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.
Task Force Scoping Review Citation
Ristagno G, Mancini MB, Avis S, Brooks S, Castren M, Chung S, Considine J, Kudenchuk P, Perkins GD, Semeraro F, Smith C, Smyth M , Morley PT, Olasveengen TM -on behalf of the International Liaison Committee on Resuscitation Basic Life Support Task Force. Pad size, orientation and placement for Cardiac Arrest - Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, 2019 Dec 30th. Available from: http://ilcor.org
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 Giuseppe Ristagno and Mary B. Mancini with involvement of clinical content experts, Mary B. Mancini and Theresa Olasveengen. A new search strategy was developed by an IS and literature reviewed independently by G. Ristagno and MB. Mancini. Evidence for adult literature was sought and considered by the Basic Life Support Adult Task Force. “Defibrillation pad” was defines as single use adhesive defibrillation pads placed on patients’ skin and connected to a defibrillator to administer an electrical shock in patients with arrhythmias (such as ventricular fibrillation or ventricular tachycardia). “Pad size” was defined as size of defibrillator pads. “Pad orientation/ position” was defined as placement of pads in various positions or orientations on the thorax to maximize effectiveness in terminating shockable cardiac rhythms.
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Adults in any setting (in-hospital or out-of-hospital) with cardiac arrest.
Intervention: The use of any specific pad size/orientation and position.
Comparators: Standard resuscitation or other specific paddle/pad size/orientation and position.
Outcomes: 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. Termination of VF, rates of recurrence of fibrillation/re-fibrillation were included as 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) are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded.
It is anticipated that there will be insufficient studies from which to draw a conclusion; case series will be included in the initial search and included as long as they contain ≥ 5 cases.
Timeframe: Since 1st Jan 2009 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 Nov 11, 2019.
Search Strategies
|
# |
Searches |
Results |
|
1 |
Electric Countershock/ |
34142 |
|
2 |
Defibrillators/ |
25777 |
|
3 |
(defibrillat* or AED or electroversion? or electro-version? or cardioversion? or cardio-version? or electric countershock? or electric counter-shock?).tw,kf. |
98309 |
|
4 |
(cardiac adj2 stimulator?).tw,kf. |
397 |
|
5 |
or/1-4 [DEFIBRILLATORS] |
118529 |
|
6 |
Cardiography, Impedance/ or Electric Impedance/ or Electric Conductivity/ |
105507 |
|
7 |
((transthoracic adj2 (impedance or resistance)) or TTI or TTR).tw,kf. |
14275 |
|
8 |
(electric* adj2 (conductiv* or impedance)).tw,kf. |
34663 |
|
9 |
((orientation? or position* or placement or placed or placing or situated or shape? or size? or rectangl* or square or anterior* or posterior* or anteroposterior* or antero-posterior* or lateral* or lateroposterior* or latero-posterior* or longitudinal* or transverse*) adj2 (pad? or paddle? or electrode? or defibrillat* or AED)).tw,kf. |
31181 |
|
10 |
or/6-9 [IMPEDANCE] |
167696 |
|
11 |
5 and 10 |
4393 |
|
12 |
exp Animals/ not (exp Animals/ and Humans/) |
17007990 |
|
13 |
11 not 12 [ANIMAL-ONLY REMOVED] |
2973 |
|
14 |
exp Child/ not (exp Adult/ or Adolescent/) |
2341969 |
|
15 |
exp Infant/ not (exp Adult/ or Adolescent/) |
1394532 |
|
16 |
13 not (14 or 15) [CHILD- AND INFANT-ONLY REMOVED] |
2913 |
|
17 |
(comment or editorial or news or newspaper article).pt. |
1999971 |
|
18 |
(letter not (letter and randomized controlled trial)).pt. |
2133143 |
|
19 |
16 not (17 or 18) [OPINION PIECES REMOVED] |
2837 |
|
20 |
19 and (2009* or 2010* or 2011* or 2012* or 2013* or 2014* or 2015* or 2016* or 2017* or 2018* or 2019*).dt. |
530 |
|
21 |
20 use ppez |
530 |
|
22 |
cardioversion/ |
34142 |
|
23 |
defibrillator/ or exp external defibrillator/ |
44633 |
|
24 |
(defibrillat* or AED or electroversion? or electro-version? or cardioversion? or cardio-version? or electric countershock? or electric counter-shock?).tw,kw. |
100874 |
|
25 |
(cardiac adj2 stimulator?).tw,kw. |
397 |
|
26 |
or/22-25 [DEFIBRILLATORS] |
125397 |
|
27 |
impedance cardiography/ or impedance/ or electric conductivity/ or electric resistance/ |
116760 |
|
28 |
((transthoracic adj2 (impedance or resistance)) or TTI or TTR).tw,kw. |
14352 |
|
29 |
(electric* adj2 (conductiv* or impedance)).tw,kw. |
35095 |
|
30 |
((orientation? or position* or placement or placed or placing or situated or shape? or size? or rectangl* or square or anterior* or posterior* or anteroposterior* or antero-posterior* or lateral* or lateroposterior* or latero-posterior* or longitudinal* or transverse*) adj2 (pad? or paddle? or electrode? or defibrillat* or AED)).tw,kw. |
31272 |
|
31 |
or/27-30 [IMPEDANCE] |
178673 |
|
32 |
26 and 31 |
4677 |
|
33 |
exp animal experimentation/ or exp animal model/ or exp animal experiment/ or nonhuman/ or exp vertebrate/ |
48908645 |
|
34 |
exp human/ or exp human experimentation/ or exp human experiment/ |
39003017 |
|
35 |
32 not (33 not 34) [ANIMAL-ONLY REMOVED] |
4140 |
|
36 |
exp adolescent/ not (exp adult/ and exp adolescent/) |
1157279 |
|
37 |
exp child/ not (exp adult/ and exp child/) |
3066400 |
|
38 |
fetus/ not (exp adult/ and fetus/) |
221918 |
|
39 |
35 not (36 or 37 or 38) [UNDER 18 REMOVED] |
4006 |
|
40 |
editorial.pt. |
1141732 |
|
41 |
letter.pt. not (randomized controlled trial/ and letter.pt.) |
2133370 |
|
42 |
39 not (40 or 41) [OPINION PIECES REMOVED] |
3893 |
|
43 |
conference abstract.pt. |
3641955 |
|
44 |
42 not 43 [CONFERENCE ABSTRACTS REMOVED] |
2937 |
|
45 |
44 and (2009* or 2010* or 2011* or 2012* or 2013* or 2014* or 2015* or 2016* or 2017* or 2018* or 2019*).dc. |
757 |
|
46 |
45 use oemezd |
757 |
|
47 |
Electric Countershock/ |
34142 |
|
48 |
Defibrillators/ |
25777 |
|
49 |
(defibrillat* or AED or electroversion? or electro-version? or cardioversion? or cardio-version? or electric countershock? or electric counter-shock?).tw,kw. |
100874 |
|
50 |
(cardiac adj2 stimulator?).tw,kw. |
397 |
|
51 |
or/47-50 [DEFIBRILLATORS] |
120546 |
|
52 |
Cardiography, Impedance/ or Electric Impedance/ or Electric Conductivity/ |
105507 |
|
53 |
((transthoracic adj2 (impedance or resistance)) or TTI or TTR).tw,kw. |
14352 |
|
54 |
(electric* adj2 (conductiv* or impedance)).tw,kw. |
35095 |
|
55 |
((orientation? or position* or placement or placed or placing or situated or shape? or size? or rectangl* or square or anterior* or posterior* or anteroposterior* or antero-posterior* or lateral* or lateroposterior* or latero-posterior* or longitudinal* or transverse*) adj2 (pad? or paddle? or electrode? or defibrillat* or AED)).tw,kw. |
31272 |
|
56 |
or/52-55 [IMPEDANCE] |
167991 |
|
57 |
51 and 56 |
4438 |
|
58 |
exp Child/ not (exp Adult/ or Adolescent/) |
2341969 |
|
59 |
exp Infant/ not (exp Adult/ or Adolescent/) |
1394532 |
|
60 |
57 not (58 or 59) [CHILD- AND INFANT-ONLY REMOVED] |
4347 |
|
61 |
conference abstract.pt. |
3641955 |
|
62 |
60 not 61 [CONFERENCE ABSTRACTS REMOVED] |
3421 |
|
63 |
62 and (2009* or 2010* or 2011* or 2012* or 2013* or 2014* or 2015* or 2016* or 2017* or 2018* or 2019*).up,pd,dp,dr. |
3418 |
|
64 |
63 use coch [COCHRANE DATABASE OF SYSTEMATIC REVIEWS] |
9 |
|
65 |
63 use cctr [COCHRANE CENTRAL] |
241 |
|
66 |
63 use acp [ACP JOURNAL CLUB] |
1 |
|
67 |
63 use dare [DATABASE OF ABSTRACTS OF REVIEWS OF EFFECTS] |
2 |
|
68 |
63 use clcmr [COCHRANE METHODOLOGY REGISTER DATABASE] |
0 |
|
69 |
63 use clhta [HEALTH TECHNOLOGY ASSESSMENT DATABASE] |
0 |
|
70 |
63 use cleed [NATIONAL HEALTH SERVICE ECONOMIC EVALUATION DATABASE] |
6 |
|
71 |
21 or 46 or 64 or 65 or 66 or 67 or 68 or 69 or 70 [ALL DATABASES - NO DUPLICATES REMOVED] |
1546 |
|
72 |
remove duplicates from 71 [TOTAL UNIQUE RECORDS] |
1063 |
|
73 |
72 use ppez [MEDLINE UNIQUE RECORDS] |
119 |
|
74 |
72 use oemezd [EMBASE UNIQUE RECORDS] |
734 |
|
75 |
72 use coch [COCHRANE DATABASE OF SYSTEMATIC REVIEWS UNIQUE RECORDS] |
9 |
|
76 |
72 use cctr [CENTRAL UNIQUE RECORDS] |
192 |
|
77 |
72 use acp [ACP JOURNAL CLUB UNIQUE RECORDS] |
1 |
|
78 |
72 use dare [DATABASE OF ABSTRACTS OF REVIEWS OF EFFECTS UNIQUE RECORDS] |
2 |
|
79 |
72 use clcmr [COCHRANE METHODOLOGY REGISTER DATABASE] |
0 |
|
80 |
72 use clhta [HEALTH TECHNOLOGY ASSESSMENT DATABASE] |
0 |
|
81 |
72 use cleed [NATIONAL HEALTH SERVICE ECONOMIC EVALUATION DATABASE] |
6 |
CINAHL via Ebsco
|
# |
Query |
Results |
|
S14 |
S13 and EM 20090101-20191231 |
261 |
|
S13 |
S12 NOT (PT commentary OR PT letter OR PT editorial) |
444 |
|
S12 |
S11 NOT MH (("child+" NOT "adult+") OR ("adolescence+" NOT "adult+")) |
478 |
|
S11 |
S10 NOT (MH "Animals+") NOT ((MH "Human") AND (MH "Animals+")) |
502 |
|
S10 |
S4 and S9 |
535 |
|
S9 |
S5 or S6 or S7 or S8 |
7,237 |
|
S8 |
TI ((orientation? or position* or placement or placed or placing or situated or shape? or size? or rectangl* or square or anterior* or posterior* or anteroposterior* or antero-posterior* or lateral* or lateroposterior* or latero-posterior* or longitudinal* or transverse*) N1 (pad? or paddle? or electrode? or defibrillat* or AED)) or AB ((orientation? or position* or placement or placed or placing or situated or shape? or size? or rectangl* or square or anterior* or posterior* or anteroposterior* or antero-posterior* or lateral* or lateroposterior* or latero-posterior* or longitudinal* or transverse*) N1 (pad? or paddle? or electrode? or defibrillat* or AED)) |
2,018 |
|
S7 |
TI (electric* N1 (conductiv* or impedance)) or AB (electric* N1 (conductiv* or impedance)) |
675 |
|
S6 |
TI ((transthoracic N1 (impedance or resistance)) or TTI or TTR) or AB ((transthoracic N1 (impedance or resistance)) or TTI or TTR) |
699 |
|
S5 |
MH ("Cardiography, Impedance" or "Electric Impedance") |
4,280 |
|
S4 |
S1 or S2 or S3 |
16,130 |
|
S3 |
TI (cardiac N1 stimulator?) or AB (cardiac N1 stimulator?) |
5 |
|
S2 |
TI (defibrillat* or AED or electroversion? or electro-version? or cardioversion? or cardio-version? or electric countershock? or electric counter-shock?) or AB (defibrillat* or AED or electroversion? or electro-version? or cardioversion? or cardio-version? or electric countershock? or electric counter-shock?) |
13,805 |
|
S1 |
MH ("Defibrillators" or "Defibrillators, Automated External" or "Cardioversion") |
5,821 |
Inclusion and Exclusion criteria
Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Animal/lab studies, mathematical models, simulation and mannikin studies, algorithm studies with no outcome data, studies on double sequential defibrillation approaches, and unpublished studies (e.g., conference abstracts, trial protocols) and reviews were excluded.
Data Tables
Not applicable.
Task Force Insights
1. Why this topic was reviewed.
This topic was suggested by the Australian Resuscitation Council. The BLS taskforce was supportive of an updated evidence review as this topic had not been reviewed by ILCOR since 2010.
2. Narrative summary of evidence identified
There were insufficient studies identified to support a more specific systematic review.
3. Narrative Reporting of the task force discussions
Key issues from BLS Task Force discussions:
- Aspects of the 2010 PICOSTs addressing paddles should be removed as modern equipment using self-adhesive pads have replaced paddles.
- Although some studies have shown that antero-posterior electrode placement is more effective than the traditional antero-apical position in elective cardioversion of atrial fibrillation, the majority have failed to demonstrate any clear advantage of any specific electrode position. Transmyocardial current during defibrillation is likely to be maximal when the electrodes are placed so that the area of the heart that is fibrillating lies directly between them (i.e. ventricles in VF/pulseless VT, atria in AF). Therefore, the optimal electrode position may not be the same for ventricular and atrial arrhythmias.
- Recent approaches including double sequential defibrillation, in which differently oriented sequential defibrillations are delivered, have been evaluated by the ALS Task Force in a separate evidence review.
- This scoping review was unable to identify any new studies that needed to be added to the previous systematic review. In light of this we believe that the existing CoSTR does not need to be modified (with the exception of removing reference to “paddles” as noted above).
2010 COSTR: It is reasonable to place paddles/pads on the exposed chest in an anterior-lateral position. Acceptable alternative positions are anterior-posterior (for paddles/pads) and apex-posterior (for pads). In large-breasted individuals it is reasonable to place the left electrode paddle/pad lateral to or underneath the left breast, avoiding breast tissue. Consideration should be given to the rapid removal of excessive chest hair before the application of paddles/pads but emphasis must be on minimizing delay in shock delivery. There is insufficient evidence to recommend a specific electrode size for optimal external defibrillation in adults. However, it is reasonable to use a paddle/pad size >8 cm.
Knowledge Gaps
Current knowledge gaps include but are not limited to:
- No human studies have evaluated the electrode position as a determinant of ROSC or survival from VF/pVT
- No Randomized Controlled Trials have addressed the impact of pads size/position on clinical outcome
- No study addressed the interaction between pad size and orientation
- No study evaluated the interaction between pads size/orientation and biphasic defibrillation waveforms
References
Not applicable.