Pad size, orientation and placement (BLS): Scoping Review

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This Review 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 Review 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: 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.


Scoping Review

Discussion

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