Rethinking defibrillation: a viewpoint on alternative strategies for refractory ventricular fibrillation

Refractory ventricular fibrillation (RVF) remains one of the most dramatic and frustrating scenarios in emergency care [1]. Despite timely, high-quality cardiopulmonary resuscitation (CPR) and adherence to advanced cardiovascular life support (ACLS) algorithms, some patients remain in persistent ventricular fibrillation, unresponsive to standard defibrillation and medications [2]. For years, the default approach in such cases has been repetition: same energy, pad placement, and same result [2,3]. Recently, alternative defibrillation strategies (ADS), that is, double sequential external defibrillation (DSED) and vector change defibrillation (VCD), have emerged as promising options [1,4–10]. These techniques offer a potential exit from therapeutic inertia (Fig. 1); however, despite growing enthusiasm, especially in prehospital care, they are inconsistently used and often implemented without protocols or institutional support. The time has come to move from improvisation to integration, transforming scattered efforts into structured escalation pathways.