Removal of bra for pad placement and defibrillation – Scoping Review: BLS 2604 TF ScR

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 Synthesis Citation

Bray J, Anne S Noerskov, Julie Considine, Ziad Nehme, Theresa Olasveengen, Laurie J.Morrison

on behalf of the International Liaison Committee on Resuscitation Basic Life Support Task Force. Removal of bra for pad placement and/or defibrillation in Adults and Children Task Force Synthesis of a Scoping Review [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, 2024 October 2024. Available from: http://ilcor.org

Methodological Preamble and Link to Published Scoping Review

The continuous evidence evaluation process started with a scoping review of basic life support conducted by the ILCOR BLS Task Force Scoping Review team. Evidence for adult and pediatric literature was sought and considered by the Basic Life Support Adult Task Force.

Scoping Review

Anne S Noerskov, Julie Considine, Ziad Nehme, Theresa Olasveengen, Laurie J. Morrison, Peter Morley, Bray J. Removal of bra for pad placement and/or defibrillation: A Scoping Review.

PICOST

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

Population: Adults and children in cardiac arrest

Concept: Adverse events and outcomes associated with pad placement and/or defibrillation without removing the patient’s bra/brassiere (including those with metal components)

Context: In patients wearing a bra/brassiere in any setting (in-hospital or out-of-hospital)

Study Designs: All relevant publications in any language will be included as long as there is an English abstract. Animal studies and case series and industrial reports will be included if no clinical evidence is found. Conference abstracts will be included if there is a lack of full text studies.

Timeframe: Databases searched from inception to September 26, 2024. Grey literature searched October 1^st 2024.

Search Strategies

Articles for review were obtained by searching PubMed, EMBASE, Cochrane for all entries from database inception to September 26, 2024.

Keywords included in the search were “bra”, “undergarment”, “underwire”, “bra removal”, “bare chest”, “undress”, “defibrillation”, and “AED” including their MESH terms, and Embase exploded terms.

Inclusion and Exclusion criteria

To be included, studies needed to address cardiac arrest in any setting and the intervention of removal of a bra (or brassiere) for AED pad placement and defibrillation. Only studies of external defibrillation were included. Publications in any language were included if an English abstract was available. All outcomes were included when related to the subject matter. Inclusion was not restricted to certain study designs; however, public opinion surveys were excluded. Broad eligibility criteria were chosen, as the literature on this subject matter was sparse.

Data tables: BLS 2605 Bra removal Sc R Et D

Task Force Insights

1. Why this topic was reviewed.

This topic was chosen for review by the BLS Task Force because of ongoing controversies in the published literature:

• In preparation for defibrillation, defibrillator pads or paddles must come into full contact with the skin of the chest wall and avoid contact with metal objects. Some Resuscitation guidelines recommend the removal of all clothes covering the chest, including bras, as they may contain metal (e.g., underwire, and clips), under the assumption that this may result in the defibrillator malfunctioning or harm to the patient or rescuer.¹
• However, a growing body of research has identified that women are less likely to receive CPR and defibrillation by the public.^2,3 Public opinion surveys show that some members of the public do not feel comfortable exposing women's breasts, and fear accusations of inappropriate touching and sexual assault.⁴ These concerns may impact bystanders' willingness to perform CPR and defibrillation and explain why rates are lower in women.⁴ Whether it is necessary to remove such undergarments is unknown.

2. Narrative summary of evidence identified

• In our search of 283 titles and abstracts, no studies reporting patient outcomes were identified. No additional studies were found in the grey literature search.
• Three studies met inclusion criteria, including one animal study⁵ and two simulation mannikin studies.^6,7 Two studies were published as conference abstracts from the same group of authors who were employed by a company that develops and manufactures AEDs.^5,6
• In the animal study, published as a conference abstract, investigators gave 126 shocks (200J) to four pigs via self-adhering AED pads that were in direct contact with the metal underwire of a bra.⁵ The authors report 100% 1st shock success, with no adverse events: no arcing or redirection of current, scorching or burning of the bra or pig’s skin, and no adverse events to the rescuer or AED.
• A simulation study, published as a conference abstract, of 78 untrained AED users tested the impact of the addition of bra removal on time to place pads or the delivery of the first shock.⁶ No differences were seen in these times for clothed male or female manikins.
• The remaining fully reported simulation study, in 69 rescuers using an AED, noted that male rescuers were less likely to completely de-robe the female manikin than female rescuers (13.3% vs 66.7%, p=0.002). When interviewed, participants cited being unaware of the need to remove the bra, social norms, and concerned for the patient’s modesty, and men did not want to remove more clothing than necessary.⁷

3. Narrative Reporting of the task force discussions

The following discussion points were considered by the BLS Task Force:

• Bystander defibrillation is associated with the greatest survival from out-of-hospital cardiac arrest, but rates are lower in women.^3,4 Removing barriers to the public applying pads is a priority.
• Guideline writing organisations and training organisations need to produce guidelines to minimise CPR interruptions and delays to defibrillation.
• This scoping review demonstrated scant evidence on this topic. Peer review only occurred for two of the three included studies, and we identified gaps in the published literature (as described below).
• We found no evidence reporting patient outcomes or any case studies reporting adverse events about defibrillation without removing a bra.
• Some AED’s verbal and written instructions do not describe bra removal, so the public may not currently remove it to place pads.
• There are likely to be privacy and cultural issues associated with fully exposing a woman’s chest.
• Some resuscitation groups are already actively training to keep the bra on to overcome hesitancy in bystanders; although correct and timely pad placement must be a priority.
• Leaving the bra on could result in inaccurate pad placement, but routine removal could compromise timely defibrillation, particularly in bystander situations.
• Many modern bras do not have underwires or have underwires made of moulded plastic rather than metal. The proportion of metal in bras was uncertain; however, checking for the presence of a metal wire during resuscitation would take critical time.
• Although insufficient studies were identified to support a more specific systematic review of defibrillation while wearing a bra at this time, the Task Force felt the need to highlight and address the inequality in AED application in women by making Good Practice Statements to highlight this issue to the international community.
• We put greater weight on placing the pads in the right place over routine bra removal.
• Implementing the Good Practice Statements may reduce inequity, address an important problem, align with the goals of the relevant organisations, may benefit society, and are likely to be acceptable and feasible.

Good Practice Statements

There is insufficient evidence to guide the routine removal of a bra, but it may not always be necessary to remove a bra for defibrillation. Pads must be placed on bare skin in the correct position, which may be possible by adjusting the bra's positioning rather than removing it (Good Practice Statement).

Manufacturers should develop realistic manikins that reflect different body sizes that can impact pad placement (Good Practice Statement).

Where possible, CPR training should cover defibrillation for patients wearing bras, focusing on correct pad placement and minimizing pauses in compressions (Good Practice Statement).

Knowledge Gaps

• It is unknown whether removing a bra is necessary with modern bras, pads and defibrillators
• Fully published peer-reviewed data on this topic is needed
• Understanding sex-specific barriers through listening to emergency calls may provide critical insights to address in public messaging and CPR training
• To address gender disparities in BLS, research with consumer involvement to understand public opinions and sociocultural sensitivities related to exposing the chest is needed.

References

1. Panchal AR, Bartos JA, Cabanas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142:S366-S468. doi: 10.1161/CIR.0000000000000916
2. Perman SM, Shelton SK, Knoepke C, Rappaport K, Matlock DD, Adelgais K, Havranek EP, Daugherty SL. Public Perceptions on Why Women Receive Less Bystander Cardiopulmonary Resuscitation Than Men in Out-of-Hospital Cardiac Arrest. Circulation. 2019;139:1060-1068. doi: doi:10.1161/CIRCULATIONAHA.118.037692
3. Grunau B, Humphries K, Stenstrom R, Pennington S, Scheuermeyer F, van Diepen S, Awad E, Al Assil R, Kawano T, Brooks S, et al. Public access defibrillators: Gender-based inequities in access and application. Resuscitation. 2020;150:17-22. doi: 10.1016/j.resuscitation.2020.02.024
4. Ishii M, Tsujita K, Seki T, Okada M, Kubota K, Matsushita K, Kaikita K, Yonemoto N, Tahara Y, Ikeda T, et al. Sex- and Age-Based Disparities in Public Access Defibrillation, Bystander Cardiopulmonary Resuscitation, and Neurological Outcome in Cardiac Arrest. JAMA Network Open. 2023;6:e2321783-e2321783. doi: 10.1001/jamanetworkopen.2023.21783
5. Di Maio R, O’Hare P, Crawford P, McIntyre A, McCanny P, Torney H, Adgey J. Self-adhesive electrodes do not cause burning, arcing or reduced shock efficacy when placed on metal items. Resuscitation. 2015;96:11. doi: 10.1016/j.resuscitation.2015.09.026
6. O’Hare P, Di Maio R, McCanny R, McIntyre C, Torney H, Adgey J. Public access defibrillator use by untrained bystanders: Does patient gender affect the time to first shock during resuscitation attempts? Resuscitation 2014;85S:S15–S121. doi.org/10.1016/j.resuscitation.2014.03.124
7. Kramer CE, Wilkins MS, Davies JM, Caird JK, Hallihan GM. Does the sex of a simulated patient affect CPR? Resuscitation. 2015;86:82-87. doi.org/10.1016/j.resuscitation.2014.10.016