Hand position during compressions (BLS #357): Systematic Review

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This CoSTR is a draft version prepared by ILCOR, with the purpose to allow the public to comment and is labeled “Draft for Public Comment". The comments will be considered by ILCOR. The next version will be labelled “draft" to comply with copyright rules of journals. The final COSTR will be published on this website once a summary article has been published in a scientific Journal and labeled as “final”.

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: (Olasveengen, author on one of the included papers)

CoSTR Citation

Avis S, Olasveengen TM, Mancini MB, Brooks S, Castren M, Chung S, Considine J, Kudenchuk P, Perkins G, Ristagno G, Semeraro F, Smyth M , Morley PM-on behalf of the International Liaison Committee on Resuscitation BLS Life Support Task Force.

Hand position during compressions Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, 2020 February 16. Available from:

Methodological Preamble

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of basic life support conducted by Suzanne Avis and Theresa M. Olasveengen with involvement of clinical content experts. Evidence for adult and pediatric literature was sought and considered by the Basic Life Support Adult Task Force. These data were taken into account when formulating the Treatment Recommendations.


The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Adults and children in any setting (in-hospital or out-of-hospital) with cardiac arrest.

Intervention: any other location for chest compressions

Comparators: delivery of chest compressions on the lower half of the sternum

Outcomes: Any clinical outcome. Survival to hospital discharge with good neurological outcome and survival to hospital discharge were ranked as critical outcomes. Return of spontaneous circulation (ROSC) was ranked as an important outcome. Physiological outcomes including blood pressure, coronary perfusion pressure or EtCO2 were also considered important outcomes.

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) reporting clinical outcomes are eligible for inclusion.

Timeframe: All years and all languages were included as long as there was an English abstract. Mannikin studies and unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search updated to October 31, 2019.

Consensus on Science

There were no studies reporting the critical outcomes of favourable neurologic outcome, survival, or ROSC.

For the important outcome of physiological end points, we identified 3 very low certainty studies (downgraded for bias, indirectness, and imprecision).(Orlowski 1986 667; Cha 2013 691; Qvigstad 2013 1203) One crossover study in 17 adults with prolonged resuscitation from non-traumatic cardiac arrest observed improved peak arterial pressure during compression systole (114 ± 51 mm Hg versus 95 ± 42 mm Hg) and end-tidal carbon dioxide (ETCO2; 11.0 ± 6.7 mm Hg versus 9.6 ± 6.9 mm Hg) when compressions were performed in the lower third of the sternum compared with the centre of the chest, whereas arterial pressure during compression recoil, peak right atrial pressure, and coronary perfusion pressure did not differ.{Cha 2013 691} A second crossover study in 30 adults observed no difference between ETCO2 values and hand placement.{Qvigstad 2013 1203} A further crossover study in 10 children observed higher peak systolic pressure and higher mean arterial blood pressure when compressions were performed on the lower third of the sternum compared with the middle of the sternum.{Orlowski 1986 667}

Treatment Recommendations

We suggest performing chest compressions on the lower half of the sternum on adults in cardiac arrest (weak recommendation, very low certainty evidence).

Justification and Evidence to Decision Framework Highlights

The existing ILCOR treatment recommendation was first published in 2010.{Sayre 2010 S298; Koster 2010 e48}, and also reviewed in detail for the 2015 CoSTR. {Travers 2015 s51; Perkins 2015 e43}

We did not identify any RCTs comparing standard care in any study population. There were no studies that evaluated any specific hand position’s effect on short- or long-term survival after cardiac arrest, and only physiologic surrogate outcomes were evaluated.

Imaging studies were excluded from the current systematic review as they do not report clinical outcomes for patients in cardiac arrest, but they do provide some supportive background information. Imaging studies examining hand position for chest compressions describe the optimal position for compressions based on the anatomical structures underlying the recommended and alternative hand positions. Evidence from recent imaging studies indicates that, in most adult and pediatric patients, the maximal ventricular cross-sectional area underlies the lower third of the sternum/xiphisternal junction, and the ascending aorta and left ventricular outflow tract underlie the center of the chest.{Park 2018 e576; Lee 2018 1; Nestaas 2016 54; Cha 2013 615; Papadimitriou 2013 549; Holmes 2015 401}. Imaging studies also suggest there might be important differences in anatomy between individuals depending on factors including age, Body Mass Index, congenital cardiac disease and pregnancy, and as such one specific hand placement strategy might not provide optimal compressions across a range of persons.{Park 2016 303; Lee 2018 1; Holmes 2015 401}. However, there is an absence of robust clinical evidence reporting survival outcomes or harm from any alternate hand position for chest compressions.

In reconfirming the recommendation to perform chest compressions on the lower half of the sternum, with rewording to be consistent with the GRADE process, we placed a high value on consistency with previous recommendations, in the absence of compelling clinical data suggesting the need to change the recommended approach. The BLS Task Force acknowledges that every change in guidelines comes with a significant risk and cost as CPR educators and providers are asked to change current practice and implement new treatment strategies. Important gaps remain in evaluating how to identify optimal hand placement and/or compression point for individuals in cardiac arrest using physiologic feedback or incorporating previous imaging.

Knowledge Gaps

Current knowledge gaps include but are not limited to:

• Associations between different hands-positions during CPR and patient outcomes

• Should strategies to identify optimal individual hand placement during CPR be developed?

• Which physiological parameter is most useful in evaluating optimal hand placement during CPR?


Evidence-to-Decision Table: BLS-357-Hand-position-during-compressions


Cha KC, Kim YJ, Shin HJ, Cha YS, Kim H, Lee KH, Kwon W, Hwang SO. Optimal position for external chest compression during cardiopulmonary resuscitation: an analysis based on chest CT in patients resuscitated from cardiac arrest. Emergency Medicine Journal. 2013 Aug 1;30(8):615-9.

Cha KC, Kim HJ, Shin HJ, Kim H, Lee KH, Hwang SO. Hemodynamic effect of external chest compressions at the lower end of the sternum in cardiac arrest patients. J Emerg Med. 2013 Mar;44:691-7.

Holmes S, Kirkpatrick ID, Zelop CM, Jassal DS. MRI evaluation of maternal cardiac displacement in pregnancy: implications for cardiopulmonary resuscitation. Am J Obstet Gynecol. 2015 Sep;213(3):401-e1

Koster RW, Sayre MR, Botha M, Cave DM, Cudnik MT, Handley AJ, Hatanaka T, Hazinski MF, Jacobs I, Monsieurs K, Morley PT. Part 5: Adult basic life support: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation. 2010 Oct 1;81(1):e48-70.

Lee J, Oh J, Lim TH, Kang H, Park JH, Song SY, Shin GH, Song Y. Comparison of optimal point on the sternum for chest compression between obese and normal weight individuals with respect to body mass index, using computer tomography: A retrospective study.Resuscitation. 2018 Jul;128:1-5

Nestaas S, Stensæth KH, Rosseland V, Kramer-Johansen J. Radiological assessment of chest compression point and achievable compression depth in cardiac patients. Scandinavian journal of trauma, resuscitation and emergency medicine. 2016 Dec;24(1):54.

Orlowski JP. Optimum position for external cardiac compression in infants and young children. Ann Emerg Med. 1986 Jun;15(6):667-73.

Papadimitriou P, Chalkias A, Mastrokostopoulos A, Kapniari I, Xanthos T. Papadimitriou 2013 Anatomical structures underneath the sternum in healthy adults and implications for chest compressions.Am J Emerg Med. 2013 Mar;31(3):549-55.

Park JB, Song IK, Lee JH, Kim EH, Kim HS, Kim JT. Optimal Chest Compression Position for Patients With a Single Ventricle During Cardiopulmonary Resuscitation. Pediatr Crit Care Med. 2016 Apr;17(4):303-6.

Park M, Oh WS, Chon SB, Cho S. Optimum Chest Compression Point for Cardiopulmonary Resuscitation in Children Revisited Using a 3D Coordinate System Imposed on CT: A Retrospective, Cross-Sectional Study. Pediatr Crit Care Med. 2018 Nov;19(11):e576-e584.

Qvigstad E, Kramer-Johansen J, Tømte Ø, Skålhegg T, Sørensen Ø, Sunde K, Olasveengen TM. Clinical pilot study of different hand positions during manual chest compressions monitored with capnography. Resuscitation. 2013 Sep;84:1203-7.

Sayre MR, Koster RW, Botha M, Cave DM, Cudnik MT, Handley AJ, Hatanaka T, Hazinski MF, Jacobs I, Monsieurs K, Morley PT. Part 5: adult basic life support: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. 2010 Oct 19;122(16_suppl_2):S298-324.

Systematic Review


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