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Part 3: Defibrillation Resuscitation (2005) 67, 203—211 Part 3: Defibrillation International Liaison Committee on Resuscitation The 2005 Consensus Conference considered ques- sic devices achieve higher first-shock success rates tions related to the sequence of shock delivery than monophasic defibrillators. This fact, combined and the use and effectiveness of various waveforms with the knowledge that interruptions to chest and energies. These questions have been grouped compressions are harmful, suggests that a one- into the following categories: (1) strategies before shock strategy (one shock followed immediately by defibrillation; (2) use of automated external defib- CPR) may be preferable to the traditional three- rillators (AEDs); (3) electrode-patient interface; (4) shock sequence for VF and pulseless ventricular use of the electrocardiographic (ECG) waveform to tachycardia (VT). alter management; (5) waveform and energy lev- els for the initial shock; (6) sequence after failure of the initial shock (i.e. second and subsequent Strategies before defibrillation shocks; and (7) other related topics. The International Guidelines 20001 state that Precordial thump defibrillation should be attempted as soon as ven- W59,W166B tricular fibrillation (VF) is detected, regardless of the response interval (i.e. time between collapse Consensus on science. No prospective studies and arrival of the AED). If the response interval have evaluated the use of the precordial (chest) is >4—5 min, however, there is evidence that thump. In three case series (LOE 5)2—4 VF or pulse- 1.5—3 min of CPR before attempted defibrillation less VT was converted to a perfusing rhythm by a may improve the victim’s chance of survival. The precordial thump. The likelihood of conversion of data in support of out-of-hospital AED programmes VF decreased rapidly with time (LOE 5).4 The con- continue to accumulate, and there is some evi- version rate was higher for unstable or pulseless VT dence supporting the use of AEDs in the hospital. than for VF (LOE 5).2—6 Analysis of the VF waveform enables prediction of Several observational studies indicated that an the likelihood of defibrillation success; with this effective thump was delivered by a closed fist from information the rescuer can be instructed to give a height of 5—40 cm (LOE 5).3,4,6—8 Other obser- CPR or attempt defibrillation. This technology was vational studies indicated that additional tach- developed by analysis of downloads from AEDs; yarrhythmias, such as unstable supraventricular it has yet to be applied prospectively to improve tachycardia (SVT), were terminated by precordial defibrillation success and is not available outside thump (LOE 5).9,10 Potential complications of the research programmes. precordial thump include rhythm deteriorations, All newdefibrillators deliver a shock witha such as rate acceleration of VT, conversion of VT biphasic waveform. There are several varieties of into VF, complete heart block, and asystole (LOE biphasic waveform, but the best variant and the 5;3,5,6,8,11,12 LOE 613). Existing data do not enable optimal energy level and shock strategy (fixed ver- an accurate estimate of the likelihood of these com- sus escalating) have yet to be determined. Bipha- plications. 0300-9572/$ — see front matter © 2005 International Liaison Committee on Resuscitation, European Resuscitation Council and American Heart Association. All Rights Reserved. Published by Elsevier Ireland Ltd. doi:10.1016/j.resuscitation.2005.09.017 204 Part 3: Defibrillation Treatment recommendation. One immediate pre- Approximately 80% of out-of-hospital cardiac cordial thump may be considered after a monitored arrests occur in a private or residential setting (LOE cardiac arrest if an electrical defibrillator is not 4).34 However, there are insufficient data to sup- immediately available. port or refute the effectiveness of home AED pro- grammes. CPR before defibrillation W68,W177 Treatment recommendation. Use of AEDs by trained lay and professional responders is recom- mended to increase survival rates in patients with Consensus on science. In a before—after study cardiac arrest. Use of AEDs in public settings (air- (LOE 4)14 and a randomised trial (LOE 2),15 ports, casinos, sports facilities, etc.) where wit- 1.5—3 min of CPR by paramedics or EMS physicians nessed cardiac arrest is likely to occur can be use- before attempted defibrillation improved return of ful if an effective response plan is in place. The spontaneous circulation (ROSC) and survival rates response plan should include equipment mainte- for adults with out-of-hospital VF or VT when the nance, training of likely responders, coordination response interval (ambulance dispatch to arrival) with local EMS systems, and programme monitor- and time to defibrillation was ≥4—5 min. This ing. No recommendation can be made for or against contrasts with the results of another trial in adults personal or home AED deployment. with out-of-hospital VF or VT, in which 1.5 min of paramedic CPR before defibrillation did not AED Programme quality assurance and improve ROSC or survival to hospital discharge 16 maintenance (LOE 2). In animal studies of VF lasting ≥5 min, W178 CPR (often with administration of adrenaline (epinephrine)) before defibrillation improved 17—21 Consensus on science. No published trials eval- haemodynamics and survival rates (LOE 6). uated specifically the effectiveness of AED pro- gramme quality improvement efforts to further Treatment recommendation. A 1.5- to 3-min improve survival rates. Case series and reports sug- period of CPR before attempting defibrillation may gest that potential improvements can be made be considered in adults with out-of-hospital VF or by reviewing AED function (rhythm analysis and pulseless VT and EMS response (call to arrival) inter- shock), battery and pad readiness, operator perfor- vals >4—5 min. There is no evidence to support or mance, and system performance (e.g. mock codes, refute the use of CPR before defibrillation for in- time to shock, outcomes) (LOE 5).35—42 hospital cardiac arrest. Treatment recommendation. AED programmes should optimise AED function (rhythm analysis and Use of AEDS shock), battery and pad readiness, operator perfor- mance, and system performance (e.g. mock codes, AED programmes time to shock, outcomes). W174,W175 AED use in hospitals Consensus on science. A randomised trial of W62A trained lay responders in public settings (LOE 2)22 and observational studies of CPR and defibrillation Consensus on science. No published randomised performed by trained professional responders in trials have compared AEDs with manual defibril- casinos (LOE 5)23 and lay responders in airports lators in hospitals. One study of adults with in- (LOE 5)24 and on commercial passenger aircraft hospital cardiac arrest with shockable rhythms (LOE 5)25,26 showed that AED programmes are safe showed higher survival-to-hospital discharge rates and feasible and significantly increase survival from when defibrillation was provided through an AED out-of-hospital VF cardiac arrest if the emergency than by manual defibrillation alone (LOE 4).43 In response plan is effectively implemented and sus- an animal model, use of an AED substantially inter- tained. In some studies defibrillation by trained rupted and delayed chest compressions compared first responders (e.g. firefighters or police officers) with manual defibrillation (LOE 6).44 A manikin has improved survival rates from witnessed out-of- study showed that use of an AED significantly hospital VF sudden cardiac arrest (LOE 2;27 LOE increased the likelihood of delivering three shocks 3;28,29 LOE 4;30,31 LOE 532). In other studies AED but increased the time to deliver the shocks when defibrillation by trained first-responders has not compared with manual defibrillators (LOE 6).45 In improved survival.14,33 contrast, a study of mock arrests in simulated Part 3: Defibrillation 205 patients showed that use of monitoring leads and 12-cm electrodes than with 8-cm electrodes. Small fully automated defibrillators reduced time to electrodes (4.3 cm) may be harmful (myocardial defibrillation when compared with manual defibril- injury can occur). lators (LOE 7).46 Self-adhesive defibrillation pads versus paddles Treatment recommendation. Use of AEDs is rea- W71 sonable to facilitate early defibrillation in hospitals. Consensus on science. One randomised trial (LOE 65 50,66 Electrode-patient interface 2) and two retrospective comparisons (LOE 4) showed that TTI is similar when either pads or pad- Electrode pad/paddle position dles are used. One prospective comparison of pads and size and paddles (LOE 3)67 showed lower TTI when pad- W63A,W63B,W173A dles were applied at an optimal force of 8 kg com- pared with pads. One randomised study of chronic Consensus on science. AF showed similar effectiveness for self-adhesive Position. No studies of cardiac arrest in humans pads and manual paddles when monophasic damped have evaluated the effect of pad/paddle position sinusoidal or BTE waveforms were evaluated sepa- on defibrillation success or survival rates. Most rately (LOE 7).68 Several studies (LOE 5;69—71 LOE studies evaluated cardioversion (e.g. atrial fibril- 672) showed the practical benefits of pads over lation [AF]) or secondary end points (e.g. transtho- paddles for routine monitoring and defibrillation, racic impedance [TTI]). prehospital defibrillation, and perioperative defib- Placement of paddles or electrode pads on rillation. the superior-anterior right chest and the inferior- lateral left chest were effective (paddles studied Treatment recommendation. Self-adhesive defib- in AF, LOE 2;47 pads studied in AF, LOE 3;48 effect rillation pads are safe and effective and are an of pad position on TTI, LOE 349). Alternative paddle acceptable alternative to standard defibrillation or pad positions that were reported to be effec- paddles. tive were apex-posterior (pads studied in VF and AF, LOE 4;50 effect of pad position on TTI, LOE Waveform analysis 349), and anteroposterior (paddles studied in AF, 51 52 53 LOE 2; pads studied in AF, LOE 2; LOE 3; VF waveform analysis has the potential to improve 49 effect of pad position on TTI, LOE 3 ).
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