Ilcor 2015 SVB

Analysis of rhythm during chest compression
Question Type:
Intervention
Full Question:
Among adults and children who are in cardiac arrest in any setting (P), does analysis of cardiac rhythm during chest
compressions (I), compared with standard care (analysis of cardiac rhythm during pauses in chest compressions) (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, time to commence CPR,
CPR quality (O)?
The information provided is currently in DRAFT format and is NOT a FINAL version
Consensus on Science:
There are currently no human studies that address the identified critical outcomes criteria of neurologically intact survival,
survival or ROSC or the important outcomes criteria of CPR quality, time to commencing CPR or time to first shock.
Treatment Recommendation:
We suggest against the use of artifact-filtering algorithms for analysis of ECG rhythm during CPR unless as part of a
research programme.
Check for circulation during BLS

Question Type:
Intervention
Full Question:
Among adults and children who are in cardiac arrest in any setting (P), does interruption of CPR to check circulation (I),
compared with no interruption of CPR (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,
chest compression fraction (O)?
Still no human data to answer this specific question.
In light of absence of further studies, the 2010 recommendations can be upheld. They should however be influenced by
the findings of the questions added to the 2015 COSTR process.
Emphasis should remain on providing chest compressions, and pausing for a pulse check without strong suspicion of ROSC
may be an unnecessary delay.
Chest compression depth

Question Type:
Intervention
Full Question:
Among adults who are in cardiac arrest in any setting (P), does a different chest compression depth during CPR (I),
compared with chest compression depth to 5 cm (2 inches) (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, CPR quality, coronary perfusion pressure, cardiac output, bystander CPR performance (O)?
For the critical outcome survival with good neurological outcome, we found very low quality evidence from two
observational studies [Vadeboncoeur 2014,182] [Hostler 2011,1512] suggesting that a compression depth in adults of
more than 5 cm is better than all other compression depths during manual CPR. Evidence was downgraded for serious
bias, imprecision, and indirectness. [Vadeboncoeur 2014,182: Neurological outcome, percent of compressions 51 mm,
adjusted odds ratio 1.21 (CI 1.00 1.46) N=593, 175 missing data, which was imputed]
For the critical outcome survival to hospital discharge, we found moderate quality evidence from four observational
studies [Vadeboncoeur 2014,182] [Hostler 2011,1512] [Stiell 2012,1192] [Stiell 2014,1962] suggesting that a
compression depth range of 4.5 to 5.5 cm in adults is better than all other compression depths during manual CPR.
Evidence was upgraded for a dose - response relationship; the two largest studies had no serious bias. [Stiell 2014,1962:
Survival, N=9,136, adjusted cubic spline, optimal depth range 40 to 55 mm, peak at 46 mm]
For the critical outcome ROSC, we found moderate quality evidence from eight observational studies [Babbs 2008,306]
[Bohn 2011,257] [Edelson 2006,137] [Edelson 2008,1063] [Hostler 2011,1512] [Kramer-Johansen 2006,283] [Stiell
2012,1192] [Stiell 2014,1962] suggesting that a compression depth of more than 5 cm (range 4.5 to 5.5 cm) in adults is
better than all other compression depths during manual CPR. Evidence was upgraded for a dose - response relationship;
the two largest studies had no serious bias. [Stiell 2014,1962: N=9,136, ROSC, depth 38 51 mm, adjusted OR 0.86 (CI
0.75 0.97), reference 51 mm] [Note: this study supports >5 cm for ROSC]
For the important outcome injury, we found very low quality evidence from one observational study [Hellevuo 2013,760]
suggesting that a compression depth of more than 6 cm is associated with an increased rate of injury in adults when
compared with compression depths of 5 to 6 cm during manual CPR. Evidence was downgraded for serious risk of bias
(confounding), imprecision, and very serious indirectness.
N=170 (total 353, 183 excluded for incomplete data). With compression depth >6 cm, 63% had injuries; depth <6 cm,
31% had injuries. Injuries with <5cm, 5-6 cm, >6 cm were 28%, 27%, and 49% respectively.
Draft Treatment Recommendation:
We recommend a chest compression depth range of 4.5 cm to 5.5 cm during manual CPR in adults with cardiac arrest
(strong recommendation based on moderate quality evidence).
Values and preferences statement
In making this recommendation, we placed great importance on adequate compression depth. We put an upper limit on
compression depth in adults because no additional outcome benefit was demonstrated with compression depths of more
than 6 cm and because of the possibility of increased rate of injury.
We considered the additional training cost to be minimal. The cost to adjust limits in compression depth feedback devices
would be modest.
Chest compression only CPR vs conventional CPR

Question Type:
Intervention
Full Question:
Among adults who are in cardiac arrest outside of a hospital (P), does provision of chest compressions (without ventilation)
by untrained/trained laypersons (I), compared with chest compressions with ventilation (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, bystander CPR performance, CPR quality (O)?
For survival to one year with favourable neurological outcome we have identified very low quality evidence (downgraded
for risk of bias, indirectness, and imprecision) from one observational trial (Iwami 2007 2900) enrolling 1327 patients
showing no significant difference between compression only and standard CPR (OR 0.98, 95%CI: 0.54, 1.77).
For survival to 30 days with favourable neurological outcome we identified very quality evidence (downgraded for risk of
bias and indirectness) from 4 observational studies (Kitamura 2010 293, Kitamura 2011 3, Ong 2008 119, SOS-Kanto
2007 290) enrolling 40,646 patients demonstrating no significant difference between compression only and standard CPR.
Three moderate quality evidence RCTs (each downgraded for indirectness) demonstrated no significant difference in
outcomes between compression only CPR and standard CPR for 30d survival (Svensson 2010 434, OR 1.24 95%CI: 0.851.81), hospital discharge with favourable neuro outcome (Rea 2010 423, OR 1.25 95%CI 0.94-1.66), and hospital
discharge (Hallstrom 2000 146, OR 1.4 95%CI: 0.88-2.22).
For survival to 30 days we identified very low quality evidence (downgraded for risk of bias and indirectness) from 2
observational studies (Bohm 2007 2908, Holmberg 2001 511) enrolling 11,444 patients demonstrating no significant
difference between compression only and standard CPR.
For survival to 14 days we identified low quality evidence (downgraded for risk of bias indirectness) from 1 observational
study (Bossaert 2007 2908) enrolling 829 patients demonstrating no significant difference between compression only and
standard CPR (OR 0.76 95%CI: 0.46-1.24).
For survival to discharge with favourable neurological outcome we identified very low quality evidence (downgraded for
risk of bias, inconsistency and indirectness) from 3 observational studies (Bobrow 2010 1447, Olasveengen 2008 214, and
Panchal 2013 435) enrolling 2195 patients demonstrating no significant difference between compression only and standard
CPR.
For survival to discharge we identified very low quality evidence (downgraded for risk of bias, inconsistency and
indirectness) from 2 observational study (Gallagher 1995 1922, Mohler 2011 822,) demonstrating no enrolling 2486
patients demonstrating no significant difference between compression only and standard CPR.
We recommend all rescuers should perform chest compressions for all patients in cardiac arrest (strong recommendation,
moderate quality of evidence)
We recommend chest compressions alone for untrained laypersons responding to cardiac arrest victims (strong
recommendation, low quality of evidence).
We suggest performing chest compressions alone for trained laypersons if they are incapable of delivering airway and
breathing manoeuvres to cardiac arrest victims (weak recommendation, low quality of evidence).
We suggest the addition of ventilations for trained laypersons who are capable of giving CPR with ventilations to cardiac
arrest victims and willing to do so (weak recommendation, low quality of evidence).
Chest compression rate

Question Type:
Intervention
Full Question:
Among adults and children who are in cardiac arrest in any setting (P), does any specific rate for external chest
compressions (I), compared with a compression rate of about 100/min (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, CPR quality (O)?
For the critical outcome of survival to hospital discharge we identified very low quality of evidence from two
observational studies [Idris 2015 e-pub; Idris 2012 p3004] representing 13469 adult patients. Both studies were
downgraded due to risk of bias. Idris [2015 e-pub] compared chest compression rates of >140, 120-139, <80 and 80-99
compressions per minute with the control rate of 100-119 CC per minute. When compared to the control rate of 100-119
CC per minute, there was a 4% decrease in survival to hospital discharge with CC rates >140 per minute, 2% decrease in
survival to hospital discharge with CC rates 120-139 per minute, 1% decrease in survival to hospital discharge with CC
rates <80 per minute, and 2% decrease in survival to hospital discharge with CC rates 80-99 per minute [Idris 2015 epub]. Idris [2012 p3004] compared chest compression rates of >140 and <80 compressions per minute to the control rate
of 80-140 CC per minute. There was a 4.1% decrease in survival to hospital discharge with CC rates >140 CC/min and
1.9% increase in survival to hospital discharge with rates <80 CC/min when compared to the control rate of 80-140 CC
per minute. The adjusted odds ratios for survival to hospital discharge were 0.61 (p=0.18) for rates>140 CC/min and 1.32
(p=0.42) for rates <80 CC/min therefore showed no significant difference in survival to hospital discharge. Spline graphs
from one study [Idris 2012 p3004] suggest that survival to hospital discharge was optimised at chest compression rates of
100 to 120 CC/min and began to deteriorate at chest compressions rates of greater than 120 CC/min (Fig 1)
For the critical outcome of return of spontaneous circulation (ROSC) very low quality of evidence from three
observational studies [Idris 2015 e-pub; Idris 2012 p3004, Abella 2005 p428] representing 13566 adult patients. All
studies were downgraded due to risk of bias. All studies had different intervention and control chest compression rates:
100-119 [Idris 2015 e-pub], 80-140 CC / minute [Idris 2012 p3004] and 80-119 CC/min [Abella 2005 p428]. There was a
significant decrease in ROSC with CC rates >140 CC/min (OR=0.72, p0.006) however significance was lost when the
model was adjusted for covariates (gender, witnessed arrest, bystander CPR, first known EMS rhythm, location) [Idris
2015 e-pub]. There were non-significant decreases in ROSC at rates of <80 CC/min, 80-99 CC/min and 120-139 CC/min.
The greatest chance of ROSC occurred in the control group with a rate of 100-119 CC/min [Idris 2015 e-pub]. There was a
5% decrease in ROSC with rates >140 CC/min [I: Idris 2012 p3004] and 9% increase in ROSC with rates >120 CC/min [I:
Abella 2005 p428] when compared to their respective control chest compression rates. With rates <80 CC/min, there was
a 3% increase in ROSC in one study [I: Idris 2012 p3004] and 25% decrease in ROSC in other [I: Abella 2005 p428]. The
adjusted odds ratios for ROSC were 1.01 (p=0.95) for rates>140 CC/min [Idris 2012 p3004] and 1.18 (p=0.79) for rates
<80 CC/min [Idris 2012 p3004] therefore showed no significant difference in ROSC. Comparison of mean chest
compression rates of 95.5 - 138.7 CC/min with 40.3 - 72.0 CC/min showed a +33% increase in ROSC (p= 0.00925)
[Abella 2005 p428]. Comparison of mean chest compression rates of 87.1 - 94.8 CC/min with 40.3 - 72.0 CC/min showed
a +33% increase in ROSC (p=0.00371) [Abella 2005 p428]. Spline graphs from one study [Idris 2012 p3004] suggest that
ROSC began to improve at chest compressions rates of over 100 CC/min, were optimised at chest compression rate of
approximately 120 CC/min and began deteriorated markedly at chest compressions rates of greater than 130 CC/min (Fig
2).
Figure 1:
[Idris 2012 p3004]: test of null hypothesis that spline curve is horizontal (p = 0.012) Figure 2:
[Idris 2012 p3004]: test of null hypothesis that spline curve is horizontal (p= 0.63)
For the important outcome of end-tidal carbon dioxide levels ETCO2, very low quality of evidence from two
observational studies [Ornato 1988 p241, Kern 1992 p145] representing 41 adult patients. Both studies were downgraded
due to risk of bias. Chest compression rates of 120 CC/minute [Ornato 1988 p241, Kern 1992 p145] and 140 CC/minute
[Ornato 1988 p241] were compared to control chest compression rates of 100 CC / minute [Ornato1988 p241] and 80
CC/min [Kern 1992 p145]. At rates of 120 CC/minute, the change in mean ETCO2 ranged from a 0.1mmHg decrease
[Ornato1988 p241] to a 2 mmHg increase [Kern 1992 p145, p<0.01]. At chest compression rates of 140 / minute, there
was no change in mean ETCO2 [Ornato1988 p241]. Only one study examined changes in ETCO2 at lower chest
compression rates of 60 CC/minute and 80 CC/minute compared with the control rate of 100 CC/minute [Ornato1988
p241]. At both 60 and 80 CC/minute there was a 0.1 mmHg decrease in mean ETCO2 no p value was reported.
[Ornato1988 p241].
For the important outcome of systolic blood pressure, very low quality of evidence from one observational study
[Ornato1988 p241] representing 18 adult patients was identified. This study was downgraded due to risk of bias. This
study compared intervention chest compression rates of 60, 80, 120 and 140 CC/min to the control date of 100 CC/min.
Changes in mean systolic blood pressure ranged from -6 mmHg (140 CC/minute) to +7 mmHg (60 CC/minute). No p
values were reported. It did appear from the study results that there was a linear relationship between increased chest
compression rates and decreasing mean systolic blood pressure: CC rate 100/min = mean SPB 524 mmHg; CC rate of
120/min = mean SPB 484; CC rate of 140 /min = mean SPB 464 mmHg.
For the important outcome of diastolic blood pressure, very low quality of evidence from one observational study
[Ornato1988 p241] representing 18 adult patients was identified. This study was downgraded due to risk of bias. This
study compared intervention chest compression rates of 60, 80, 120 and 140 CC/min to the control rate of 100 CC/min.
Changes in mean systolic blood pressure ranged from -1(80 and 140 CC/minute) to nil (60 and 120 CC/minute). No p
values were reported.
For the important outcome of number of chest compressions per minute, very low quality of evidence from one
observational study [Idris 2012 p3004] representing 3098 adult patients was identified. This study was downgraded due to
risk of bias. This study compared chest compression rates of >140 CC/min and <80 CC/min with the control rate of 80140 CC/min. The number of chest compressions delivered per minute increased when a chest compression rate of >140
CC/minute were used. No p values were reported.
TREATMENT RECOMMENDATION:
We suggest a manual chest compression rate of 100 to 120 compressions per minute for adults in cardiac arrest in any
setting (weak recommendation, very low quality of evidence).
Values and preferences statement: In making this recommendation, we place a higher value on compatibility with previous
guidelines than introducing changes which might incur addition costs (e.g. re-programming feedback devices, educational
programmes) in the absence of definitive evidence showing benefit for any of the critical or important outcomes
Chest wall recoil

Question Type:
Intervention
Full Question:
Among adults and children who are in cardiac arrest in any setting (P), does maximizing chest wall recoil (I), compared
with ignoring chest wall recoil (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,
coronary perfusion pressure, cardiac output (O)?
For the critical outcomes of Return of Spontaneous Circulation, Survival at Hospital Discharge and Survival with Favorable
Neurologic/Functional Outcome we found no evidence to inform the question.
For the important outcome of Coronary Perfusion Pressure (CPP) we found three observational studies (two animal and
one human non-cardiac arrest model) representing very low quality evidence, following downgrading for serious risk of
bias and very serious indirectness.(Glatz, 2013, 1674, Yannopoulos, 2005, 363, Zuercher, 2010, 1141) All three studies
reported reduced coronary perfusion with incomplete recoil. Glatz et al analysed two levels of leaning (10% and 20%) and
noted a dose response, with increased levels of leaning force associated with reduced coronary perfusion pressure.(Glatz,
2013, 1674) Similarly Zuercher et al analysed both 10% and 20% leaning, but the reduction in CPP only became
significant at the 20% level.(Zuercher, 2010, 1141)
For the important outcome of cardiac output/cardiac index we found two observational studies (one animal and one human
non-cardiac arrest model) also representing very low quality evidence downgraded for serious risk of bias and very serious
indirectness.(Glatz, 2013, 1674, Zuercher, 2010, 1141) The animal study by Zuercher et al reported a reduction in cardiac
index when 10% and 20% leaning forces were applied.(Zuercher, 2010, 1141) In contrast, Glatz et al found that leaning
forces had no effect on cardiac index/ output.(Glatz, 2013, 1674)
We suggest that chest wall leaning should be avoided as opposed to ignoring chest wall recoil in adults and children who
are in cardiac arrest in any setting (weak recommendation, very low quality of evidence).
Compression ventilation ratio

Question Type:
Intervention
Full Question:
Among adults and children who are in cardiac arrest in any setting (P), does delivery of CPR with another specific C:V ratio
(I), compared with CPR using a 30:2 compression:ventilation ratio (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, hands-off time (O)?
For the critical outcome of survival with favourable neurological / functional outcome at discharge, we identified two
observational cohort before and after studies (Hinchey 2010, p. 348 ; Olasveengen 2009, p. 407) which were downgraded
for risk of bias and indirectness. These studies included 1,711 patients, which showed those who were treated under the
2005 guidelines have slightly higher survival than those patients treated under the 2000 guidelines (8.9% vs. 6.5%).
For the critical outcome of survival with favourable neurological / functional outcome at 30 days, 60 days, 180 days and/or
1 year, we did not identify any studies.
For the critical outcome of survival at discharge, we identified four observational cohort before and after studies (Hinchey
2010, p. 348 ; Olasveengen 2009, p. 407 ; Sayre 2009, p. 469 ; Steinmetz 2008, p. 908) which were downgraded for risk
of bias and indirectness. These studies included 4,183 patients, which showed those who were treated under the 2005
guidelines have slightly higher survival than those patients treated under the 2000 guidelines (11.0% vs. 7.0%).
For the critical outcome of survival to 30 days, we identified one observational cohort before and after study (Steinmetz
2008, p. 908) which was downgraded for risk of bias and indirectness. This study included 791, which showed those who
were treated under the 2005 guidelines have slightly higher survival than those patients treated under the 2000 guidelines
(16.0% vs. 8.3%).
For the critical outcome of survival at 60 days, 180 days and/or 1 year, we did not identify any studies.
For the critical outcome of any ROSC, we identified two observational cohort before and after studies (Hinchey 2010, p.
348; Olasveengen 2009, p. 407) which were downgraded for risk of bias and indirectness. These studies included 1,711
patients, which showed those who were treated under the 2005 guidelines had a ROSC more often than those patients
treated under the 2000 guidelines (38.7% vs. 30.0%).
For the critical outcome of a ROSC at hospital admission, we identified two observational cohort before and after studies
(Olasveengen 2009, p. 407; Steinmetz 2008, p. 908) which were downgraded for risk of bias and indirectness. These
studies included 1,708 patients, which showed those who were treated under the 2005 guidelines had a ROSC at hospital
admission more often than those patients treated under the 2000 guidelines (34.5% vs. 17.1%).
For the important outcome of hands-off time, we identified two observational cohort before and after studies (Olasveengen
2009, p. 407; Sayre 2009, p. 469) which were downgraded for risk of bias and indirectness. These studies included 694
patients, which showed those who were treated under the 2005 guidelines had less hands-off time those patients treated
under the 2000 guidelines.
One observational cohort study (Hostler 2007, p. 446), although meeting our inclusion criteria, was excluded due to
concerns regarding the study design, analytical technique and challenges with data reporting and abstraction.
We suggest a compression to ventilation ratio of 30:2 (weak recommendation based on low level evidence).
Values and Preferences Statement: We recognize that no study directly answered the PICO question. Therefore, in making
this recommendation, we placed emphasis on the methodological rigor of the studies included. Any study that compared
two compression to ventilation strategies were included, although we acknowledge there are other interventions included
in addition to difference C:V ratios. We placed little emphasis on the financial implications, resource requirements, and
implementation feasibility and strategies as there were not addressed in the literature.
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)?
A literature review resulted in the retrieval of 13 articles on this topic. These included 5 randomized controlled trials (Baker
2008 p424, Jacobs 2005 p39, Ma 2012 p806, Stiell 2011 p787 and Wik 2003 p1389), 4 non-randomized trials (Bradley
2010 p155, Cobb 1999 p1182 Hayakawa 2009 p470, Koike 2011 p393), 3 meta-analysis (Huang 2014 p1, Meier 2010
p52, Simpson 2010 p925) and 1 subgroup analysis of data reported in the RCT by Stiell et al. (Rea 2014 p1). For the
purposes of this evidence based review, only pooled data from the 5 RCTs is included in the GRADE table. For one RCT (Ma
2012, p806) additional data for 23 patients with an initial rhythm of VF/pVT were obtained directly from the lead author.
The intervention assessed was a short period of chest compressions before defibrillation with a longer period of chest
compressions defined as between 90 to 180 seconds before defibrillation.
For the critical outcome of survival to one year with good neurological function (CPC 2), we identified low quality
evidence (downgraded for bias and imprecision) from a single trial (OR 1.18, 95% CI [0.522 to 2.667])
(Wik 2003 p1389).
For the critical outcome of survival to one year, we identified low quality evidence (downgraded for bias and imprecision)
from 2 RCTs (OR 1.15, 95% CI [0.625 to 2.115])
(Jacobs 2005p39; Wik 2003p1389).
For the critical outcome of survival to hospital discharge with favorable neurological outcome (defined as CPC score of 2,
MRS score 3), we identified low quality evidence (downgraded for inconsistency and imprecision) from 4 RCTs (OR 0.95,
95% CI [0.786 to 1.15])
(Stiell 2011 p 787; Wik 2003 p1389; Baker 2008 p424; Ma 2012 p806).
For the critical outcome of survival to hospital discharge, we identified low quality evidence (downgraded for bias and
imprecision) from 4 RCTs (OR 1.095, 95% CI [0.695 to 1.725])
(Jacobs 2005 p39; Wik 2003 p1389; Baker 2008 p424; Ma 2012 p806)
With respect to ROSC, we identified low quality evidence (downgraded for bias and imprecision) from 4 RCTs (OR 1.193,
95% CI [0.871 to 1.634])
(Jacobs 2005 p39; Wik 2003 p1389; Baker 2008 p424; Ma 2012 p806)
Two subgroups analyses were also considered in this review. One subgroup analysis looked at enrollments based on EMS
response time comparing those with times less than 4 to 5 minutes vs. those 4 to 5 minutes. Within this subgroup, one
RCT (Wik 2003 p1389) found a favorable relation with CPR for 180 seconds before defibrillation when response time was
5 minutes but this relationship was not confirmed in 3 other RCTs (Baker 2008 p424, Jacobs 2006 p39, Stiell 2011 p787 ).
The second subgroup analysis (Rea 2014 p1) examined outcomes from early vs. late analysis based on baseline EMS
agency VF/pVT survival rates. These authors reported that survival was better with early analysis and defibrillation for
agencies in which low baseline survival to hospital discharge rate (defined as <20% for an initial rhythm of VF/pVT) while
3 minutes of CPR followed by analysis and defibrillation resulted in better outcomes in and in EMS agencies with high
baseline survival to hospital discharge rates (defined as > 20% for an initial rhythm of VF/pVT). Although no study has
suggested harmful effects from up to 180 seconds of CPR prior to defibrillation, an exploratory analysis from one RCT
(Stiell 2011 p787) suggested a decline in survival to hospital discharged from a prolonged period of CPR (180 seconds)
with delayed defibrillation in patients with an initial rhythm of VF/pVT that had received bystander CPR compared to a
shorter period of CPR (30-60 seconds) followed by defibrillation.
In all of the RCTs reviewed, chest compressions were performed prior to initial analysis while the defibrillator equipment
was being applied. The exact duration of this period was documented precisely in only one RCT (Stiell 2011 p787) and
noted to be between 30-60 seconds. Subgroup analysis suggested potential benefit from a longer period of chest
compressions (180 seconds) in patients with prolonged EMS response times ( 4 to 5 minutes) in one RCT (Wik 2003, p
1389) although this was not confirmed by three other RCTs (Baker 2008 p424, Jacobs 2006 p39, Stiell 2011 p787). In
another subgroup analysis (Rea 2014 p1) a prolonged period of CPR (180 seconds) was more beneficial in EMS agencies
with high baseline survival to hospital discharge (defined as > 20% for an initial rhythm of VF/pVT). Lastly, a post hoc
analysis (Stiell 2011 p787) suggested that a longer period of CPR (180 seconds) may be harmful to patients receiving
bystander CPR. In summary, the quality of evidence summarized in this GRADE review suggests that in patients with an
initial rhythm of VF/pVT, there is no benefit to a period of CPR of 90 to 180 seconds prior to defibrillation when compared
to immediate defibrillation with CPR being performed while the defibrillator equipment is being applied.
We suggest an initial period of CPR for 30-60 seconds while the defibrillator is being applied (weak recommendation, low
quality of evidence).
Values and Preferences Statement: In making this recommendation, value was placed on randomized controlled clinical
trials and non-randomized trials were not considered. We also recognize that the evidence in support of these
recommendations comes from randomized trials of variable quality conducted in several countries and varying 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. 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.
Dispatcher instruction in CPR

Question Type:
Intervention
Full Question:
Among adults and children who are in cardiac arrest outside of a hospital (P), does the ability of a dispatch system to
provide CPR instructions (I), compared with a dispatch system where no CPR instruction are ever provided (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, delivery of bystander CPR, time to first shock, time
to commence CPR, CPR parameters (O)?
For the critical outcome of survival with favourable neurological outcome, we have identified low to very low quality
evidence from two RCTs (one reporting outcomes at hospital discharge [Rea 2010, 423] the other at end-of-study
[Hallstrom 2000, 190]), one cohort study (outcome at 30 days [Akahane 2012, 1410]), and one before-after study
(outcome at one year [Tanaka 2012, 1235]). The before-after study [Tanaka 2012, 1235] was the only one to show a
marginal benefit at one year [3/20 (15%) survived before, and 10/35 (29%) after the educational intervention; p=0.044].
For the critical outcome of survival, we have identified very low to moderate quality evidence from three RCTs (one
reporting outcomes at one day, 30 days, and hospital discharge [Svensson 2010, 434]; one to hospital admission and
hospital discharge [Hallstrom 2000, 190]; and one to hospital discharge only [Rea 2010, 423]), five before-after studies
(one reporting outcomes at hospital admission [Stipulante 2014, 177], two at hospital admission and hospital discharge
[Bray 2011, 1393 and Vaillancourt 2007, 877], two at hospital discharge [Culley 1991, 362 and Eisenberg 1985, 47], and
one at one year [Tanaka 2012, 1235]), and four cohort studies (three reporting outcomes at hospital discharge [Bang
1999, 175; Kuisma 2005, 89; and Rea 2001, 2513], one at 30 days [Akahane 2012, 1410]). Hpfl [2010, 1552] metaanalysed the three RCTs (moderate quality) and found an absolute survival benefit of 2.4% (95%CI 0.1%-4.9%) in favour
of continuous chest compressions over traditional CPR [NNT 41; (95%CI 20-1,250); RR 1.22 (95%CI 1.01-1.46)]. One
cohort study [Akahane 2012, 1410] showed a survival benefit at 30 days when T-CPR was provided to a pediatric OHCA
population vs. not [Adj. OR 1.46 (95%CI 1.05-2.03)]. One before-after study [Tanaka 2012, 1235] showed a survival
benefit at one year from an educational program for dispatchers on CCC and agonal breathing [Adj. OR 1.81 (95%CI 1.202.76)].
For the critical outcome of ROSC, we have identified low to very low quality evidence from one RCTs [Rea 2010, 423], and
one before-after study [Vaillancourt 2007, 877], neither of which reported a statistically significant benefit.
For the important outcome of delivery of bystander CPR, we have identified low to very low quality evidence from six
before-after studies, and one cohort study. All showed a strong association between the studied intervention and
bystander CPR. The cohort study [Akahane 2012, 1410] showed increased performed chest compressions [Adj. OR 6.04
(95%CI 4.72-7.72)] and ventilations [Adj. OR 3.10 (95%CI 2.44-3.95)] from T-CPR. [Bray 2011, 1393] studied two MPDS
versions, [Culley 1991, 362; Eisenberg 1985, 47; and Vaillancourt 2007, 877] studies T-CPR vs. not, and [Stipulante
2014, 177 and Tanaka 2012, 1235] each study various educational programs.
For the important outcome of time to commence CPR, we have identified very low quality evidence from four before-after
studies [Culley 1991, 362; Eisenberg 1985, 47; Stipulante 2014, 177; and Tanaka 2012, 1235], and one cohort study
[Rea 2001, 2513], none of which reported a statistically significant benefit.
For the important outcome of CPR parameter (assessed with initial rhythm of VF/VT), we have identified very low quality
evidence from one RCT [Svensson 2010, 434], and one before-after study [Vaillancourt 2007, 877], neither of which
reported a statistically significant benefit.
We recommend that dispatchers should provide CPR instructions to callers in order to improve survival from OHCA.
(serious indirectness, strong recommendation, moderate quality of evidence).
We recommend that dispatchers should provide CPR instructions to callers in order to improve bystander CPR rates. (some
indirectness, strong recommendation, low to very low quality of evidence).
Values and Preferences Statement: We recognize that the evidence in support of these recommendations comes from
randomized trials and observational data of variable quality. However, the available evidence consistently favors telephone
CPR protocols using a compression-only CPR instruction set, suggesting a dose effect, e.g. quick telephone instructions
in chest compressions result in more compressions and faster administration to the patient. In making these
recommendations, we placed a higher value on the initiation of bystander CPR and a lower value on the harms of
performing CPR on patients who are not in cardiac arrest.
Drowning
Question Type:
Prognostic
Full Question:
In adults and children who are submerged in water (P), does any particular factors in search and rescue operations (e.g.
duration of submersion, salinity of water, water temperature, age of victim) (I), compared with no factors (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 (O)?
Overall the review identified 29 relevant articles. The critical outcomes were survival with favourable neurological outcome
and survival measured at various time points following hospital discharge or 30 days. The studies reviewed are
characterised by their diversity in terms of the countries from which the data were drawn, definitions for adverse outcomes
(although adverse neurological outcomes were universally severe in nature (e.g. coma, persistent vegetative state or
severe disability), the populations evaluated (all drownings, cardiac arrests only, EMS treated cases, ED treated cases or
those admitted to hosptial). Relatively few studies reviewed adjusted for all known confounders and several studies lacked
complete follow-up data. The studies covered nearly 4 decades which limited in some cases the generalisability of findings
to current clinical practice.
AGE
For the critical outcome of neurologically intact survival we identified very low quality evidence from 11 observational
studies which included 4054 patients (Frates, 1981, 1006; Nagel, 1990, 422; Quan, 1990, 586; Anderson, 1991, 27; Niu,
1992, 81; Mizuta, 1993, 186; Kyriacou, 1994, 137; Al-Mofadda, 2001, 300; Blasco Alonso, 2005, 20; Nitta, 2013, 1568;
Quan, 2014, 790). These studies as a group were very varied in the populations (inclusive community/population based to
OHCA EMS to hospitalized ICU/ OHCA cases) with widely varying proportions of good outcomes/survivors, especially
among older victims (range 13-92%). The studies spanned nearly 4 decades (1979-2014). Few studies adjusted for
confounding. Therefore the quality of evidence was downgraded to very low due to serious risk of bias, inconsistency,
indirectness and imprecision. Ten studies evaluated neurologic outcome at hospital discharge (Frates, 1981, 1006; Nagel,
1990, 422; Quan, 1990, 586; Anderson, 1991, 27; Niu, 1992, 81; Mizuta, 1993, 186; Kyriacou, 1994, 137; Al-Mofadda,
2001, 300; Blasco Alonso, 2005, 20; Quan, 2014, 790) and one neurological outcome at 1 month(Nitta, 2013, 1568) . Of
these, 7 were pediatric studies which was defined variably as children <15-21 years of age(Frates, 1981, 1006; Nagel,
1990, 422; Quan, 1990, 586; Niu, 1992, 81; Mizuta, 1993, 186; Kyriacou, 1994, 137; Al-Mofadda, 2001, 300) . Of these
7 pediatric studies, 6 found that young age, variably defined as <3, 4, 5 or 6 years, was not associated with neurologically
intact survival(Frates, 1981, 1006; Nagel, 1990, 422; Niu, 1992, 81; Mizuta, 1993, 186; Al-Mofadda, 2001, 300). A single
pediatric study which included 166 children aged <15 years reported better outcomes in children aged < 5 years (relative
risk 0.12 (95% CI 0.03-0.44)( Kyriacou, 1994, 137). The cases included in this study were mostly from swimming pool
drowning and there were relatively few cases in the older age group (21 cases, 13%). Two pediatric studies included
known confounders in a multivariate analysis and reported age had no effect on outcome(Frates, 1981, 1006; Quan, 1990,
586).
Of the 3 studies of all ages of drowning victims, 2 found no relationship between age and outcome. Anderson et al
reported on 39 cases and found no difference according to age less than or greater than 3 years (relative risk 1.17(0.911.53), absolute difference -13.9% (-33.7 to 15.5%)(Anderson, 1991, 27). Blasco et al reported on 62 cases dicotomising
outcomes based on an age of less than or greater than 4). There was no difference in outcomes (relative risk 0.88 (0.681.14), absolute difference (10.3% (-10.5 to 30.4%)(Blasco Alonso, 2005, 20). The largest single study which included
1094 cases over a 22 year study period reported worse outcomes amongst children aged > 5 (relative risk 0.66(0.510.85). These findings persisted after multi-variate analysis which adjusted for known confounders.(Quan, 2014, 790)
The one study of neurologic outcome at 1 month found that young age, <5 years, was not associated with good outcome
on multivariate analysis. However, this was a unique study: from Japan, a country with the greatest longevity in the world,
in which the median age of drowned adults was 77 years who primarily drowned in bath tubs. Moreover, there was only
1% favourable outcome in this study.(Nitta, 2013, 1568)
For the critical outcome of survival we identified very low quality evidence from 6 observational studies which included
1313 patients(Orlowski, 1979, 176; Mosayebi, 2011, 187; Claesson, 2012, 1072; Dyson, 2013, 1114; Claesson, 2014,
644; Vahatalo, 2014) . The studies spanned over 3 decades (1979-2014). The quality of evidence was downgraded for risk
of bias, inconsistency, indirectness and imprecision. Three studies included children only (Mosayebi, 2011, 187; Orlowski,
1979, 176; Vahatalo, 2014), one adults only (Claesson, 2012, 1072) and two all ages (Dyson, 2013, 1114; Claesson,
2014, 644). The pediatric study which grouped children according to age < or > 3 years (Orlowski, 1979, 176) found older
age was associated with better outcomes (relative risk 1.51 (1.19-1.90), absolute difference -31.1%(-45.6% to -14.1%).
This study was conducted at 4 hospitals in 4 different high and low income countries. The methods used for case
ascertainment were unclear. The two others pediatric studies found no difference according to age > or < 5 years (relative
risk (Mosayebi, 2011, 187) relative risk (Vahatalo, 2014). The adult only study identified better outcomes in adults aged
less than 58 years (relative risk 0.27 (0.08-0.96), absoulte difference 7.9% (0.6% to 15.8%) (Claesson, 2012, 1072). For
the two studies which included adults and children one reported age < 46 years was associated with better survival on
multivariate analysis ((Claesson, 2014, 644) whilst the second found no difference with an age cut of of 18 years (relative
risk 0.52 (0.17-1.56, abolute difference 5.5%(-3.4% to 16.4%).
EMS RESPONSE TIME
No studies were identified which addressed the critical outcome of neurologically intact survival.
For the critical outcome of survival we identified low quality evidence from 2 observational studies which included 415
patients in the Swedish EMS OHCA registry ((Claesson, 2008, 381; Claesson, 2012, 1072) They were by the same author
in the same highly sophisticated EMS system with short response durations (<10minutes) in an HIC (high income
country). The second study included the sample population studied in the first paper Inclusion criteria were limited to only
patients who had received resuscitation by EMS; thus it excluded patients who had drowned and had bystander successful
resuscitation or were declared dead at the scene without EMS involvement. Follow-up rates were incomplete in both
studies. This led to the quality of evidence being downgraded for risk of bias, indirectness and imprecision. Outcomes were
compared between patients who receive an EMS response within or more than 10 minutes. For the smaller study the
relative risk of death was 0.29 (0.13-0.66) and absolute difference 12.7%(5.1-20.6%) favouring EMS response times of <
10 min. The larger study reported EMS response time < 10 min as being associated with better survival on univariate
(P=0.02) and multivariate analysis (odds ratio 0.44 (0.06-0.83).
SALINITY
CONSENSUS ON SCIENCE
For the critical outcome of intact neurologic survival we identified low quality evidence from 4 observational studies which
included 1842 drowning victims (370 in salt water, 1427 in fresh water)(Mizuta, 1993, 186; Blasco Alonso, 2005, 20;
Forler, 2010, 14; Quan, 2014, 790) . The quality of evidence was downgraded due to serious risk of bias (failure to adjust
for confounding) and very serious risk from indirectness (as 3 studies considered only hospitalised patients). Two of three
of the hospital based studies showed salt water was associated with better outcomes (Relative risk 1.3 (1.12-1.5),
absolute difference -23.1%( -36.1 to - 6.2 %)(Blasco Alonso, 2005, 20) ; RR 1.2 (1.1 1.4) absolute difference -13.7% (21.9 to -3.1)(Mizuta, 1993, 186) while the third showed water type was not associated with outcome RR 1.1 (0.95 1.2)
abstolute difference -6% (-16.9 to 11.0)(Forler, 2010, 14) . The fourth and largest study (Quan, 2014, 790) evaluated all
drownings (dead on arrival, EMS attended, ED attended and and hospitalized). Univariate analysis showed that water type
did not affect outcome (RR 1.14 (0.9 1.4), absolute difference- 3.3%( -9.7 to 2.7)). This finding was confirmed on
multivariate analysis.
For the critical outcome of survival we identified very low quality evidence from 3 studies(Orlowski, 1979, 176; Bierens,
1990, 1390; Dyson, 2013, 1114) . The quality of evidence was downgraded due to serious risk of bias (failure to adjust for
confounding), serious imprecision and very serious risk from indirectness. Two studies assessed hospitalised patients only.
One reported better outcomes amongst those drowning in salt water (RR 1.34 (1.19 to 1.52) absolute difference -25.8%
(-35.8% to -23.8%). Personal communication with the author of the second study provided survival outcomes according to
water type which showed no difference (RR 1.22 (0.95-1.56), absolute difference 16% (-30% to 15.6%))(Bierens, 1990,
1390) . The single EMS study (Dyson, 2013, 1114) showed salt water was associated with worse survival on univariate
(RR 0.18 (0.03 1.43) absolute difference 9% (-1.1 to 17.1%) and multi-variate analysis (AOR 0.69, 95% CI 0.01 to
0.84)(Dyson, 2013, 1114) . However, the multivariate analysis did not include submersion duration which other studies
using multivariate analyses show is the key predictor.
SUMBERSION DURATION
The studies examined in this section varied in the critical timepoints by which they defined shorter and longer immersion
intervals. For the purposes of this review we considered studies in 3 groups. We defined those with submersion intervals <
5-6 min with > 5-6 min as short duration, <10 min compared to > 10 min as intermediate duration and those with
submersion intervals of < 20-25 min compared to greater than 20-25 min as prolonged immersion. The studies reviewed
demonstrated a sigmoid shape relationship between short durations of submersion (low number of adverse outcomes), a
steady increase in the proportion of adverse outcomes between 10-25 minutes and almost universal adverse outcomes
with submersion durations of > 25 minutes. This dose response gradient led us to upgrade the quality of evidence across
all critical outcomes.
Short submersion intervals (<5-6 min)
For the critical outcome of intact neurological survival we identified high quality evidence from 11 observational studies
which included 2,409 cases(Kruus, 1979, 315; Frates, 1981, 1006; Quan, 1990, 586; Anderson, 1991, 27; Niu, 1992, 81;
Mizuta, 1993, 186; Kyriacou, 1994, 137; Graf, 1995, 312; Al-Mofadda, 2001, 300; Torres, 2009, 234; Quan, 2014, 790) .
The quality of evidence was noted to be at serious risk from bias and serious risk from indirectness. All studies noted
worse outcomes amongst patients with submersion durations which exceeded 5 minutes (point estimate for relative risks
ranged between 0.05 (Quan, 2014, 790) and 0.61(Kyriacou, 1994, 137) . 712/822 (86.6%) of patients who had outcome
information available and were submerged for short durations had good outcomes compared to 117/1060 (17%) with
longer submersion durations.
For the critical outcome of survival we identified moderate quality evidence from 5 observational studies comprising 317
cases(Orlowski, 1979, 176; Kaukinen, 1984, 34; Bierens, 1990, 1390; Veenhuizen, 1994, 906; Mosayebi, 2011, 187) .
The quality of evidence was downgraded for risk of bias, indirectness and imprecision. All studies noted worse outcomes
amongst patients with prolonged compared to short submersion durations (point estimate for relative risks ranged
between 0.27 (Kaukinen, 1984, 34) and 0.83(Veenhuizen, 1994, 906) . 159/170 (93.5%) patients submerged for short
durations had good outcomes compared to 45/84 (53%) with longer submersion durations.
Intermediate submersion intervals (<10 min)
For the critical outcome of intact neurological survival we identified high quality evidence from 8 observational studies
which included 2,348 cases(Kruus, 1979, 315; Quan, 1990, 586; Quan, 1992, 909; Mizuta, 1993, 186; Kyriacou, 1994,
137; Graf, 1995, 312; Suominen, 1997, 111; Quan, 2014, 790) . The quality of evidence was limited by bias and
indirectness. All studies noted worse outcomes amongst patients with prolonged submersion durations compared to
intermediate submersion durations (point estimate for relative risks ranged between 0.02 (Quan, 2014, 790) and 0.45
(Kyriacou, 1994, 137; Graf, 1995, 312) . 775/997 (86.6%) patients submerged for intermediate durations had good
outcomes compared to 30/879 (3.4%) with longer submersion durations.
For the critical outcome of survival we identified low quality evidence from 2 observational studies comprising 121
cases(Bierens, 1990, 1390; Panzino, 2013, 178) . The quality of evidence was downgraded due to bias, indirectness and
imprecision. The first study reported 56/73 (77%) of those submerged for < 10 min survived compared to none of the 7
patients who were submerged for more prolonged periods (relative risk not estimatable, absolute difference 76.7%(39.7 to
94.9%). The second study also noted better survival amongst those submerged for < 10 min (46/50, 96% survived)
compared to those submerged for longer (> 10 min, 2/5 (40%) survived)(Panzino, 2013, 178) .
Prolonged submersion intervals (<15-25 min)
For the critical outcome of intact neurological survival we identified moderate quality evidence from 2 observational studies
which included 739 cases(Quan, 1990, 586; Mizuta, 1993, 186) . The quality of evidence was downgraded due to serious
risk from bias in one study (Mizuta, 1993, 186) , indirectness as the settings / populations from which the studies were
drawn varied widely (e.g. EMS attended, ED attendances, hospital admission) and serious imprecision due to the small
sample size. A dose response gradient was noted with worse outcomes being associated longer submersion durations. The
largest study analysed data from 604 children who drowned over a 7 year period of which submersion duration was
available for 398(Mizuta, 1993, 186) . A submersion duration of less than 20 min was associated with improved survival
(289/370, 78% good outcome) compared to submersion durations which exceeded 20 min (1/27, 4% good outcome)
(relative risk 0.05(0.01-0.31), absolute difference (74.5%(59.7% to 79.5). The second study evaluated outcomes of
children aged < 20 years over a 10 year period(Quan, 1990, 586) . Amongst these children those submerged for < 25
minutes had better outcomes (68/101, 67% neurologically intact survival) compared to none of the four children surviving
whos submersion interval exceeded 25 minutes.
For the critical outcome of survival we identified low quality evidence from a single study comprising 49 patients(Kaukinen,
1984, 34) . The quality of evidence was downgraded for bias, indirectness and imprecision. In cases with a submersion
interval of < 15 min had an overall survival rate of 82% (33/39) compared to none of the two victims whos submersion
duration exceeded 15 min (relative risk not estimatable, 84.6% (17.3% to 92.8%) absolute difference.
WATER TEMPERATURE
For the critical outcome of intact neurological survival we identified low quality evidence from 1 large study (1094 cases).
The quality of evidence was downgraded due to indirectness and imprecision. The study included all unintentional
drownings in open waters (lakes, ponds, rivers, ocean) in a single, large region, collected from medical examiners, EMS
systems and all regional hospitals)( Quan, 2014, 790). Univariate analysis according to temperatures < or > 6 C or < or >
16C found no difference in neurological survival (relative risk 1.11 (0.9-1.37), absolute difference 3.5% (-10% to 3.5%).
Relative risk 1.02(0.81-1.27), absolute difference (-0.5% (-7.5% to 6.1%) respectively. Multivariate analysis also showed
that water temperature was not associated with outcome.
For the critical outcome of survival, we identified very low quality evidence from a single study which included of 250
patients (Claesson 2012, 1072). The quality of evidence was downgraded due to serious risk of bias, indirectness and
imprecision. This study included only drowning victims whod had an OHCA and received EMS care and included those with
intentional (suicide and homicide) drowning. This study too showed no relationship between water temperature < or > 15
C and outcome (relative risk 0.94(0.34-2.62), absolute difference 0.36% (-6.4% to 6.5%).
WITNESSED STATUS
An un-witnessed drowning might have a worse prognosis since that portends a longer period of time of anoxia. All
available studies are of EMS OHCA registries routinely record witness Y/N for cardiac arrest(Dyson 2013, Claesson 2008,
Claesson 2014, Nitta, 2013, 1568). However, we do not know what is the definition for witnessed they use for a drowning.
Does it mean the cardiac arrest was witnessed when the victim was pulled from the water? One cannot witness an arrest
of a drowning victim because they are usually submerged. Therefore, these studies provide no data on the predictive value
of a witnessed vs un-witnessed status as assessed by EMS in drowning cases and have thus been downgraded for very
serious indirectness.
For the critical outcome of intact neurologic survival, we found very low quality of evidence from 1 observational study
(Nitta, 2013, 1568), downgraded for indirectness (an unusual population- much older, mostly drowning in bath tubs, with
very low favorable outcomes) and imprecision. Univariate analysis reported by the study authors reported an unadjusted
odds ratio for good outcomes in the group where submersion was witnessed OR 16.33 (5.58-47.77). In the studys
multivariate analysis, witnessed status was definitely related to favorable outcome (adjusted OR 11.8 (2.84-49.08),
however, the analysis did not include submersion duration which several studies have found is an independent and the
most important predictor.
For the critical outcome of survival, we found low quality evidence from 4 studies (Dyson 2013, Claesson 2008, Claesson
2014, Nitta, 2013, 1568) involving a total of 2857 victims. The quality of evidence was downgraded for risk of bias,
indirectness (cardiac arrest patients only evaluated, differentiation between witnessed submersion and witnessed cardiac
arrest poorly defined) and imprecision. Two studies (Claesson, 2014, 644; Claesson, 2012, 1072) were from the same
EMS system and both used multivariate analysis. The smaller study (255 victims) showed witnessed status was not
significantly associated with improved survival (relative risk 0.55 (0.17-1.75), absolute difference 3% (-3.1% to 11.2%)(
Claesson, 2012, 1072). However, in the larger subsequent study from that same EMS system, witnessed status predicted
better outcome (reported univariate analysis P=0.05, adjusted odds ratio 2.5 (1.38-4.52)(Claesson, 2014, 644). A further
study (Dyson, 2013, 1114) showed no association of witnessed status with improved survival (relative risk 0.82 (0.262.59), absolute difference 168% (-7.29-14.79%). The large observational study from Japan (Nitta, 2013, 1568) reported
an unadjusted odds ratio of 7.38 (3.81-14.3) and adjusted odds ratio of 6.5(2.81-15.02) although the unusual population
of much older, mostly drowning in bath tubs, with very low favorable outcomes limit generalizability of these findings.
We recommend that a rescuer can use a submersion duration <10 minutes as a factor to predict a very high chance of
favorable outcome and survival in adults and children submerged in water (strong recommendation, high quality of
evidence)
We suggest a submersion durations >25 minutes can be used to predict a very low chance of favorable outcomes (weak
recommendation, low quality of evidence). We suggest that a submersion duration of > 25 minutes (weak
recommendation, moderate quality of evidence)
We suggest EMS response time (> 10 minutes) can be used as a factors to predict very low chance of survival in adults
and children submerged in water. (weak recommendation, very low quality of evidence)
We recommend against the use of age, water type (fresh / salt), water temperature and witness status as factors to
predict adverse outcome in adults and children submerged in water (strong recommendation, very low quality of
10
evidence).
EMS CC only vs standard CPR

Question Type:
Intervention
Full Question:
Among adults who are in cardiac arrest outside of a hospital (P), does provision of chest compressions with delayed
ventilation by EMS (I), compared with chest compressions with early ventilations by EMS (C), change survival with
favorable neurologic outcome, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC, time to first
shock, time to first compressions, CPR quality (O)?
For critical outcome survival to discharge with favourable neurological outcome in all out-of-hospital cardiac arrests we
have identified very low quality evidence (downgraded for risk of bias and indirectness) from one observational trial
(Bobrow 2009 656) that enrolled 1019 patients showing no benefit (unadjusted OR 1.07 95% CI 1.41 -8.79).
For the critical outcome of survival with favourable neurological outcome in the subset of witnessed/shockable out of
hospital cardiac arrest, we identified very low quality evidence (downgraded for risk of bias and indirectness) from three
observational studies (Kellum 2008 244, Kellum 2006 335, Bobrow 2009 656) that enrolled 1325 patients showing benefit
(OR 3.6 95%CI 1.77-7.35); (5.24 95%CI 2.16-12.75) and (Adj OR 2.5 95%CI 1.3-4.6)
For the critical outcome survival to discharge in the subgroup of all out of hospital cardiac arrest, we identified very low
quality evidence (downgraded for risk of bias, indirectness and imprecision) from 3 observational studies (Mosier 2010
269, Bobrow (cohort) 2008 1158, Bobrow (before/after) 2008 1158) showing benefit (OR 3.26 95%CI 2.46-4.34), (OR
2.50 95%CI 1.75-3.58) and (OR 3.05 95%CI 1.07-8.66).
For the critical outcome survival to hospital discharge in the subgroup of shockable/witnessed cardiac arrest, we identified
verylow quality evidence (downgraded for indirectness and imprecision) in three observational studies (Kellum 2008 244,
Kellum 2006 335, Bobrow (cohort) 2008 1158, Bobrow (before/after) 2008 1158) that showed benefit (OR 3.67 95%CI
1.98-7.12), (OR 5.58 95%CI 2.36-13.20), (OR 2.94 95%CI 1.82-4.74) and (OR 4.3 95%CI 0.98-19.35)
For the critical outcome of ROSC in all out of hospital cardiac arrest patients, we identified very low quality evidence
(downgraded for risk of bias and indirectness) in one observational study (Bobrow 2009 656) showing no benefit (OR 0.85
95%CI 0.64-1.11).
We suggest the use of chest compressions with delayed positive pressure ventilations (up to three cycles of 120 seconds of
200 continuous chest compression with interposed shocks) for witnessed shockable out of hospital cardiac arrest by EMS
systems similar to those characterized in published studies (weak recommendation, very low quality of evidence)
Feedback for CPR quality

Question Type:
Intervention
Full Question:
Among adults and children who are in cardiac arrest in any setting (P), does real-time feedback and prompt device
regarding the mechanics of CPR quality (e.g. rate and depth of compressions and/or ventilations) (I), compared with no
feedback (C), change survival with favorable neurologic outcome, Survival only at discharge, 30 days, 60 days, 180 days
AND/OR 1 year, ROSC, bystander CPR rates, time to first compressions, time to first shock, CPR quality (O)?
This review identified 12 studies of which two studies [Hostler 2011 p 342; Bohn 2011 p257] were randomised studies and
ten studies [Abella 2007 p54; Berg 1994 p35; Bobrow 2013 p47; Chiang 2005 p297; Kern 1992 p145; Kramer-Johansen
2006 p283; Lukas 2012 p1212; Niles 2009 p553; Sainio 2013 p50; Sutton 2014 p70] were observational of before and
after design studies. The included studies including nine studies [Abella 2007 p54; Bobrow 2013 p47; Bohn 2011 p257;
Chiang 2005 p297; Hostler 2011 p 342; Kern 1992 p145; Kramer-Johansen 2006 p283; Lukas 2012 p1212; Sainio 2013
p50] on 3716 adults and three studies [Berg 1994 p35; Niles 2009 p553; Sutton 2014 p70] on 34 paediatric patients. Four
studies included patients from in-hospital cardiac arrests [Abella 2007 p54; Berg 1994 p35; Niles 2009 p553; Sutton 2014
p70], seven studies with out-of-hospital cardiac arrests [Bobrow 2013 p47; Bohn 2011 p257; Chiang 2005 p297; Hostler
2011 p 342; Kramer-Johansen 2006 p283; Lukas 2012 p1212; Sainio 2013 p50], one study [Kern 1992 p145] had a
mixture of patients from in and out-of-hospital setting. Feedback devices examined included accelerometry-based devices
[Abella 2007 p54; Bobrow 2013 p47; Bohn 2011 p257; Hostler 2011 p 342; Kramer-Johansen 2006 p283; Lukas 2012
p1212; Niles 2009 p553; Sainio 2013 p50; Sutton 2014 p70] and audiotape of prompts [Berg 1994 p35; Chiang 2005
11
p297; Kern 1992 p145]. Compared to previous worksheet in 2010, this review identified eight new studies that were
included for analysis [Bobrow 2013 p47; Bohn 2011 p257; Hostler 2011 p 342; Kramer-Johansen 2006 p283; Lukas 2012
p1212; Niles 2009 p553; Sainio 2013 p50; Sutton 2014 p70].Overall, the reviewers had serious concerns for trial
methodology of included studies. The nature of using feedback technology meant that all studies suffered from
performance and detection bias as healthcare professionals were not blinded to intervention (feedback or no feedback)
groups study.
For the critical outcome of favourable neurological outcome we identified moderate quality evidence from one cluster
randomised [Hostler 2011 p342] representing 1586 patients and very low evidence from two observational studies in
adults [Bobrow 2013 p47; Sainio 2013 p50] representing 670 patients. All studies were downgraded due to risk of bias.
The randomised trial found no difference in the number of patients who achieved favourable neurological outcome (control
10.1% vs 10.3%, p=0.855). No studies showed a statistically significant difference in favourable neurological outcome
with the use of CPR feedback. Effect of CPR feedback on survival with favourable neurological outcome ranged from -0.8 to
+5.8.
For the critical outcome of survival to hospital discharge we identified moderate quality evidence from one cluster
randomised [Hostler 2011 p342] representing 1586 patients and very low evidence from four observational studies in
adults [Abella 2007 p54; Bobrow 2013 p47; Kramer-Johansen 2006 p283; Sainio 2013 p50] and one observational study
in children [Sutton 2014 p70] representing 1192 patients. All studies were downgraded due to risk of bias. The
randomised trial found no difference in the number of patients who achieved survival to hospital discharge (control 44.7%
vs 44.3%, p=0.962). No studies showed a statistically significant difference in survival to hospital discharge with the use
of CPR feedback. Effect of CPR feedback on survival to hospital discharge ranged from -0.9 to +5.2.
For the critical outcome of return of spontaneous circulation (ROSC) we identified moderate quality of evidence from two
randomised studies [Hostler 2011 p342; Bohn 2011 p257] representing 1886 patients and very low quality of evidence
from seven observational studies in adults [Abella 2007 p54; Bobrow 2013 p47; Bohn 2011 p257; Chiang 2005 p297;
Kramer-Johansen 2006 p283; Lukas 2012 p1212; Sainio 2013 p50] and one observational study in children [Sutton 2014
p70] representing 3447 patients. All studies were downgraded due to risk of bias. The randomised trial found no difference
in the number of patients who achieved ROSC (control 44.7% vs 44.3%, p=0.962). Only one study [Sainio 2013 p50]
showed a statistically significant difference in ROSC with the use of feedback, however in this study feedback was
activated at the discretion of the HEMS physician and no details of the decision making process to activate / not activate
feedback were provided. Effect of CPR feedback on return of spontaneous circulation ranged from -4.4% to 17.5%: one
study had a 50% increase in ROSC with CPR feedback however this small study had only four patients in each group
[Sutton 2014 p70].
For the important outcome of chest compression rate we identified moderate quality evidence from two randomised
studies [Hostler 2011 p342; Bohn 2011 p257] representing 1474 patients and very low evidence from four observational
studies: three in adults [Abella 2007 p54; Bobrow 2013 p47; Kramer-Johansen 2006 p283] representing 777 patients and
one in children [Sutton 2014 p70] representing 8 patients. All studies were downgraded due to risk of bias. The cluster
randomised controlled trial [Hostler 2011 p342] found a significant difference of -4.7 compressions per minute and the
prospective randomised trial [Bohn 2011 p257] no difference in compression rates with and without feedback and in both
randomised trials, compression rates were all close to international recommendations of 100 compressions per minute.
One observational study [Abella 2007 p54] showed no difference in chest compression rates with and without feedback
and again all compression rates were close to international recommendations of 100 compressions per minute. Two
observational studies [Bobrow 2013 p47; Kramer-Johansen 2006 p283] showed lower compression rates in the group with
CPR feedback, however the mean compression rates in the intervention groups were 105 and 109 respectively and the
compression rates in both control groups exceeded 120 compressions per minute which is not congruent with international
recommendations. The paediatric study [Sutton 2014 p70] found a median difference of -10 compressions per minute with
feedback and again, the chest compression rate in the control group exceeded 120 compressions per minute. The use of
CPR feedback devices may be effective in limiting compression rates that are too fast.
For the important outcome of chest compression depth we identified moderate quality of evidence from two randomised
studies [Hostler 2011 p342; Bohn 2011 p257] representing 1296 patients and very low evidence from four observational
studies: three in adults [Abella 2007 p54; Bobrow 2013 p47; Kramer-Johansen 2006 p283] representing 777 patients and
one in children [Sutton 2014 p70] representing 8 patients. All studies were downgraded due to risk of bias. The cluster
randomised controlled trial [Hostler 2011 p342] found a significant +1.6mm (cluster adjusted) difference in chest
compression depth with feedback, however this is of questionable clinical significance and compression depths were less
than international recommendations of 5cm in adults (3.96 and 3.87 cm). The prospective randomised trial [Bohn 2011
p257] found no significant difference in compression depth with and without feedback, and all compression depths were
close to, but slightly less than international recommendations of 5cm in adults. One observational study [Abella 2007 p54]
showed no difference in chest compression depth with and without feedback and all compression rates were close to, but
less than international recommendations of 5cm in adult patients (4.4 and 4.3cm). Two observational studies [Bobrow
2013 p47; Kramer-Johansen 2006 p283] showed significantly deeper chest compressions in the groups with CPR
feedback: Bobrow [2013 p47] found a +1.06cm difference (5.43 vs 4.37cm) however the difference found by KramerJohansen [2006 p283] was 0.04cm so of questionable clinical significance. The paediatric study [Sutton 2014 p70] found a
no median difference in compression depth. The use of CPR feedback devices did not seem to make an appreciable
difference to chest compression depth.
For the important outcome of chest compression fraction we identified moderate evidence from one randomised study
[Hostler 2011 p342] and very low level evidence from three observation studies in adults [Abella 2007 p54; Bobrow 2013
p47; Kramer-Johansen 2006 p283] and one in children [Sutton 2014 p70]. All studies were downgraded due to risk of
bias. The randomised study found a cluster adjusted difference of +1.9% (65.9% vs 64.0%) (p=0.016): although
statistically significant difference such a small difference has questionable clinical significance. The adult studies found no
significant difference between groups and the sample size of the paediatric study was too small to enable inferential
statistical analysis. The use of CPR feedback devices did not seem to make an appreciable difference to chest compression
12
fraction.
For the important outcome of ventilation rate we identified very low evidence from three observational studies in adults
[Abella 2007 p54; Bobrow 2013 p47; Kramer-Johansen 2006 p283] representing 532 patients. All studies were
downgraded due to risk of bias. None of the studies showed a significant difference in ventilation rates with and without
CPR feedback. Ventilation rates varied from 20 breaths per minute [Abella 2007 p54] control group] to 9.5 breaths per
minute [Kramer-Johansen 2006 p283] intervention group]. The use of CPR feedback devices did not seem to make an
appreciable difference to ventilation rate.
For the important outcome of end-tidal carbon dioxide we identified very low evidence from two observational studies in
adults [Kern 1992 p145; Bobrow 2013 p47] representing 131 patients. All studies were downgraded due to risk of bias.
Kern [1992 p145] found that ETCO2 was significantly higher when CPR feedback was used (+6.3mmHg with compression
rate feedback of 120 compressions per minute and +4.3mmHg with compression rate feedback of 80 compressions per
minute. Bobrow [2013 p47] found an absolute difference of -2.2mmHg with CPR feedback. The clinical significance of
these differences is questionable.
For the important outcome of leaning force during chest compressions we identified very low quality of evidence from
one observational studies in children [Niles 2009 p553] representing 20 patients. This study was downgraded due to risk
of bias. Leaning force was decreased by 0.9kg with the use of feedback.
This question focused on the use of CPR feedback devices alone and excluded studies where the technology was used with
system wide quality improvement initiates or post event debriefing. Within the focused scope of this question, we suggest
against routine implementation of CPR feedback devices in systems in which they are currently not used (weak
recommendation, very low quality of evidence). In systems currently using CPR feedback devices we suggest the devices
may continue to be used that there is no evidence suggesting significant harm (weak recommendation, very low quality of
evidence).
Values and preferences statement: In making this recommendation, we place a higher value on resource allocation and
cost effectiveness than widespread implementation of a technology with uncertain effectiveness.
Harm from CPR to victims not in arrest

Question Type:
Intervention
Full Question:
Among Adults and children who are NOT in cardiac arrest outside of a hospital (P), does provision of chest compressions
from lay rescuers (I), compared with no use of chest compressions (C), change Survival with Favorable
neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, harm (eg rib fracture),
complications, major bleeding, risk of complications (eg, aspiration), Survival only at discharge, 30 days, 60 days, 180
days AND/OR 1 year, survival to admission (O)?
For the important outcome of harm we have identified very low quality evidence (downgraded for risk of bias due to
missing controls and loss to follow up and for imprecision due to sample size and baseline risk difference) from four
observational studies enrolling 762 patients who received CPR outside the hospital without being in cardiac arrest. Three of
the studies (White 2010, 91; Haley 2011, 282; and Moriwaki 2012, 3) reviewed the medical records to identify harm and
one had follow-up telephone interviews (White 2010, 91). Pooled data from these three studies, encompassing 345
patients, showed a bone fracture (ribs and clavicle) incidence of 1.7% (95% CI 0.4% 3.1%), pain in the area of chest
compression 8.7% (95% CI 5.7% 11.7%), and no clinically relevant visceral injury. The forth study (Tanaka 2014,
1751), relied on fire department observations at the scene and there were no reported injuries in 417 patients.
We recommend that lay persons initiate CPR without concerns of harm to patients not in cardiac arrest (strong
recommendation, very low quality of evidence). The benefits of bystander initiated CPR are well documented and outweigh
potential harm from chest compressions that include 1.7% risk of fractures of chest wall bones and 8.7% risk of chest wall
pain.
Values and Preferences Statement: In making this recommendation we place a high value on the outcome impact of CPR
initiated by lay persons in patients in cardiac arrest.
Minimizing pauses in chest compressions

13
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)?
Pauses in chest compression can be for ventilations, for rhythm analysis and defibrillation shocks or for other reasons.
*For the critical outcome neurologically intact survival we found one low quality observational study (downgraded for
imprecision) (Beesems, 2013, 1585) enrolling 199 patients showing no harm of allowing the duration of two ventilations
up to 10 seconds. We found no studies addressing pauses for rhythm analysis and shock.
*For the critical outcome survival to hospital discharge we have identified moderate quality evidence (downgraded for
indirectness) from one RCTs (Jost, 2010, 1614) enrolling 845 patients showing no benefit (OR 0.81 95% CI 0.33 2.01)
of reducing pre-and post-shock pauses. We found low to moderate quality evidence from three observational studies
(partly upgraded for dose-response gradient) (Cheskes 2011, 58; Cheskes 2014, 336; Christenson 2009, 1241), including
3327 patients showing a strong relationship with shorter pre-post pauses (less for post-shock pauses) or higher chest
compression fraction. We found no studies on pauses for ventilations.
*For the critical outcome ROSC we found no studies on ventilation, one very low quality observational study (Sell 2010,
822) (downgraded for risk of bias and inprecision) including 35 patients indicating benefit from limiting pre- and postshock
pauses and one very low quality study (downgraded for risk of bias) (Vaillancourt 2011, 1502) including 2103 patients,
suggesting benefit from achieving higher chest compression fractions >40%.
*For the important outcome shock success we found one low quality observational study 9downgraded for imprecision)
(Edelson 2006, 137) including 60 patients, indicating benefit of shorter pre-shock pauses [OR 1.86 (1.10-3.15)/5 sec].
We suggest that two ventilations are delivered within 10 seconds (weak recommendation, low quality of evidence). When
airway is protected, we recommend that ventilations are delivered within 5 seconds (added (added for discussion)
We suggest that pre-shock and post-shock pauses in chest compressions be as short as possible. For manual defibrillators,
we suggest that pre-shock pauses are 10 seconds (weak recommendation, low quality of evidence).
We suggest that chest compression fraction should be >60% (weak recommendation, low quality of evidence).
Passive ventilation techniques

Question Type:
Intervention
Full Question:
Among adults and children who are in cardiac arrest in any setting (P), does addition of any passive ventilation technique
(eg positioning the body, opening the airway, passive oxygen administration) to chest compression-only CPR (I), compared
with just chest compression-only CPR (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,
bystander initiated CPR, oxygenation (O)?
For the critical outcome of favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1
year,, we identified two studies; one randomized controlled trial (Saissy JM 2000;1523) and one retrospective study
(Bobrow BJ 2009;656). Both studies were downgraded due to risk of serious bias. Saissy et al studied continuous
insufflation of air or oxygen (CIO) through microcannulas inserted into the inner wall of a modified intubation tube and
generating a permanent positive intrathoracic pressure; endpoints were respiratory effects of the intervention compared
with intermittent positive pressure ventilation; however, none of the patients in either group survived to hospital
discharge. In the Bobrow et al. study, paramedics selected either oropharyngeal airway and high flow oxygen by
nonrebreather facemask [46/459 (10%) survivors with adjusted neurologically intact survival to hospital discharge)]
without assisted ventilation, or bag-valve-mask ventilation at 8/min [53/560 (9.5%)] survivors with adjusted
neurologically intact survival to hospital discharge]. There was an advantage with selected either oropharyngeal airway
and high flow oxygen by nonrebreather facemask over bag-valve-mask ventilation in neurologically intact survival at
hospital discharge in patients with witnessed VF/VT [39/102 (38.2%) vs. 31/120 (25.8%); OR 2.5 (95% CI 1.3-4.6)]; this
positive effect vanished when assessing non-witnessed VF/VT [3/41 (7.3%) vs. 8/58 (13.8%); OR 0.5 (95% CI 0.2-1.6)],
or non-shockable rhythms [4/316 (1.3%) vs. 14/381 (3.7%); OR 0.3 (95% CI 0.1-1.0)].
For the critical outcome of survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, there was only data
from the retrospective Bobrow et al. study, with identical numbers to the aforementioned analysis of neurologically intact
14
(oropharyngeal airway and high flow oxygen by nonrebreather facemask [46/459 (10%) survivors with adjusted
neurologically intact survival to hospital discharge)] without assisted ventilation vs. bag-valve-mask ventilation at 8/min
[53/560 (9.5%)].
For the critical outcome of return of spontaneous circulation, there were two RCTs [the aforementioned Saissy study and
Bertrand C 2006;843 (constant flow insufflation of oxygen (CFIO) through Boussignac multichannel endotracheal
compared to standard endotracheal intubation and mechanical ventilation)] and the aforementioned study by Bobrow et al.
In the Saissy study, outcome of experimental treatment vs. standard treatment was comparable [13/48 (27.1%) vs.
10/47 (21.3%) P=NS, calculated OR 0.71 (95 % CI 0.27 to 1.82)]; in the Bertrand study it was comparable as well
[67/355 (19%) vs. 71/341 (21%) P=0.99, calculated OR 1.13 (95 % CI 0.7786 to 1.6411) and also comparable in the
retrospective Bobrow et al study [123/459 (26.8%) vs. 169/560 (30.2%), reported OR 0.8 (0.7-1.0)].
For the important outcome of oxygenation, there were two RCTs [the aforementioned Saissy and Bertrand study, while
the aforementioned study by Bobrow et al. did not report respiratory parameters. In the Saissy study, outcome of
experimental treatment vs. standard treatment was PaO2 375 147 vs. 195 101 mm Hg (ICU admission) and PaCO2
34 3 vs. 65 18 mm Hg (ICU admission); both P<0.05. In the Bertrand study, outcome of experimental treatment vs.
standard treatment was 35% vs. 25% with SpO2 >70% (P=0.009). However, quality was low in both studies.
For the important outcome of bystander CPR, data was available in the Bertrand and Bobrow studies; outcome of
experimental treatment vs. standard treatment in the Bertrand study was 31/355 (9%) vs. 33/341 (10%); P=0.65; while
it was in the Bobrow study 177/459 (38.6%) vs. 242/560 (43.2%); P=n/a, reported OR 0.8 (0.6-1.1).
We suggest that in cardiac arrest in the prehospital setting, EMS providers may consider passive ventilation using an
orophyrangeal tube and oxygen delivery mask while performing continuous chest compressions (weak evidence, low
quality of evidence, subject to serious bias).
Public access AED programs

Question Type:
Intervention
Full Question:
Among adults and children who are in cardiac arrest outside of a hospital (P), does implementation of a public access AED
program (I), compared with traditional EMS response (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, bystander CPR rates, bystander use of AED, time to commence CPR (O)?
For survival to one year with favourable neurological outcome we have identified very low quality evidence (downgraded
for risk of bias) from one observational trial (Cappato 2006 553) enrolling 1394 patients showing improved outcomes with
public access defibrillation (unadjusted OR 3.53 95% CI 1.41 -8.79)
For survival to 30 days with favourable neurological outcome we identified very low quality evidence (downgraded for
inconsistency and indirectness) from 3 observational studies (Kitamura 2010 994, Kitamura 2012 2834, Mitani 2013 1259)
enrolling 182,119 patients demonstrating improved survival (range 31.6% to 55%) with public access defibrillation
compared to no program (range 3% to 37%). If combined in a formal meta-analysis, a summary effect measure of OR
7.94 (95% CI: 7.19, 8.76) would be generated however we recognise the limitations of significant heterogeneity in
populations and interventions, as well as the risk of repeated study populations across studies.
For survival to 30 days we identified very low quality evidence (downgraded for indirectness) from 3 observational
studies (Iwami 2012 2844, Kitamura 2010 994, Mitani 2013 1259) enrolling 14,135 patients demonstrating improved
survival (range 37.2% to 65.5%) with public access defibrillation compared to no program (23.3% to 48.5%). If combined
in a formal meta-analysis, a summary effect measure of OR 1.63 (95% CI: 1.41, 1.88) would be generated however we
recognise the limitations of significant heterogeneity in populations and interventions, as well as the risk of repeated study
populations across studies.
We identified moderate quality evidence (downgraded for risk of bias) from one randomised clinical trial (Hallstrom 2004
637) enrolling 235 patients showing improved survival to discharge with favourable neurological outcome (unadjusted
RR 1.84 95% CI: 0.91, 3.71) and survival to discharge outcome (unadjusted RR 1.67 95%CI: 0.95, 2.94) with public
access defibrillation.
For survival to discharge with favourable neurological outcome we identified very low quality evidence (downgraded for
risk of bias, inconsistency and imprecision) from 3 observational studies (Berdowski 2011 2225, Cappato 2006 553,
Cappucci 2002 1065) enrolling 4581 patients demonstrating improved survival (range 4.1% to 50%) with public access
defibrillation compared to no program (1.4% to 14.8%), and 1 observational study (Kuisma 2003 149, 20 patients)
15
showing reduced survival (0% vs 30.7). If combined in a formal meta-analysis, a summary effect measure of OR 4.17
(95% CI: 3.04, 5.72) would be generated however we recognise the limitations of significant heterogeneity in populations
and interventions, as well as the risk of repeated study populations across studies.
For survival to discharge we identified very low quality evidence (downgraded for risk of bias, indirectness and
imprecision) from 9 observational studies (Berdowski 2011 2225, Cappato 2006 553, Cappucci 2002 1065, Culley 2004
1859, Fleishhackl 2008 195, , Rea 2010 163, Swor 2013 426, Weisfeldt 2010 1713, Weisfeldt 2011 313) enrolling 46,070
patients demonstrating improved survival (range 4.4% to 51%) with public access defibrillation compared to no program
(1.4% to 25.0%) and 1 observation study (Kuisma 2003 149, 20 patients) showing reduced survival (0% vs 30.7). If
combined in a formal meta-analysis, a summary effect measure of OR 4.85 (95% CI: 4.19, 5.61) would be generated
however we recognise the limitations of significant heterogeneity in populations and interventions, as well as the risk of
repeated study populations across studies.
We suggest the implementation of public access defibrillation programs to patients with out of hospital cardiac arrests in
settings similar to published studies (weak recommendation, very low quality of evidence).
Rhythm check timing

Question Type:
Intervention
Full Question:
Among adults and children who are in cardiac arrest in any setting (P), does checking the cardiac rhythm immediately after
defibrillation (I), compared with immediate resumption of chest compressions with delayed check of the cardiac rhythm
(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, recurrence of VF (O)?
For the critical outcome of survival with favorable neurological outcome at discharge we identified very low quality
evidence downgraded for serious risk of bias, indirectness and imprecision; from three observational studies enrolling 763
OHCA showing a harm effect for checking rhythm immediately after defibrillation (RR 0.62 95% CI 0.51-0.75) (Bobrow,
2008,1158; Kelliun,2006,335; Rea,2006,2760).
For the critical outcome of survival hospital discharge we identified low qualitiy evidence from one RCT enrolling 845
OHCA showing no benefit for checking rhythm immediately after defibrillation (RR 0.80 95% CI 0.55-1.15)(Jost 2010,
1614) and very low quality evidence downgraded for serious risk of bias and indirectness; from three observational studies
enrolling 3094 OHCA showing a harm effect for checking rhythm immediately after defibrillation (RR 0.55 95% CI 0.450.67) (Bobrow 2008,1158; kellum 2006,335; Rea, 2006,2760). In addition for the same outcome, we identified very low
quality evidence from one observational study 528 OHCA showing potential harm for checking rhythm immediately after
defibrillation (RR 0.42 95% CI 0.29-0.61) (Bobrow, 2008,1158).
For the critical outcome of survival to hospital admission , we have identified low quality evidence from one RCT enrolling
845 OHCA showing no benefit for checking rhythm immediately after defibrillation (RR 0.99 95% CI 0.85-1.15) (Jost, 2010
1614).
For the critical outcome of ROSC, we identified very low quality evidence downgraded for serious risk of bias and
indirectness; from two observational studies enrolling 2969 OHCA showing a harm effect for checking rhythm immediately
after defibrillation (RR 0.69 95% CI 0.61-0.78) (Bobrow, 2008,1158; Rea, 2006,2770).
For the important outcome of recurrence of VF we identified low quality evidence from one RCT enrolling 136 OHCA
showing no benefit checking rhythm immediately after defibrillation (RR 1.00 95% CI 0.81-1.23) (Berdowski,2010,72).
We suggest against the checking of cardiac rhythm immediately after defibrillation in comparison to immediate resumption
of chest compressions with delayed check of cardiac rhythm (weak recommendation, very low quality evidence). Values
and preference statement: In making this recommendation we place a higher value on avoiding interruptions in chest
compression for an intervention showing no benefit for critical and important outcomes.
Starting CPR
Question Type:
Intervention
Full Question:
Among adults and children who are in cardiac arrest in any setting (P), does CPR beginning with compressions first (30:2)
(I), compared with CPR beginning with ventilation first (2:30) (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 (O)?
16
There were no human studies identified in this review. This review identified four manikin studies; one randomised study
[Marsch 2013 p w13856] focused on adult resuscitation, one randomised study focused on paediatric resuscitation
[Lubrano 2012 p1473] and two observational studies focused on adult resuscitation [Sekiguchi 2013 p1248; Kobayashi
2008, p333]. Compared to previous worksheet in 2010, this review identified three new studies that were included for
analysis [Marsch 2013 p w13856; Lubrano 2012 p1473 and Sekiguchi 2013 p1248]. Overall, the reviewers had serious
concerns for trial methodology of included studies. The nature of comparing two different resuscitation protocols meant
that all studies suffered from performance and detection bias as healthcare professionals were not blinded to the
intervention (CAB vs ABC).
For the important outcome of time to commencement of chest compressions we identified very low quality evidence from
one randomised manikin study [Lubrano 2012 p1473] representing 155 2-person teams and very low quality evidence
from two observational manikin studies [Sekiguchi 2013 p1248; Kobayashi 2008, p333] representing 40 individual
rescuers [Sekiguchi 2013 p1248] and 33 6-person teams [Kobayashi 2008, p333]. All studies were downgraded due to
risk of bias. All studies found that CAB decreased the time to commencement of chest compression. The randomised trial
found a statistically significant 24.13 second difference (p<0.05) in favour of CAB [Lubrano 2012 p1473]. The
observational studies found statistically significant decreases of 20.6 seconds (p<0.001) [Sekiguchi 2013 p1248] and 26
seconds (p<0.001) [Kobayashi 2008, p333] respectively.
For the important outcome of time to commencement of rescue breaths we identified very low quality evidence from two
randomised manikin studies [Marsch 2013 p w13856; Lubrano 2012 p1473] representing 210 2-person teams. Both
studies were downgraded due to risk of bias. Lubrano [2012 p1473] found a statistically significant 3.53 second difference
(p<0.05) in favour of CAB during a respiratory arrest scenario however in a cardiac arrest scenario, ABC decreased the
time to commencement of rescue breaths by 5.74 seconds (p<0.05). Marsch [2013 p w13856] found that CAB decreased
time to commencement of rescue breaths by 5 seconds (p=0.003). The clinical significance of these differences is
unknown.
For the important outcome of time to completion of first CPR cycle (30 chest compressions and 2 rescue breaths) we
identified low quality evidence from one randomised manikin study [Marsch 2013 p w13856] representing 55 2-person
teams. Marsch [2013 p w13856] found that CAB decreased time to completion of first CPR cycle by 15 seconds (p<0.001).
The clinical significance of this difference is unknown.
For the important outcome of time to assess responsiveness we identified very low quality evidence from one
randomised manikin study [Lubrano 2012 p1473] representing 155 2-person teams. Lubrano [2012 p1473] there was no
difference between CAB and ABC in time taken to assess responsiveness 3.26 0.63 seconds vs 3.2 0.73 seconds
(p=NS).
For the important outcome of diagnosis of arrest we identified very low quality evidence from one randomised manikin
study [Lubrano 2012 p1473] representing 155 2-person teams. Lubrano [2012 p1473] found that CAB decreased the time
to diagnosis of respiratory arrest by 1.69 seconds (p<0.05) and cardiac arrest by 24.19 seconds (p<0.05).
We suggest a CAB as a preferable resuscitation algorithm to ABC for adults and children in cardiac arrest in any setting
(weak recommendation, very low quality of evidence).
Values and preferences statement: In making this recommendation in the absence of human data, we placed a high value
on time to specific elements of CPR (chest compressions, rescue breathing, completion of first CPR cycle).
Timing of CPR cycles (2 min vs other)

Question Type:
Intervention
Full Question:
Among adults who are in cardiac arrest in any setting (P), does pausing chest compressions at another interval (I),
compared with pausing chest compressions every two minutes to assess the cardiac rhythm (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, coronary perfusion pressure, cardiac output (O)?
Initial rhythm check only
For the critical outcomes of survival with good neurological outcome and survival we have identified low quality
evidence from one randomized controlled trial (RCT)1 enrolling 9,993 patients, demonstrating no benefit in patients with
out of hospital cardiac arrest (OHCA) with any initial rhythm. In this study, three minutes of chest compressions before the
first rhythm analysis compared to immediate rhythm analysis was not associated with good neurologic outcome at hospital
discharge (OR 1.00 95% CI 0.85-1.19) or survival to hospital discharge (OR 0.99 95% CI 0.86-1.15).
For the important outcome of return of spontaneous circulation (ROSC), low quality evidence from the same RCT1
17
demonstrates no benefit in patients with OHCA with any initial rhythm (OR 1.04 95% CI 0.95-1.13).
All rhythm checks

1 minute vs. 2 minutes
For the critical outcome of survival, we have identified very low quality evidence, downgraded for risk of bias and
indirectness, from a post-hoc subgroup analysis in one randomized controlled trial (RCT)2 enrolling 202 patients,
demonstrating no benefit in patients with out of hospital cardiac arrest (OHCA) with ventricular fibrillation (VF) or pulseless
ventricular tachycardia (VT) as initial rhythm. In this study, the randomized intervention, three minutes of chest
compressions before the first defibrillation compared to immediate defibrillation, was not associated with survival to
hospital discharge (OR 0.56 95% CI 0.25-1.25). Partway through the trial, the enrolling sites instituted a change in
resuscitation guidelines. At the start of the trial, chest compressions were paused every one minute to check the cardiac
rhythm; the guideline change recommended pausing every two minutes to check the cardiac rhythm. The authors tested
for a post-hoc association between the new guidelines and survival (RR 2.02, 95% CI 0.75, 5.42).
3 minutes vs. 1 minute

For the critical outcome of survival, we have identified moderate quality evidence, downgraded for risk of bias, from one
randomized controlled trial (RCT)3 enrolling 200 patients, demonstrating no benefit in patients with out of hospital cardiac
arrest (OHCA) with ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) as initial rhythm. In this study,
three minutes of chest compressions before the first defibrillation followed by pausing chest compressions every three
minutes to check the cardiac rhythm compared to immediate defibrillation followed by pausing chest compressions every
one minute to check the cardiac rhythm was not associated with survival to discharge (OR 1.66 95% CI 0.80-3.46) or 1year survival (OR 1.48 95% CI 0.71-3.11). For the important outcome of return of spontaneous circulation (ROSC),
moderate quality evidence, downgraded for risk of bias, from the same RCT3 demonstrates no benefit in patients with
OHCA with any initial rhythm (OR 1.49 95% CI 0.85-2.60).
Pre-specified subgroup analyses of patients with prehospital response intervals longer than five minutes found an
association between three minutes of chest compressions before the first defibrillation followed by pausing chest
compressions every three minutes to check the cardiac rhythm and ROSC (OR 2.22, 95% CI 1.06, 4.63), survival to
hospital discharge (OR 7.42, 95% CI 1.61, 34.3), and 1-year survival (OR 6.76, 95% CI 1.42, 31.4).
200 compressions vs. 1-3 minutes*

*Note: The historical control group for the following observational studies received care per the ILCOR 2000 guidelines,
which recommend pausing chest compressions every one minute to check cardiac rhythm in patients with a shockable
rhythm, and pausing chest compressions up to every three minutes in patients with a non-shockable rhythm.
For the critical outcome of survival with good neurological outcome we have identified very low quality evidence,
downgraded for risk of bias and indirectness, from three before-and-after studies4-6 enrolling 3,821 patients,
demonstrating benefit in patients with OHCA with any initial rhythm. In these studies, a new bundled protocol of
minimally interrupted chest compressions or cardiocerebral resuscitation was enacted and compared to historical
controls (ILCOR 2000 guidelines). Among other components of the new bundled protocol, pausing chest compression
every 200 compressions compared to pausing chest compressions every two minutes to check the cardiac rhythm was
associated with good neurologic outcome at hospital discharge (OR 2.53 95% CI 1.92-3.32).
For the critical outcome of survival we have identified very low quality evidence, downgraded for risk of bias and
indirectness, from five before-and-after studies4-8 enrolling 4,907 patients, demonstrating benefit in patients with OHCA
with any initial rhythm In these studies, a new bundled protocol of minimally interrupted chest compressions or
cardiocerebral resuscitation was enacted and compared to historical controls (ILCOR 2000 guidelines). Among other
components of the new bundled protocol, pausing chest compression every 200 compressions compared to pausing chest
compressions every two minutes to check the cardiac rhythm was associated with survival to hospital discharge (OR 2.09
95% CI 1.70-2.57).
For the important outcome of return of spontaneous circulation (ROSC), we have identified very low quality evidence,
downgraded for risk of bias and indirectness, from two before-and-after studies7,8 enrolling 1,086 patients, demonstrating
no benefit in patients with OHCA with any initial rhythm. In these studies, a new bundled protocol of minimally interrupted
chest compressions or cardiocerebral resuscitation was enacted and compared to historical controls (ILCOR 2000
guidelines). Among other components of the new bundled protocol, pausing chest compression every 200 compressions
compared to pausing chest compressions every two minutes to check the cardiac rhythm was not associated with ROSC
(OR 1.05 95% CI 0.77-1.44).
Theoretical probability modeling

We have identified supplementary evidence from one mathematical analysis of defibrillator recordings from 249 in-hospital
cardiac arrest cases.9 In this study, the authors modeled time-dependent probabilities of transitioning from a
nonshockable rhythm to a shockable rhythm or ROSC with the Aalen-Johansen estimator. For initial rhythms of PEA or
asystole, most patients remained in these rhythms during the first 8 minutes of resuscitation, suggesting there is little
benefit of frequent rhythm assessments during this initial time frame.
18
In summary, there is insufficient evidence to recommend for or against pausing chest compressions at another interval
compared with pausing chest compressions every two minutes to assess the cardiac rhythm in adults who are in cardiac
arrest in any setting.
References:
1) Stiell IG, Nichol G, Leroux BG, Rea TD, Ornato JP, Powell J, Christenson J, Callaway CW, Kudenchuk PJ, Aufderheide TP,
Idris AH, Daya MR, Wang HE, Morrison LJ, Davis D, Andrusiek D, Stephens S, Cheskes S, Schmicker RH, Fowler R,
Vaillancourt C, Hostler D, Zive D, Pirrallo RG, Vilke GM, Sopko G, Weisfeldt M; ROC Investigators. Early versus later
rhythm analysis in patients with out-of-hospital cardiac arrest. N Engl J Med. 2011 Sep 1;365(9):787-97.
2) Baker PW, Conway J, Cotton C, Ashby DT, Smyth J, Woodman RJ, Grantham H; Clinical Investigators. Defibrillation or
cardiopulmonary resuscitation first for patients with out-of-hospital cardiac arrests found by paramedics to be in
ventricular fibrillation? A randomised control trial. Resuscitation. 2008 Dec;79(3):424-31.
3) Wik L, Hansen TB, Fylling F, Steen T, Vaagenes P, Auestad BH, Steen PA. Delaying defibrillation to give basic
cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation: a randomized trial. JAMA. 2003 Mar
19;289(11):1389-95.
4) Kellum MJ, Kennedy KW, Ewy GA. Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac
arrest. Am J Med. 2006 Apr;119(4):335-40.
5) Kellum MJ, Kennedy KW, Barney R, Keilhauer FA, Bellino M, Zuercher M, Ewy GA. Cardiocerebral resuscitation improves
neurologically intact survival of patients with out-of-hospital cardiac arrest. Ann Emerg Med. 2008 Sep;52(3):244-52.
6) Mosier J, Itty A, Sanders A, Mohler J, Wendel C, Poulsen J, Shellenberger J, Clark L, Bobrow B. Cardiocerebral
resuscitation is associated with improved survival and neurologic outcome from out-of-hospital cardiac arrest in elders.
Acad Emerg Med. 2010 Mar;17(3):269-75.
7) Bobrow BJ, Clark LL, Ewy GA, Chikani V, Sanders AB, Berg RA, Richman PB, Kern KB. Minimally interrupted cardiac
resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA. 2008 Mar 12;299(10):1158-65.
8) Garza AG, Gratton MC, Salomone JA, Lindholm D, McElroy J, Archer R. Improved patient survival using a modified
resuscitation protocol for out-of-hospital cardiac arrest. Circulation. 2009 May 19;119(19):2597-605.
9) Nordseth T, Edelson DP, Bergum D, Olasveengen TM, Eftestl T, Wiseth R, Kvaly JT, Abella BS, Skogvoll E. Optimal
loop duration during the provision of in-hospital advanced life support (ALS) to patients with an initial non-shockable
rhythm. Resuscitation. 2014 Jan;85(1):75-81.
We suggest adhering to the current recommendation to pause chest compressions every two minutes to assess the cardiac
rhythm (weak recommendation based on very low level evidence).
Values and Preferences Statement: In making this suggestion, we note the absence of contradictory evidence, and place
value on simplifying resuscitation logistics by coordinating rhythm checks with standard recommendations for rotating the
provider performing chest compressions.
19

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Analysis of rhythm during chest compression

Check for circulation during BLS

Chest compression depth

Chest compression only CPR vs conventional CPR

Chest compression rate

Chest wall recoil

Compression ventilation ratio

CPR prior to defibrillation

Dispatcher instruction in CPR

EMS CC only vs standard CPR

Feedback for CPR quality

Harm from CPR to victims not in arrest

Minimizing pauses in chest compressions

Passive ventilation techniques

Public access AED programs

Rhythm check timing

Timing of CPR cycles (2 min vs other)

All rhythm checks

3 minutes vs. 1 minute

200 compressions vs. 1-3 minutes*

Theoretical probability modeling

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