Philips SMART Biphasic therapy

Application note
 Philips SMART Biphasic therapy

Introduction
Since Philips introduced the first biphasic waveform for an external defibrillator in 1996,
biphasic therapy has gained acceptance and is now recognized as the standard of care.
However, the various defibrillator manufacturers recommend a wide range of energy
(joules) dosages. This is because defibrillator manufacturers have created distinct biphasic
waveform “formulations.” So each manufacturer recommends energy doses appropriate
for their shock formulation. While energy (joules) remains entrenched in defibrillator
vocabulary as a descriptor of shock strength, current (amperes) has been shown to be a
better predictor. For meaningful shock strength comparisons of biphasic waveforms, it’s
necessary to look beyond energy levels and compare the current delivered to the patient.

All presently available Philips HeartStart defibrillators incorporate a proprietary biphasic

truncated exponential (BTE) waveform formulation employing high current delivered
in a low energy dosage. Further, Philips uses real-time impedance compensation to
automatically adjust the waveform to deliver shock strength personalized to the needs of
each patient, starting with the first shock.

Philips therapy has been rigorously studied and is backed by a substantial body of
peer-reviewed, published data demonstrating effectiveness across the full spectrum of
patients, including those considered “difficult-to-treat.”

While biphasic waveforms effectively terminate arrhythmias, meaningful clinical

differences between defibrillators may lie in the amount of energy needed for successful
defibrillation and its negative impact on post-resuscitation myocardial function. While high
current defibrillates, high energy is associated with negative side effects. So the optimal
waveform formulation delivers high current at lower energy doses to help reduce the
total energy delivered. Meaningful clinical differences may also lie in how quickly a shock
is delivered following the CPR pause, as this may substantially influence shock success.
Only Philips AEDs and the Philips MRx Monitor/Defibrillator in AED mode offer Quick
Shock technology, which helps shorten time-to-shock after CPR and increase the chance
a shock will successfully return circulation, which may improve survival.

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 Philips SMART Biphasic therapy

Biphasic waveforms use distinct formulations

Not all biphasic waveforms are the same. Manufacturers American Heart Association and European Resuscitation Council
use distinct shock formulations, making their individual positions on current
energy dosages an invalid comparison tool for evaluating
their relative shock strength. This can be likened to
“ Because it is accepted that defibrillation is
pharmaceuticals.
accomplished by the passage of sufficient
Although different drugs within a class may all be current through the heart, the concept of
considered safe and effective, each requires its own
current-based defibrillation is appealing.
dosage due to its distinctive molecular structure. For
example, statins are proven to lower LDL cholesterol.1 Energy is a non-physiologic descriptor of
Yet, the maximum 80mg dose of Lipitor ® (atorvastatin defibrillation despite its entrenchment in
calcium) is not necessarily more therapeutic than
traditional jargon…Transition to current-
the 40mg maximum dose of Crestor ® (rosuvastatin
calcium)3 simply because it is twice the dose. Because based description is timely and should be
each drug in a class has a unique formulation, the encouraged.”
number of milligrams of one drug in a class is not
– American Heart Association 2

necessarily indicative of therapeutic strength relative to

another, and does not lend itself to “apples to apples”
comparisons. “ Although energy levels are selected for
defibrillation, it is the transmyocardial current
Biphasic waveforms as a class have been proven to
flow that achieves defibrillation. Current
effectively terminate arrhythmias. They deliver “electric
medicine” and, similar to pharmaceutical medications, correlates well with successful defibrillation
use distinctive waveform formulations. For biphasic and cardioversion…Future technology may
waveforms, the formulation is driven by different device
enable defibrillators to discharge according
components, waveform shape, and duration, which
produce current. According to the American Heart to transthoracic current: a strategy that
Association and European Resuscitation Council, it’s may lead to greater consistency in shock
current that defibrillates, not the amount of energy
success…manufacturers are encouraged to
(joules).2,3 Due to varying waveform formulations, it is
possible for the recommended first shock dosage of 150J explore further this move from energy-based
from one defibrillator manufacturer to deliver higher to current-based defibrillation.”
current levels than a 200J first shock from another – European Resuscitation Council 3
defibrillator manufacturer, even though the latter
delivers a larger energy dosage.

3
A 5-second jolt from Theoretically, when
the typical 1200V the connectors
taser used by law of a 9V battery
enforcement would are placed on a
incapacitate a person, conductive surface,
but the person would such as a person’s
only absorb a 1/4J tongue, the person
shock. would eventually
absorb 360J.

Current, not energy, determines shock strength Waveform formulation key terms
If the connectors of a common 9V battery were placed
Capacitor – A key component of the defibrillator design that stores electrons.
on a person’s tongue, the person would eventually
Manufacturers have created distinct waveform formulations that use various
absorb 360J. Of course, no one would consider using a
size capacitors to generate voltage and current for defibrillation. The size
9V battery to defibrillate a patient as it lacks sufficient
of the capacitor impacts the amount of energy (joules) needed to produce
voltage and current.
voltage and current. Smaller capacitors typically use fewer joules to pack the
necessary voltage and current punch for effective defibrillation. Whereas,
On the other hand, a person incapacitated by the typical
larger capacitors usually use more joules to achieve comparable levels.
1200V taser used by law enforcement for 5 seconds would
only absorb a ¼J shock. After one excruciating minute, Voltage – The force that pushes the electrons through the patient. The
just 3J would be absorbed. With sufficient voltage and amount of voltage stored on the capacitor drives the amount of current
current, a ¼J shock can be quite strong indeed. available for defibrillation. The higher the voltage level, the greater the force
and amount of current that can be delivered for defibrillation.
The point of these examples is that while energy (joules) Current – The movement of electrons, measured in amperes, which achieves
remains entrenched in defibrillator vocabulary as a defibrillation. For biphasic waveforms, distinctive formulations driven by
descriptor of shock strength, published studies have different device components, waveform shape, and duration produce current.
shown that current (amperes) is a better predictor.4,5
Impedance – The resistance of the body to the flow of current, which is
The American Heart Association and the European
measured in ohms. Human impedance levels typically range from 25 ohms to
Resuscitation Council are both advocating a shift to
180 ohms.
current-based defibrillation.
Voltage gradient – Reflects the actual intensity of a defibrillation shock in
For effective defibrillation, a defibrillator must generate terms of the electric field it generates within the myocardium itself. Accurate
high voltage in order to drive a sufficiently high current measurement of intracardiac voltage gradients requires instrumenting the
over the duration when the heart cells are physiologically heart with electrodes to capture the data.
most receptive to defibrillation (See Table 1 for Duration – The period over which the current is delivered to the heart. The
Waveform formulation key terms). Therefore, for goal is to deliver therapy over an optimal time period to increase the chance
meaningful shock strength comparisons of biphasic of defibrillation.
waveforms, it is necessary to look beyond energy and
compare the current delivered to the patient. Table 1

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 Philips SMART Biphasic therapy

The Philips SMART Biphasic waveform formulation to the heart – when comparing each manufacturer’s
When Philips set out to design the first biphasic recommended first shock energy setting. The authors
waveform for an external defibrillator, the engineers concluded that energy descriptors correlate poorly
chose a smaller 100 microfarad (μF) capacitor that to actual shock intensities and provide an inaccurate
used fewer joules to pack the necessary voltage and measure of relative shock strength among different
current punch for effective defibrillation. Philips external defibrillators. The authors also concluded that
patented the use of a smaller capacitor for external peak current is a better measure of shock strength.
defibrillation, which led other manufacturers
to select larger (200 μF) capacitors for their The Philips SMART Biphasic waveform formulation
formulations. Larger capacitors typically use more delivers high voltage to drive high current and generate
joules to achieve voltage and current, meaning shock high voltage gradients at the heart with fewer joules.
strength, comparable to Philips. Using standard
protocols, this means that Philips delivers higher Voltage levels by recommended first shock energy setting
shock strength starting with the first shock than
other typical biphasic waveforms that escalate their 150J 1,683V
energy levels to reach equivalent shock strength. 200J 1,479V
Escalating potentially wastes time and shocks during Voltage levels by recommended first shock energy setting
0 1,000 2,000
an arrest. 150J Voltage 1,683V
Philips (100 µF capacitor) Another biphasic waveform (200 µF capacitor)
The amount of voltage stored on the defibrillator’s 200J 1,479V

capacitor determines the amount of current delivered 0 1,000 2,000

Voltage
to the patient, which is responsible for defibrillating the
Philips (100 µF capacitor) Another biphasic waveform (200 µF capacitor)
heart and considered a more accurate measure of shock
strength. Figure 1 shows that the Philips waveform Figure 1 Measurements based on a resistive load of 80 ohms.

(using a 100 μF capacitor) at its recommended first

shock energy setting can produce significantly higher
voltage than another common biphasic waveform (using Delivered current by recommended first shock energy setting
a 200 μF capacitor) at its recommended first shock
setting.6 Philips distinct waveform formulation uses 150J 21.0A

fewer joules to achieve higher voltage levels. 200J 18.5A

Delivered current by recommended first shock energy setting
0 15 30
Higher voltage drives higher current to the patient. 150J Current (Amps) 21.0A
Applying basic physics, namely Ohm’s Law, Figure 2 shows Philips (100 µF capacitor) Another biphasic waveform (200 µF capacitor)
200J 18.5A
how the Philips formulation is able to generate higher
Figure
0 2 15 Assumes an average patient impedance
30 of 80 ohms.
current with fewer joules at its recommended first shock
Current (Amps)
energy setting than that of another common biphasic
Philips (100 µF capacitor) Another biphasic waveform (200 µF capacitor)
waveform (using a 200 μF capacitor).7 This biphasic
waveform requires more energy to deliver current Measures of shock strength:
equivalent to the Philips waveform. First shock (simulated human impedance at 75 ohms )
12
Current (Amps)

A swine study by Niemann, et al.8 * measured whether 20

energy or peak current measured at the body surface
V/cm

6
is a better predictor of the actual shock electric- 10
field strength to which the heart is exposed. Porcine
hearts were instrumented with electrodes to measure 0 0
voltage gradients within the heart achieved by various Philips 150J Physio 200J Zoll 120J
defibrillator brands. Figure 3 demonstrates that Philips
delivers the highest observed peak current and voltage Peak voltage gradient (V/cm) Peak current (Amps)
gradients – meaning more defibrillation therapy right Figure 3

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 Philips SMART Biphasic therapy

Evidence-based therapy with consistently With no head-to-head comparison data available, two
high efficacy peer-reviewed, published clinical trials using different
As the first biphasic waveform in an external biphasic waveforms in out-of-hospital, long-downtime VF
defibrillator, the performance of Philips therapy has patients were of similar size, design, and purpose.25,28 *
been rigorously studied and reported in numerous The observed response conditions for these studies
peer-reviewed, published manuscripts. They reflect were largely similar in terms of average patient weight,
waveform performance in both animals9–12 and humans, call-to-shock time, percent of witnessed arrest, and
including the challenging long-duration VF relevant to percent of bystander CPR. The first study by Schneider,
hospital code teams and responders in out-of-hospital et al. using Philips biphasic therapy (150J fixed-energy
settings.13–26 These data demonstrate consistently high protocol) showed a 96% first shock efficacy. Seventy-
efficacy, regardless of factors such as: patient size, age, six (76) percent of patients experienced return of
impedance, incidence of refibrillation, or underlying spontaneous circulation (ROSC). Of surviving patients,
cause of cardiac arrest, including myocardial infarction. 94% showed good/moderate neurological function.
Survival to discharge was 28%. The second study by van
Philips therapy was the first biphasic therapy Alem et al. using Physio-Control’s high-energy biphasic
with sufficient evidence to receive a Class IIa therapy (200-360J escalating energy protocol) also
recommendation from the American Heart Association: reported a high first shock efficacy of 98%. Sixty-one
“Standard of care”, “Intervention of choice”. 27 percent of patients experienced ROSC and 14% survived
In contrast, some biphasic therapies on the market to discharge. (Figure 4)
today have limited or no published out-of-hospital
clinical data. With no published, peer-reviewed Another study by Stiell, et al.29 * using Physio-Control’s
studies in humans directly comparing the performance high-energy biphasic therapy (200-360J escalating
of various biphasic waveforms in treating VF, the energy protocol) reported first shock efficacy of 89%.
American Heart Association (AHA) advises, “The Forty nine (49) percent of patients experienced ROSC
safety and efficacy data related to specific biphasic and 82% of surviving patients showed good/moderate
waveforms must be evaluated on an individual basis.” 27 neurological function. Survival to discharge was 16%.
Accordingly, clinicians are cautioned about generalizing This study also included a low-energy (150J non-
conclusions about one manufacturer’s biphasic therapy’s escalating energy protocol) arm that used a low-current
performance to other manufacturer’s therapy. design not comparable to the Philips high-current 150J
waveform. Rather, the study compared a manufacturer’s
standard adult high energy/high current protocol with
the same manufacturer’s non-standard adult low energy/
Two out-of-hospital defibrillation trials
low current protocol.
100%

80%

60%

40%

20%

0%
% of patients 1st shock ROSC Survival to
defibrillated efficacy discharge
(Physio-Control not
reported)

Philips therapy 150J Physio-Control therapy 200-360J

Figure 4

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 Philips SMART Biphasic therapy

Proven across the full spectrum of patients

Philips therapy has been proven highly effective across the full spectrum of patients, even those considered “difficult-to-treat.” 23-26,30,31
The results of some of these published, peer-reviewed studies are summarized in Table 2.

Difficult-to-treat Citation Study summary

patient group

Overweight and obese White RD, et al. Critical Care Medicine. First shock efficacy and subsequent shock success, resuscitation,
(BMI > 25) patients 2004.* 23 and survival were not related to patient body weight. Philips 150J
fixed-energy protocol appears effective and appropriate.

High/low impedance patients White RD, et al. Resuscitation. 2005.* 24 With the Philips 150J fixed-energy protocol, efficacy was high.
Impedance had no bearing on defibrillation, ROSC, or survival at
discharge.

Refibrillating patients Hess EP, et al. Resuscitation. 2008.* 26 No significant difference in the frequency of shock success between
initial and recurrent episodes of VF using a Philips 150J fixed-energy
protocol was observed. VF recurrence is common and does not
adversely affect shock success, ROSC or survival.

Myocardial infarction patients Schneider T, et al. Over half the patients in this study were diagnosed with acute
Circulation. 2000.* 25 myocardial infarction, but VF was successfully terminated for all
patients using a Philips 150J fixed-energy protocol, with a 96% first
shock efficacy.

Atrial fibrillation patients Santomauro M, et al. Italian Heart Only the Philips biphasic waveform demonstrated 100%
Journal. 2004.* 30 cardioversion success for AF compared with patients treated with
a monophasic or the Zoll Rectilinear Biphasic™ waveform. The
Philips biphasic waveform required less total energy (statistically
significant) and fewer shocks per patient (not significant). The
Philips waveform appears to achieve a higher success rate at lower
energy levels.

Table 2

Philips real-time impedance compensation delivers

50
50 ohms, 150J optimized therapy
40 One major contributor to Philips biphasic therapy’s
75 ohms, 150J effectiveness across the full spectrum of patients
30
is real-time impedance-compensation technology,
Current (amps)

125 ohms, 150J

20 which optimizes every shock. Philips defibrillators
automatically measure patient impedance and in real-
10
time dynamically vary the waveform. Personalized
0 therapy is delivered to each patient, including the
difficult-to-treat ones, starting with the first shock for
-10
the best chance of success. Figure 5 shows how the
-20 Philips waveform is adjusted to compensate for varying
0 5 10 15 20 25 30 impedance levels. 32
Time (msec)

Figure 5

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 Philips SMART Biphasic therapy

Meaningful clinical differences among Tang, et al. 33 *compared the impact of various
biphasic waveforms defibrillation waveforms delivered at different energy
Dysfunction from high energy settings on post-resuscitation myocardial function using
When responding to a sudden cardiac arrest emergency, an animal model, which effectively isolated the impact of
terminating VF quickly is the only priority. However, in just the defibrillation shocks. The study showed that for
the calm of the defibrillator selection process, there is swine in long-duration VF, higher current/lower energy
the opportunity to consider the side effects of waveform and a higher current/higher energy waveform were
design, particularly in resuscitation situations that require equally effective at defibrillating. However, the higher
multiple shocks. Animal studies suggest that electric shocks energy waveform was associated with significantly higher
can have a negative inotropic influence on cardiac function levels of harmful cardiac dysfunction.
depending on the clinical circumstances, the energy dosage,
the number of shocks delivered, and the underlying cardiac Table 3 demonstrates that the high energy waveform
function.10,32,33 Too many shocks can cause transient (200 μF capacitor at 360J) required up to nine times the
cardiac injury, such as decreased contractility and reduced total energy delivered as the low energy waveform (100
cardiac output during the critical period immediately after μF capacitor at 150J) to achieve equivalent results.
severe cardiac compromise.10,33,34 While this type of injury
is not permanent, clinical data suggest that during a code Table 3 also shows the negative impact of the total
this stunning may be significant, complicating subsequent delivered energy on ejection fraction, considered a
interventions in the emergency department or intensive representative measure of dysfunction. Conversely,
care unit and potentially impacting patient outcomes.10,33,35 high peak current was the only positive predictor of
increased survival, which reinforces the importance of
Higher-energy defibrillation waveforms, whether current in the defibrillation equation.
monophasic or biphasic, are associated with increased post-
shock cardiac dysfunction. Experimental33,34 and clinical35 Tang, et al. 33 concluded that maximizing survival while
studies suggest that in typical out-of-hospital multi-shock minimizing myocardial dysfunction may be achieved
resuscitations, total energy delivered is a negative predictor with a waveform formulation that delivers higher peak
of myocardial function. An animal study noted a correlation current while minimizing total energy delivered.
between post-resuscitation myocardial dysfunction and early
death after initial successful resuscitation.33 Philips distinct biphasic waveform formulation is able to
deliver high peak current at low energy levels. This type
of lower energy shock has been shown to have fewer
Group 1 2 3 4 negative inotropic consequences than higher energy
Capacitance 100µF 100µF 200µF 200µF shocks. This clinical difference could be particularly
meaningful for the long downtime SCA patients, both
Energy 150J 200J 200J 360J
in and out-of-hospital, who typically require multiple
Median peak current 34A 40A 24A 37A shocks and could help make post-resuscitation
interventions in the ED or ICU more successful.
Survival (to 72 hours) 100% 100% 40% 100%

Median number of shocks to 1 3 5 4 Philips biphasic therapy delivers its strongest therapy
resuscitate from the first shock to maximize effectiveness,
Median CPR duration (seconds) 106 83 909 218 yet minimize total energy delivered. In contrast,
Median total energy required 155J 563J 994J 1440J defibrillators that employ high energy formulations
typically start with weaker shocks (lower current
Median ejection fraction at 95% 75% 62% 53%
delivered at lower energy settings) and escalate
30 minutes (% of baseline)**
to higher energy settings in the event of failure,
Table 3 33 ** A representative measure of dysfunction. A lower
number compared to baseline means more dysfunction. presumably to balance the trade off between shock

8
 Philips SMART Biphasic therapy

Time-to-shock after CPR and shock success

100%

80%
Shock success

60%

40%

20%

0%
<10s 10-20s 20-30s >30s
Pre-shock pause (seconds)
Figure 6 41

strength and potential post-shock dysfunction. Philips HeartStart AEDs and the MRx Monitor/
Assuming the Guidelines 2005-recommended Defibrillator in AED mode shock as fast as 8-10 seconds
protocol2 , it could take up to 6 minutes (including (typical) after CPR pause using a technology called
CPR intervals) to reach such an escalating, high- “Quick Shock.” This unique feature shortens time-to-
energy biphasic waveform’s maximum shock strength. shock after CPR, thereby increasing the chance that a
Philips does not face this trade off. shock will successfully return circulation and, in turn,
improve survival.
Time-to-shock following CPR pause impacts
shock success
Animal and clinical studies show that in longer downtime
situations (>4 minutes), CPR immediately prior to
defibrillation can help restore normal heartbeats in
more patients. 36,37 Yet, the beneficial effects of CPR
disappear in seconds, making time-to-shock following
CPR critical. 38,39 Thus, another key therapy attribute is
how quickly the defibrillator delivers a shock following
a CPR pause. In fact, a formulation that includes shorter
time-to-shock following CPR may substantially influence
shock success.40

A clinical study evaluating the impact of pre-shock

CPR interruptions on shock effectiveness reported
that, “…a 5 second decrease in pre-shock pause was
associated with an 86% increase in the odds of shock
success (p=0.02).” The study concluded that, “…
consideration should be given to the use of newer-
generation AEDs with shorter (<10 seconds) analysis
times.” 41 * (Figure 6)

9
 Philips SMART Biphasic therapy

Summary
Biphasic waveforms have become the standard of care for external defibrillation.
Manufacturers have created distinctive formulations and recommend energy (joule)
dosages appropriate for their waveforms. While energy remains entrenched in
defibrillator vocabulary as a descriptor of shock strength, current has been shown to be
a better predictor. For meaningful shock strength comparisons of biphasic waveforms,
it’s necessary to look beyond energy levels and compare the current delivered to the
patient.

Philips distinct waveform formulation is able to generate high voltage and deliver
high current, which produces high voltage gradients using fewer joules. It’s common
for other defibrillator manufacturers to use larger capacitors for their formulations
and deliver significantly more energy to achieve voltage and current, meaning shock
strength, comparable to Philips.

Philips evidence-based therapy has been rigorously studied and is supported by a

substantial body of peer-reviewed, published data. It has been clinically proven to deliver
high first shock efficacy for long-downtime SCA patients and effectively defibrillate across
the full spectrum of patients, including those labeled “difficult-to-treat.” In contrast, some
biphasic therapies on the market today have limited or no published out-of-hospital
clinical data. Philips success across such a broad patient population is due in part to its
real-time impedance-compensation technology, which automatically optimizes every
shock to deliver personalized therapy to each patient starting with the first shock.

Key waveform design attributes may result in meaningful clinical differences among
waveforms. Total delivered energy is a negative predictor of myocardial function and
survival. Philips approach reduces the total energy delivered, which minimizes the risk of
post-shock myocardial dysfunction. This means Philips can deliver its strongest shock from
the outset, without the need to consider tradeoffs with dysfunction. In addition, clinical
data demonstrate that the sooner a shock is delivered after CPR, the higher the chances
of shock success. Only Philips HeartStart AEDs and the MRx Monitor/Defibrillator in AED
mode offer Quick Shock technology, which helps shorten time-to-shock after CPR and
increase the chance a shock will successfully return circulation, which may improve survival.

10
 Philips SMART Biphasic therapy

1 Physicians’ Desk Reference. 2008. 62nd Edition. 23 White RD, Blackwell TH, Russell JK, Jorgenson DB. Body weight does
2 American Heart Association Guidelines 2005 for Cardiopulmonary not affect defibrillation, resuscitation or survival in patients with out-of-
Resuscitation and Emergency Cardiovascular Care. Circulation. hospital biphasic waveform defibrillator. Critical Care Medicine.
2005; 112. 2004; 32(9) Supplement: S387-S392.
3 European Resuscitation Council Guidelines 2005. Resuscitation. 2005; Vol 24 White RD, Blackwell TH, Russell JK, Snyder DE, Jorgenson DB.
67, Supplement 1. Transthoracic impedance does not affect defibrillation, resuscitation or
4 Dorian P, Wang MJ. Defibrillation and impedance are determinants of survival in patients with out-of-hospital cardiac arrest treated with
defibrillation energy requirements. Pacing and Clinical Electrophysiology. a non-escalating biphasic waveform defibrillator. Resuscitation.
1988; 11. 2005 Jan; 64(1):63-69.
5 Kerber RE, Martins JB, Kienzle MG, et al. Energy, current, and 25 Schneider T, Martens PR, Paschen H, et al. Multicenter, randomized,
success in defibrillation and cardioversion: clinical studies using an controlled trial of 150-J biphasic shocks compared with 200- to 360-J
automated impedance-based method of energy adjustment. Circulation. monophasic shocks in the resuscitation of out-of-hospital cardiac arrest
1988;77(5):1038-1046. victims. Circulation. 2000;102:1780-7
6 Measurements were made by discharging a standard Philips HeartStart 26 Hess EP, Russell JK, Liu PY, et al. A high peak current 150-J fixed-energy
MRx ALS Monitor/Defibrillator and Physio-Control LIFEPAK® 20 defibrillation protocol treats recurrent ventricular fibrillation (VF) as
defibrillator/monitor with pads into resistive load of 80 ohms. The effectively as initial VF. Resuscitation. 2008 Oct;79(1):28- 33.
measurement of Peak Voltage was made using a Tektronix P5210 HV 27 Cummins RO, et al. Guidelines 2000 for cardiopulmonary resuscitation
Differential probe and Agilent MSO8104A oscilloscope, as measured and emergency cardiovascular care. Supplement to Circulation. 2000;102:I-
directly across the resistive load. The voltages shown are the average of 60 - I-76.
5 samples. 28 van Alem AP, Chapman FW, Lank P, et al. A prospective, randomized and
7 Current levels were derived using the voltage levels from the stored blinded comparison of first shock success of monophasic and biphasic
capacitance equation above and applying Ohm’s Law V = IR; V = volts, waveforms in out-of-hospital cardiac arrest. Resuscitation. 2003;58:17-24.
I = current, R = resistance (patient impedance). An average patient 29 Stiell IG, Walker RG, Nesbitt LP, et al. BIPHASIC Trial: a randomized
impedance of 80 ohms was used as R. comparison of fixed lower versus escalating higher energy levels for
8 Niemann JT, Walker RG, Rosborough JP. Intracardiac voltage gradients defibrillation in out-of-hospital cardiac arrest. Circulation. 2007 Mar 27;
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injury. Academic Emergency Medicine. 2005;12(2). 30 Santomauro M, Borrelli A, Ottaviano L, et al. Transthoracic cardioversion
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swine with monophasic and biphasic waveforms. Circulation 1995;92:1634- Italian Heart Journal. Suppl. 2004 Jan; 5(1 Suppl):36-43.
1643. 31 Page RL, Kerber RE, Russell JK, et al. Biphasic versus monophasic
10 Tang W, Weil MH, Sun S, et al. The effects of biphasic and conventional shock waveform for conversion of atrial fibrillation. The results of an
monophasic defibrillation on post resuscitation myocardial function. international randomized, double-blind multicenter trial.
Journal American College Cardiology. 1999;34(3):815-822. Journal American College of Cardiology. 2002;39:1956-1963.
11 Tang W, Weil MH, Sun S, et al. A comparison of biphasic and monophasic 32 Waveforms based on actual timing of a Philips HeartStart MRx Monitor/
waveform defibrillation after prolonged ventricular fibrillation. Chest. Defibrillator (M3535A).
2001;120:948-954. 33 Tang W, Weil MH, Sun S, et al. The effects of biphasic waveform design
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defibrillation in a pediatric model of cardiac arrest and resuscitation. Cardiology. 2004;43:1228-1235.
Critical Care Medicine. 2002;30(12):2736-2741. 34 Xie J, Weil MH, Sun S, et al. High-energy defibrillation increases the
13 Page RL, Joglar JA, Kowal RC, et al. Use of automated external severity of post resuscitation myocardial function. Circulation. 1997;96:683-
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2000;343:1210-1216. 35 Weaver WD, Cobb LA, Copass MK, et al. Ventricular defibrillation-A
14 Capucci A, Aschieri D, Piepoli MF, et al. Tripling survival from sudden comparative trial using 175J and 320J shocks. New England Journal of
cardiac arrest via early defibrillation without traditional education in Medicine. 1982;307:1101-1106.
cardiopulmonary resuscitation. Circulation. 2002;106:1065-1070. 36 Cobb LA, Fahrenbruch CE, Walsh TR, et al. Influence of cardiopulmonary
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cardiac arrest. Resuscitation. 2001;49:9-14. 37 Wik L, Hansen TB, Fylling F, et al. Delaying defibrillation to give basic
16 Gliner BE, Jorgenson DB, Poole JE, et al. Treatment of out-of-hospital cardiopulmonary resuscitation to patients with out-of-hospital ventricular
cardiac arrest with a low-energy impedance-compensating biphasic fibrillation. JAMA. 2003; 289(11):1389-1395.
waveform automatic external defibrillation. Biomedical Instrumentation & 38 Yu T, Weil MH, Tang W, et al. Adverse outcomes of interrupted
Technology. 1998;32:631-644. precordial compression during automated defibrillation. Circulation. 2002;
17 White RD, Russell JK. Refibrillation, resuscitation and survival in out-of- 106:368-372.
hospital sudden cardiac arrest victims treated with biphasic automated 39 Eftestol T, Sunde K, Steen PA. Effects of interrupting precordial
external defibrillators. Resuscitation. 2002; 55(1):17-23. compressions on the calculated probability of defibrillation success during
18 Gliner BE, White RD. Electrocardiographic evaluation of defibrillation out-of-hospital cardiac arrest. Circulation. 2002;105:2270-2273.
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Resuscitation. 1999;41(2):133- 144. interruption intervals among commercially available automated external
19 Poole JE, White RD, Kanz KG. et al. Low-energy impedance- defibrillators may affect survival despite high defibrillation efficacy. Critical
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21 Gurnett CA, Atkins DL. Successful use of a biphasic waveform automated Lipitor® is a registered trademark of Parke-Davis, A Division of
external defibrillator in a high-risk child. American Journal Warner-Lambert Company LLC, A Pfizer Company.
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Resuscitation. 2001;49:233-243. ZOLL® is a registered trademark of ZOLL Medical Corporation.

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