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No Maximum # of Shocks in Cardiac Arrest

Question#: 695


I have been hearing some conflicting info regarding the new Medical Cardiac Arrest directive for PCP's. I am hoping for some clear understanding regarding the treatment for Manual Defibrillation. What does the change in # of shocks now being N/A indicate?



 In the RPPEO region, PCP's are currently not authorized to perform manual defibrillation even though you may be taught this in college. PCP's currently only use SAED mode for cardiac arrest patient's however, this is actively being discussed by the Base Hospital Physician's currently, and we are aiming to have PCP's authorized in manual defibrillation in the near future - stay tuned!

To answer your second question, in the old version of the ALS PCS there used to be a maximum number of four shocks delivered. This was previously known as, "Three on the floor and one out the door" if you were transporting or you would patch following the third analysis for a medical TOR if applicable.

In the currently ALS PCS v5.1, there is no maximum number of shocks indicated (N/A). The idea is to perform quality CPR with early defibrillation for 20 minutes unless:

1.) You obtain a ROSC (transport as soon as possible)

2.) There are any primary clinical considerations requiring early transport after one analysis/defibrillation for example:
• Pregnancy (greater or equal to 20 weeks gestation)
• Hypothermia
• Airway obstruction
• Non-opioid drug overdose/toxicology
• Other known reversible cause of arrest not addressed

3.) Your patient is in refractory VF or pulseless VT (transport after third consecutive shock)

4.) You are patching early (after the 4th analysis) for a TOR for extenuating circumstances:
• Egress
• Prolonged transport
• Significant clinical limitations


05 May 2023



Please reference the MOST RECENT ALS PCS for updates and changes to these directives.