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Minimizing pauses in chest compressions

Question Type:
Intervention
Full Question:
Among adults and children who are in cardiac arrest in any setting (P), does minimization of pauses in chest compressions for cardiac rhythm analysis or ventilations (I), compared with prolonged pauses in chest compressions for rhythm analysis or ventilations (C), change Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC, time to first shock, CPR quality, rhythm control (O)?
Consensus on Science:
For the critical outcome of favorable neurologic outcome, we found 1 low-quality observational study (downgraded for imprecision)(Beesems 2013, 1585) enrolling 199 patients. This study compared survival against a reference ventilation range of 5 to 6 seconds and found no difference with longer ranges of time for 2 breaths delivered by lay rescuers, ranging over 10 to 12 seconds (adjusted OR, 1.30; 95% CI, 0.29–5.97) and 13 seconds or greater (adjusted OR, 2.38; 95% CI, 0.46–12.1). We found no studies addressing pauses for rhythm analysis and shock.For the critical outcome of survival to hospital discharge, there were no studies examining duration required to deliver 2 breaths. For perishock pauses, we identified moderate-quality evidence (downgraded for indirectness) from 1 RCT that compared 2 AED algorithms.(Jost 2010, 1614) The study enrolled 845 patients but found no benefit (OR, 0.81; 95% CI, 0.33–2.01) of reducing preshock and postshock pauses. We found moderate-quality evidence from 3 observational studies (upgraded for dose-response gradient)(Christenson 2009, 1241; Cheskes 2011, 58; Cheskes 2014, 336) including 3327 patients showing a strong relationship with shorter preshock and postshock pauses (less so for postshock pauses) or higher chest compression fraction. For the critical outcome of ROSC, we found no studies addressing the duration required to deliver 2 breaths. For perishock pause, we found 1 very-low-quality observational study(Sell 2010, 822) (downgraded for risk of bias and imprecision) including 35 patients, indicating benefit from limiting preshock and postshock pauses and 1 very-low-quality study (downgraded for risk of bias)(Vaillancourt 2011, 1501) including 2103 patients, suggesting benefit from achieving chest compression fractions (ie, total CPR time devoted to compressions) greater than 40%. For the important outcome of shock success, we found 1 very-low-quality observational study (downgraded for imprecision)(Edelson 2006, 137) including 60 patients, indicating benefit of shorter preshock pauses: OR of 1.86 (95% CI, 1.10–3.15) for every 5 seconds.
Treatment Recommendation:
We suggest that in adult patients receiving CPR with no advanced airway, the interruption of chest compressions for delivery of 2 breaths should be less than 10 seconds (weak recommendation, low-quality evidence). We recommend that total preshock and postshock pauses in chest compressions be as short as possible. For manual defibrillation, we suggest that preshock pauses be as short as possible and no more than 10 seconds (strong recommendation, low-quality evidence). We suggest during conventional CPR that chest compression fraction (ie, total CPR time devoted to compressions) should be as high as possible and at least 60% (weak recommendation, low-quality evidence).Values, Preferences, and Task Force Insights In making these recommendations, we place a high priority on minimizing interruptions for chest compressions. We seek to achieve this overall objective by balancing it with the practicalities of delivering 2 effective breaths between cycles of chest compressions to the patient without an advanced airway.
CoSTR Attachments:
Grade Table minimizing pausesV5_n.docx    
Summary of Bias Assessments interruptionV2_n.xlsx    

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