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CPR prior to defibrillation

Question Type:
Intervention
Full Question:
Among adults and children who are in ventricular fibrillation or pulseless ventricular tachycardia in any setting (P), does a prolonged period of chest compressions before defibrillation (I), compared with a short period of chest compressions before defibrillation (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, rhythm control (O)?
Consensus on Science:
For the critical outcome of survival to 1 year with favorable neurologic outcome (Cerebral Performance Category [CPC] of 2 or less), we identified low-quality evidence (downgraded for bias and imprecision) from a single randomized trial that showed no benefit from a short period of CPR before shock delivery (OR, 1.18; 95% CI, 0.522–2.667).(Wik 2003, 1389) For the critical outcome of survival to hospital discharge with favorable neurologic outcome (defined as CPC score of 2 or less, modified Rankin Scale score of 3 or less), we identified low-quality evidence (downgraded for inconsistency and imprecision) from 4 RCTs that showed no benefit from a short period of CPR before shock delivery (OR, 0.95; 95% CI, 0.786–1.15).(Wik 2003, 1389; Baker 2008, 424; Stiell 2011, 787; Ma 2012, 806) For the critical outcome of survival to 1 year, we identified low-quality evidence (downgraded for bias and imprecision) from 2 RCTs that showed no benefit from a short period of CPR before shock delivery (OR, 1.15; 95% CI, 0.625–2.115).(Wik 2003, 1389; Jacobs 2005, 39) For the critical outcome of survival to hospital discharge, we identified low-quality evidence (downgraded for bias and imprecision) from 4 RCTs that showed no benefit from a short period of CPR before shock delivery (OR, 1.095; 95% CI, 0.695–1.725).(Wik 2003, 1389; Jacobs 2005, 39; Baker 2008, 424; Ma 2012, 806) With respect to ROSC, we identified low-quality evidence (downgraded for bias and imprecision) from 4 RCTs that showed no benefit from a short period of CPR before shock delivery (OR, 1.193; 95% CI, 0.871–1.634).(Wik 2003, 1389; Jacobs 2005, 39; Baker 2008, 424; Ma 2012, 806) Subgroup Analyses Two subgroup analyses were also considered in this review. One subgroup analysis looked at enrollments based on EMS response interval, comparing those with intervals of less than 4 to 5 minutes versus those with intervals of 4 to 5 minutes or more. Within this subgroup, 1 study(Wik 2003, 1389) found a favorable relationship with CPR for 180 seconds before defibrillation when the response interval was 5 minutes or more, but this relationship was not confirmed in 3 other RCTs.(Jacobs 2005, 39; Baker 2008, 424; Stiell 2011, 787) The second subgroup analysis(Rea 2014, 1) examined outcomes from early versus late analysis based on baseline EMS agency VF/pVT survival rates. Among EMS agencies with low baseline survival to hospital discharge (defined as less than 20% for an initial rhythm of VF/pVT), higher neurologically favorable survival was associated with early analysis and shock delivery, as opposed to CPR and delayed analysis and shock delivery. Yet for EMS agencies with higher baseline survival to hospital discharge (greater than 20%), 3 minutes of CPR followed by analysis and defibrillation resulted in higher neurologically favorable survival. Although no study has suggested harmful effects from up to 180 seconds of CPR before defibrillation, an exploratory analysis from 1 RCT(Stiell 2011, 787) suggested a decline in survival to hospital discharge from a prolonged period of CPR (180 seconds) with delayed shock delivery in patients with an initial rhythm of VF/pVT that had received bystander CPR, compared with a shorter period of CPR (30–60 seconds) followed by shock delivery. Evidence Summary In summary, the evidence suggests that among unmonitored patients with cardiac arrest outside of the hospital and an initial rhythm of VF/pVT, there is no benefit to a period of CPR of 90 to 180 seconds before defibrillation when compared with immediate defibrillation with CPR being performed while the defibrillator equipment is being applied.
Treatment Recommendation:
During an unmonitored cardiac arrest, we suggest a short period of CPR until the defibrillator is ready for analysis and, if indicated, defibrillation. Values, Preferences, and Task Force Insights In making these recommendations, we placed a higher value on the delivery of early defibrillation and a lower value on the as-yet-unproven benefits of performing CPR for a longer period of time. We recognize that the evidence in support of these recommendations comes from randomized trials of variable quality conducted in several countries with a variety of EMS system configurations. The available evidence suggests a minimal effect size overall, while recognizing that it remains possible that, in systems with higher baseline survival rates, a longer period of CPR may be superior. The task force notes that these recommendations apply to unmonitored victims in cardiac arrest. In witnessed, monitored VT/VF arrest where a patient is attached to a defibrillator, shock delivery should not be delayed.
CoSTR Attachments:
BLS 363 - CPR before Defib Forest plots 20150121_n.docx    
BLS 363 - CPR before Defib GRADE Profile 20141225_n.docx    

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