The authors reply, “A focused investigation of expedited, stack of three shocks versus chest compressions first followed by single shocks for monitored ventricular fibrillation/ventricular tachycardia cardiopulmonary arrest in an in‐hospital setting”

We appreciate the opportunity to continue dialogue regarding the optimal timing of defibrillation, standardized guidelines, and healthy skepticism as to whether they apply to all settings and patient populations. The transition to a single shock followed by resumption of chest compressions over 3 stacked shocks represents the integration of 2 concepts into a single algorithm.[1] The first reflects concern about delays in chest compressions related to rhythm analysis and charge of an automated external defibrillator. This justified a single shock followed by chest compressions to avoid unnecessary pauses. The same guidelines also recommended 2 minutes of cardiopulmonary resuscitation (CPR) prior to the initial and each subsequent defibrillation attempt, providing substrate to the myocardium and increasing the likelihood of shock success.[2, 3, 4] The underlying physiological concept is described by Weisfeldt and Becker as part of their 3‐phase model of ventricular fibrillation.[2, 5] Large randomized out‐of‐hospital studies have demonstrated that high‐quality CPR may prime the heart before defibrillation, as suggested by the 3‐phase model.[6, 7, 8]

Regardless of the theoretical construct(s) upon which the original recommendations were based, we agree with Mr. Stewart that these are misapplied to the inpatient setting that allow for expeditious attempts at defibrillation and stacking of subsequent attempts.