Three Stacked Shocks were removed from the standard ALS algorithm as part of the 2010 CoSTR changes. It is now included under the special circumstances in resuscitation guideline.
Where a patient with a perfusing rhythm develops a shockable rhythm in a witnessed and monitored setting and the defibrillator is immediately available and they were previously well perfused and oxygentated pre-arrest then the use of 3 stacked shocks may be considered.
This situation is rare and may occur in the pre-hospital setting, emergency departments, critical care and coronary care units, and possibly also in the operating room. In these settings it may be appropriate to use a 3 stacked-shock technique, especially where there may be a relative contraindication to external cardiac compressions (e.g. after cardiac surgery).
The “3 stacked-shock sequence” can be optimized by immediate rhythm analysis and charging of the defibrillator. This sequence may be of benefit in scenarios where the time required for rhythm recognition and for recharging the defibrillator is short (ie:. <10 seconds). In these situations, such as in-hospital arrests, it would be expected to deliver the sequence of shocks (up to three) in no more than 30 seconds.
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