CPR: Hands-on or Hands-off Defibrillation

01 Nov
November 1, 2013

CPRPauses in chest compressions are known to be detrimental to survival in cardiac arrest, so much so that the 2010 American Heart Association (AHA) emphasize high-quality compressions while minimizing interruptions. There have been some studies that now advocate for continuous chest compressions during a defibrillation shock. There have been substantial changes to external defibrillation technology  including:

  • Biphasic shocks with real-time impedance monitoring to reduce peak voltages
  • Paddles being replaced by adhesive pre-gelled electrodes
  • Enhancement in ECG filtering permitting rhythm monitoring during chest compressions.

So the mantra of “hard and fast” may be true when it comes to CPR, but the real question now becomes, should we be continuing CPR during defibrillation?

How important is uninterrupted chest compressions in cardiac arrest resuscitation? (22633716) (11705826)

Cardiac Perfusion and Interruptions in CPR

  • It has been well documented in several swine models that coronary perfusion pressure decreases with interruptions in chest compressions.
  • Furthermore, it takes several minutes of chest compressions to build up to an adequate coronary perfusion pressure.

Does increased coronary perfusion pressure (CPP) correlate with the chance of return of spontaneous circulation (ROSC)? (2386557)

  • 100 patients with cardiac arrest
  • Only patients with maximal CPPs of 15 mm Hg or more had ROSC
  • A CPP > 15 mm Hg did not guarantee ROSC
  • Conclusion: Increased CPP correlates with increase chance of ROSC

How important are pauses in chest compressions prior to defibrillation? (21690495)

  • 815 patients with out of hospital cardiac arrest (OHCA)
  • Pre-shock chest compression pause ≥ 20 seconds had OR 0.47 for survival vs pauses < 10 seconds
  • Pre-shock chest compression pause ≥ 40 seconds had OR 0.54 for survival vs pauses < 20 seconds
  • Conclusion: Longer periods of pre- and peri-shock pauses independently are associated with decrease chance of survival

If continuous, uninterrupted CPR improves coronary perfusion pressure, which in turn increases the likelihood of ROSC, and pre-/peri-shock pauses in CPR negatively affect the likelihood of ROSC, maybe continuous CPR through defibrillation is a good idea.

Well, wait just one second before we draw any final conclusions…

What is the evidence for continuous hands-on CPR during defibrillation? (18458166)

  • 43 hands-on shocks (4 at 100J, 27 at 200J, and 8 at 360J)
  • None of the shocks were perceptible to the rescuers, who wore polyethylene gloves
  • 11.1% of shocks exceeded the allowable 0.5 mA of current leakage
  • Authors’ Conclusion: Uninterrupted CPR during shock delivery is feasible
  • My thoughts: Although these were low levels of electricity, just over 1 in 10 rescuers received more than the allowable minimum shock from doing hands-on CPR! I would question the conclusion of this study.

Do medical examination gloves protect rescuers from defibrillation during hands-on CPR? (22925991)

  • 4 types of medical gloves tested (chloroprene, latex, nitrile, and vinyl) with external defibrillation
  • Single glove and double glove both tested
  • Concerning: 45% of single gloves and 77% of double gloves allowed at least 0.1 mA of current flow with external defibrillation
  • Very concerning: 7.5% of single gloves and 6.2% of  gloves allowed at least 10 mA of current flow with external defibrillation
  • Conclusion: Few of the tested gloves limit the current to levels proven to be safe

Final Thoughts

Currently, I do not feel there is sufficient evidence to perform hands-on defibrillation safely, but do agree that minimizing peri-shock pauses in CPR is a must. Would love others thoughts on this.

Other Thoughts:

More References:

  1. Brady W et al. Hands-on defibrillation during active chest compressions: eliminating another interruption. Am J Emerg Med 2016; S0735-6757(16)30504-6. PMID: 27645811

Bibliography

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Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of R.E.B.E.L. EM
Tags: , ,
10 replies
  1. j. S. Wieters says:

    Sal,

    diggin the new website! Very good review on an interesting topic 😉 I’m a REBEL fan! keep up the good work!

    JSW

    Reply
  2. Mark case - AENurseUK says:

    I guess the logical step is the development of CPR/Defib gloves! Who’s cornering the market already?

    Reply
  3. Roque Ruggero says:

    I was discussing this very topic with a colleague- thanks for the succinct review!

    Reply
  4. Nadim Lalani (@ERmentor) says:

    hi Salim,
    nice review! FYI there was an article or two a while back re cardioversion for Afib and measuring current leakage into cardiologist. It suggested it was safe and reduced the joules needed to cardiovert.
    thanks
    N

    Reply

Trackbacks & Pingbacks

  1. […] CPR: Hands-on or Hands-off Defibrillation […]

  2. […] Realizing the vital importance of minimizing pauses in chest compressions, it has recently become popular for providers to go as far as continuing to perform chest compressions during defibrillation (“hands-on defibrillation”) – the goal being to effectively eliminate the additional interruption. There has been much debate as to whether this practice is safe for the provider or not. I am not going to get into this debate here as it has already been discussed on REBEL EM. […]

  3. […] Realizing the vital importance of minimizing pauses in chest compressions, it has recently become popular for providers to go as far as continuing to perform chest compressions during defibrillation (“hands-on defibrillation”) – the goal being to effectively eliminate the additional interruption. There has been much debate as to whether this practice is safe for the provider or not. I am not going to get into this debate here as it has already been discussed on REBEL EM. […]

  4. […] för ROSC (Salim Rezaie på REBEL EM har gjort en bra genomgång av evidensen i ett inlägg om “hands-on defib”). Även om kompressioner under chock inte kan rekommenderas innebär den sedvanliga […]

  5. […] had some heated debates on the topic of hands-on defibrillation (HOD) for the past few years. We all know the most important time to avoid a pause during CPR is the […]

  6. […] Salim Rezaie on REBEL EM: CPR: Hands-on or Hands-off Defibrillation […]

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