Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: (none applicable)
The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: (none applicable)
Smith CM, Dee R, Rajendran K, Smith M, Perkins GD, Mancini MB, Avis S, Brooks S, Castren M, Chung S, Considine J, Kudenchuk P, Ristagno G, Semeraro F, Smyth, Morley P, Olasveengen TM on behalf of the BLS Task Force. Alternative compression techniques Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, 2020 Jan 1. Available from: http://ilcor.org
The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of alternative means of cardiopulmonary resuscitation (cough CPR, precordial thump, fist pacing) in adult or paediatric cardiac arrest (out-of-hospital or in-hospital). It was conducted by ILCOR evidence reviewers (Smith CM and Perkins) with involvement of clinical content experts (Dee, Rajendran, Smith M). Evidence was sought and considered by the Basic Life Support (BLS) Task Force group.
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Adults and children of any age who suffer cardiac arrest, whether in-hospital or out-of-hospital
Intervention: Cough CPR; precordial thump; fist pacing
Comparators: Standard CPR
Outcomes: Survival with favourable neurological outcome until and beyond hospital discharge or 30 days; survival until and beyond hospital discharge or 30 days; Return of Spontaneous Circulation (ROSC); restoration of cardiac output / circulation
Study Designs: We included RCTs, non-randomised studies, case-series with at least five cases. We considered papers in all languages provided there was an English language abstract available for review. We excluded unpublished studies, conference abstracts, manikin or simulation studies, narrative reviews, editorials or opinions with no primary data, animal studies and experimental / lab models.
Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search updated to October 2019.
PROSPERO Registration CRD42019152925
Consensus on Science
For the critical outcomes of survival to hospital discharge (n=1 study, Caldwell 1985 627) and important outcome restoration of cardiac output / circulation (n=3, Petelenz 1998 326; Nieman 1980 141; Marozsan 1990 401), we identified only observational studies. The overall certainty of evidence was rated as very low for all outcomes due to a very serious risk of bias. Because of this and a high degree of heterogeneity, no meta-analyses could be performed and individual studies are difficult to interpret.
For the critical outcome survival to hospital discharge we identified very-low-certainty evidence (downgraded for very serious risk of bias) from one cohort study including 500 adult patients admitted to ICU, CCU or general medical or surgical wards or suffering OHCA over 12 months.(Caldwell 1985 627) Six adult patients used cough CPR to terminate VT (reverting to sinus rhythm in five cases and rapid AF in one case), and all six survived to hospital discharge. Two of these patients also had a precordial thump (one before and one after coughing, on both occasions VT returning after successful initial termination).
For the important outcome restoration of cardiac output / circulation we identified very-low-certainty evidence (downgraded for very serious risk of bias) from three case series (out-of-hospital setting: Petelenz 1998 326, in-hospital setting: Nieman 1980 141; Marozsan 1990 401O). In the out-of-hospital setting one hundred and fifteen adult patients received instruction about how to perform cough CPR, following a diagnosis with Morgagni Adams Stokes syndrome. Sixty-six subsequently reported using it in 365 prodromal events out-of-hospital. These were not monitored and whether or not these represented cardiac arrhythmias associated with pending cardiac arrest is unclear. None of these 66 patients reported syncopal episodes after performing cough CPR for a mean of 1.6 minutes and there were no deaths.(Petelenz 1998 326) For the in-hospital setting we identified very-low-certainty evidence (downgraded for very serious risk of bias) from two case series.(Nieman 1980 141; Marozsan 1990 401) In the first, seven adult patients (six in cardiac catheter laboratory and one in CCU) with VF (n=4), asystole (n=2) and high-grade AV block (n=1) patients remained conscious whilst performing cough CPR until either defibrillation (for VF cases) or the patient’s own rhythm returned. Three patients with VF (all in the catheter laboratory) also had chest compressions performed at other times during the same episode.(Nieman 1980 141) The second case series reported on 92 transient arrythmias from a series of 131 coronary angiographies in adult patients: 13 of these (2 VF, 11 asystole) were rhythms that definitely associated with cardiac arrest. Coughing at a rate of one per second maintained consciousness in the 11 patients with asystole, and their normal rhythm ultimately returned. The two cases of VF occurred within eight seconds of initial rhythm disturbance when cough CPR was not performed, and VF was terminated in both cases by defibrillation. All 13 patients survived the event (Marozsan 1990; 401).
For the critical outcomes of survival to hospital discharge (n=5 studies, Nehme 2013 1691; Pellis 2009, 17; Caldwell 1985 627; Gertsch 1992 181; Rajagopalan 1971, 725) important outcome ROSC (n=1, Miller 1984 791) and important outcome termination of VT or VF (n=10, Rahner 19781659; Cotoi 1980 285; Pennington 1970 1192; Morgera 1979 69; Haman 2009 14; Amir 2007 153; Befeler 1978 832; Volkmann 1990 453; Miller 1985 175; Nejima 1991 40), we identified only observational studies. The overall certainty of evidence was rated as very low for all outcomes primarily due to a very serious risk of bias. Because of this and a high degree of heterogeneity, no meta-analyses could be performed and individual studies are difficult to interpret.
For the critical outcomes of survival to hospital we identified very-low-certainty evidence (downgraded for very serious risk of bias) from five observational studies.(Out-of-hospital setting: Nehme 2013 1691; Pellis 2009 17, and in-hospital setting: Caldwell 1985 627; Gertsch 1992 181; Rajagopalan 1971, 725) In the out-of-hospital setting a retrospective cohort study compared precordial thump first with defibrillation first for EMS-witnessed, monitored VF/VT OHCA in patients aged 16 or over (very serious risk of bias). Survival to hospital discharge (70.2% defibrillation first vs 70.9% thump first) and overall ROSC (89.9% defibrillation first and 93.2% thump first) were similar in both groups. Immediate ROSC was significantly higher in the defibrillation first group than the thump first group (57.8% vs 4.9%, p<0.0001). Rhythm deterioration (12.3% defibrillation first vs 9.7% thump first) was similar in both groups (p=0.48). (Nehme 2013 1691) The other out-of-hospital cohort study reported on 363 OHCA in 2004-5 (age range not specified), 144 of whom received a precordial thump by EMS. Survival to hospital discharge was 8/144 (5.6%) in the precordial thump group and 14/219 (6.4%) in the non-precordial thump group (p=ns). ROSC was seen in 31/144 (21.5%) precordial thump and 43/219 (19.6%) non-precordial thump patients (p=ns). A rhythm change was seen in 6/144 (4.2%) precordial thump patients. (Pellis 2009, 17)
In the in-hospital setting a cohort study of 5000 adult patients admitted to ICU, CCU or general medical or surgical wards or suffering OHCA over 12 months, nineteen adult patients successfully had their tachyarrhythmia (4 VF, 11 VT, 2 asystole, 2 unknown rhythm) terminated by precordial thump. Eleven of these 19 survived to hospital discharge (10/16 in-hospital and 2/3 following OHCA) (Caldwell 1985 627). A second case series of “randomly selected” adult patients with coronary artery disease, 13/19 instances of VT were successfully treated with serial chest thumps (5-7 thumps delivered at a rate faster than VT) in 8/14 patients. Nine patients (4 in successfully converted group, and 5 in unsuccessfully converted group) survived to at least hospital discharge: mean follow-up for survival was 25 months. (Gertsch 1992 181). In the third case series of five adult patients with VT resistant to treatment with antiarrhythmic drugs, subsequently successfully treated with precordial thump, two patients survived to hospital discharge (Rajagopalan 1971, 725).
For the important outcome of ROSC we identified very-low-certainty evidence (downgraded for very serious risk of bias) from one observational case series including 50 adult patients treated by EMS for OHCA. All developed VT or VF at some point during the resuscitation effort and received a precordial thump. In VT patients, 3/27 (11%) were thumped into a “better” rhythm, of whom 2 out of 3 (66.7%) achieved ROSC; 12 (44%) had no change in rhythm of whom 6 (50%) achieved ROSC; 12/27 were thumped into a “worse” rhythm, of whom 3 (25%) achieved ROSC. Overall, 11/27 (41%) patients received precordial thump for VT had ROSC. There was no change in rhythm for all of the 23 patients who received a precordial thump for VF, and 12 of them (52%) achieved ROSC. (Miller 1984, 791)
For the important outcome of termination of VT or VF we identified very-low-certainty evidence (downgraded for very serious risk of bias) from 10 observational studies.(Rahner 19781659; Cotoi 1980 285; Pennington 1970 1192; Morgera 1979 69; Haman 2009 14; Amir 2007 153; Befeler 1978 832; Volkmann 1990 453; Miller 1985 175; Nejima 1991 40) Some of these studies selectively report on successful use of the precordial thump (Rahner 1978,1659) (Cotoi 1980, 285) (Pennington 1970, 1192). In other studies the successful use of precordial thump to terminate the arrhythmia was: 22/45 instances of VT in 17 adult patients (Morgera 1979;69); 2/155 adult patients with VT (Haman 2009;14); 1/52 adult patients with VT and 0/28 adult patients with VF (Amir 2007, 153); 10/18 adult patients with VT (Befeler 1978;832); 20/37 cases of VT and 0/10 cases of VF or ‘ventricular flutter’ in 33 adult patients (Volkmann 1990; 453); 0/11 episodes of VT in 9 adult patients (Miller 1985, 175); 28/46 episodes of VT in 13/27 adult patients (Nejima 1991, 40).
For the critical outcomes of survival to hospital discharge (n=1 study, Klumbies 1988 348), important outcome ROSC (n=1, Iseri 1987 348) and important outcome restoration of cardiac output / circulation (n=2, Paliege 1982 1094; Scherf 1960 30), we identified only observational studies. The overall certainty of evidence was rated as very low for all outcomes primarily due to a very serious risk of bias. Because of this and a high degree of heterogeneity, no meta-analyses could be performed and individual studies are difficult to interpret.
For the critical outcomes of survival to hospital we identified very-low-certainty evidence (downgraded for very serious risk of bias) from one observational study including one hundred patients (mean 68yrs, range 11-84) suffering asystolic or “life-threatening bradycardic” events in a variety of in-hospital settings. Ninety had an initial response to fist pacing. Ninety-five patients were monitored by ECG. Sixty-nine recovered (or did not lose) consciousness and 86 survived the event. Sixty-two survived to hospital discharge. It is not clear whether this case series represents 100 consecutive patients or whether there were other selection criteria or selective reporting. It is not clear how many paediatric patients there were in this series (Klumbies 1988, 348).
For the important outcome of ROSC we identified very-low-certainty evidence (downgraded for very serious risk of bias) from one case series including five adult men who received fist pacing sufficient to achieve a central pulse, evidence of depolarization on cardiac monitor, or both, following asystolic cardiac arrest events. The nature of these events was heterogeneous: in three cases there were periods of time where shockable rhythms occurred, requiring both CPR and defibrillation; four of the five involved the administration of pharmacological agents. Return of spontaneous circulation was reported in all five cases and post-event outcome data in two cases (one died 48hrs later, one survived to hospital discharge) (Iseri 1987, p348).
For the important outcome restoration of cardiac output / circulation we identified very-low-certainty evidence (downgraded for very serious risk of bias) from two case series. In one case series cardiac output was maintained in 41 out of 42 adult patients (35 asystolic and 7 with severe bradycardia) for up to half an hour in some cases. Twenty-six were ultimately treated by pacing wire, but 16 had a permanent pacemaker implantation. Fifteen of these were done as an emergency, and eight of these fifteen patients died (Paliege 1982, 1094). In the other case series published in 1960, eleven adult patients who developed ‘ventricular standstill’ at some point during their clinical course, ectopic beats were generated on an ECG trace by fist pacing. Ultimately, nine of these patients subsequently died, one survived to hospital discharge, and the outcome in the eleventh was unclear.(Scherf 1960, 30)
We recommend against “cough CPR” for cardiac arrest (strong recommendation, very-low-certainty evidence).
We suggest cough CPR may only be considered as a temporizing measure in an exceptional circumstance in a witnessed, monitored, in-hospital setting (such as a cardiac catheterization laboratory) if a non-perfusing rhythm is recognised promptly before loss of consciousness (weak recommendation, very-low-certainty evidence).
We recommend against the use of a precordial thump for cardiac arrest (strong recommendation, very-low-certainty evidence).
We recommend against fist pacing for cardiac arrest (strong recommendation, very-low-certainty evidence).
We suggest fist pacing may only be considered as a temporizing measure in an exceptional circumstance in a witnessed, monitored, in-hospital setting (such as a cardiac catheterization laboratory) if a non-perfusing rhythm is recognised promptly before loss of consciousness (weak recommendation, very-low-certainty evidence).
Justification and Evidence to Decision Framework Highlights
This topic was last reviewed in the 2010 CoSTR. In contrast with the current systematic review, the 2010 CoSTR considered alternative CPR techniques in adults only, and included case series with fewer than five patients.
The very-low-quality evidence available precludes meaningful meta-analysis. Two studies (both on precordial thump) had a direct comparator group (standard CPR), and both of these had a very serious risk of bias. The others were limited case series or cohorts without a comparator group.
There is no evidence of the effectiveness of cough CPR in established OHCA. Very-low-quality evidence from one study (Petelenz 1998, 326) addresses the use of cough CPR for prodromal symptoms of collapse in high-risk patients, where the cardiac rhythm was not known and the likelihood of progressing to cardiac arrest uncertain. Accepting the benefit of cough CPR for the general population would require us to accept that an untrained patient could reliably identify a cardiac arrest rhythm in time to initiate coughing to maintain a cardiac output. This seems highly unlikely.
There are periodic stories (on social media for example) instructing members of the public to perform cough CPR in case of imminent collapse, so it is important that we address this topic. We should be clear that we do not recommend cough CPR in OHCA. The risks are 1) that it delays effective treatment (early call for help, early CPR and defibrillation if the patient loses consciousness and stops breathing normally) and 2) that members of the public confusing ‘cardiac arrest’ with ‘heart attack’ delay seeking help when suffering chest pain or other symptoms indicating a possible ischaemic cardiac event.
There is no evidence to contradict the position from CoSTR 2010 that we could consider cough CPR in the exceptional circumstance of monitored, witnessed cardiac arrests occurring in-hospital. There is limited very-low quality evidence that this may be effective in all arrhythmias that can cause cardiac arrest, and not just VF and VT. This evidence is for adult patients only. There is some evidence that cough CPR increases aortic, left atrial and left ventricular pressures, but a causative link between cough CPR and termination of the malignant arrhythmia is lacking. It would not be appropriate to prioritise cough CPR over other measures with proven efficacy, but clinicians may consider it as a temporary measure if there a delay to defibrillation.
We have considered the potential benefit of precordial thumping against the potential for harm, A precordial thump can potentially interrupt a life-threatening VT by generating an electrical impulse, resulting in a premature ventricular beat. However, there is a risk of deterioration of cardiac rhythm (from VT to VF, akin to a ‘R on T’ phenomenon), and a delay to CPR or defibrillation. Delay to definitive treatment is a particularly concern in situations where lay rescuers are providing cardiac arrest interventions.
A causal link between precordial thump and the critical outcomes of survival to hospital discharge and ROSC is lacking. Defibrillation is a more effective treatment for the termination of VF and VT and should be prioritised. There is concern from one study (very-low-quality evidence) that use of precordial thump could compromise first shock success (Nehme 2013, 1691)
In many of the included studies it is unclear whether the tachyarrhythmia (VT) represents cardiac arrest or impending loss of cardiac output – it is very likely that this is not the case for many of the cases included in individual studies.
Across studies, there is a lack of standardization regarding the technique of precordial thump, the number of times it was used, other pharmacological treatments delivered before or after its delivery and, in some cases, its timing related to the onset of the tachyarrhythmia.
The evidence is limited to three cases series (100, 42 and 5 patients, respectively) in asystole or bradycardia, suggesting that cardiac output can be maintained if fist pacing is initiated very quickly after their onset. An electrical impulse is generated, sufficient to cause myocardial contraction.
There is no evidence comparing fist pacing with standard CPR (chest compressions) in established asystolic cardiac arrest. We again highlight the importance of prompt, high-quality chest compressions for the treatment of cardiac arrest.
There is no evidence to contradict the position from CoSTR 2010 that we could consider fist pacing in the exceptional circumstance of monitored, witnessed cardiac arrests occurring in-hospital. This evidence is for adults only. It would not be appropriate to prioritise fist pacing over other measures with proven efficacy, but clinicians may consider it as a temporary measure if there a delay to defibrillation.
Current knowledge gaps include but are not limited to:
- There is no data directly comparing cough CPR and fist pacing to standard CPR
- There is no data for any alternative CPR technique assessing survival with a favourable neurological outcome
- There is limited, very-low quality evidence assessing the critical outcome of survival to hospital discharge.
- There is no data on any outcome following alternative CPR techniques performed in children.
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