Vancouver Fire Department (R.B.), Vancouver, Canada; Windsor Base Hospital (P.B.), Windsor, Canada; and Emergency Medical Services (S.S.), Edmonton, Canada.

Correspondence to Dr Ian G. Stiell, Clinical Epidemiology Unit, Office F657, Ottawa Health Research Institute, The Ottawa Hospital, Civic Campus, 1053 Carling Ave, Ottawa, Ontario, Canada, K1Y 4E9. E-mail istiell{at}ohri.ca

Received June 26, 2006; accepted December 22, 2006.

Background— There is little clear evidence as to the optimal energy levels for initial and subsequent shocks in biphasic waveform defibrillation. The present study compared fixed lower- and escalating higher-energy regimens for out-of-hospital cardiac arrest.

Methods and Results— The Randomized Controlled Trial to Compare Fixed Versus Escalating Energy Regimens for Biphasic Waveform Defibrillation (BIPHASIC Trial) was a multicenter, randomized controlled trial of 221 out-of-hospital cardiac arrest patients who received 1 shock given by biphasic automated external defibrillator devices that were randomly programmed to provide, blindly, fixed lower-energy (150-150-150 J) or escalating higher-energy (200-300-360 J) regimens. Patient mean age was 66.0 years; 79.6% were male. The cardiac arrest was witnessed in 63.8%; a bystander performed cardiopulmonary resuscitation in 23.5%; and initial rhythm was ventricular fibrillation/ventricular tachycardia in 92.3%. The fixed lower- and escalating higher-energy regimen cases were similar for the 106 multishock patients and for all 221 patients. In the primary analysis in multishock patients, conversion rates differed significantly (fixed lower, 24.7%, versus escalating higher, 36.6%; P=0.035; absolute difference, 11.9%; 95% CI, 1.2 to 24.4). Ventricular fibrillation termination rates also were significantly different between groups (71.2% versus 82.5%; P=0.027; absolute difference, 11.3%; 95% CI, 1.6 to 20.9). For the secondary analysis of first shock success, conversion rates were similar between the fixed lower and escalating higher study groups (38.4% versus 36.7%; P=0.92), as were ventricular fibrillation termination rates (86.8% versus 88.8%; P=0.81). There were no distinguishable differences between regimens for survival outcomes or adverse effects.

Conclusions— This is the first randomized trial to compare fixed lower and escalating higher biphasic energy regimens in out-of-hospital cardiac arrest, and it demonstrated higher rates of ventricular fibrillation conversion and termination with an escalating higher-energy regimen for patients requiring multiple shocks. These results suggest that patients in ventricular fibrillation benefit from higher biphasic energy levels if multiple defibrillation shocks are required.

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