Part 3: Adult basic life support and automated external defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations☆
Introduction
This Part of the 2015 International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) Science With Treatment Recommendations (CoSTR) presents the consensus on science and treatment recommendations for adult basic life support (BLS) and automated external defibrillation (AED). After the publication of the 2010 CoSTR, the Adult BLS Task Force developed review questions in PICO (population, intervention, comparator, outcome) format.1 This resulted in the generation of 36 PICO questions for systematic reviews. The task force discussed the topics and then voted to prioritize the most important questions to be tackled in 2015. From the pool of 36 questions, 14 were rated low priority and were deferred from this round of evidence evaluation. Two new questions were submitted by task force members, and 1 was submitted via the public portal. Two of these (BLS 856, and BLS 891) were taken forward for evidence review. The third question (368: Foreign-Body Airway Obstruction) was deferred after a preliminary review of the evidence failed to identify compelling evidence that would alter the treatment recommendations made when the topic was last reviewed in 2005.2
Each task force performed a systematic review using detailed inclusion and exclusion criteria, based on the recommendations of the Institute of Medicine of the National Academies.3 With the assistance of information specialists, a detailed search for relevant articles was performed in each of 3 online databases (PubMed, Embase, and the Cochrane Library).
Reviewers were unable to identify any relevant evidence for 3 questions (BLS 811, BLS 373, and BLS 348), and the evidence review was not completed in time for a further question (BLS 370). A revised PICO question was developed for the opioid question (BLS 891). The task force reviewed 23 PICO questions for the 2015 consensus on science and treatment recommendations, including BLS 811, BLS 373, and BLS 348. The PICO flow is summarized in Fig. 1
Using the methodological approach proposed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group,4 the reviewers for each question created a reconciled risk-of-bias assessment for each of the included studies, using state-of-the-art tools: Cochrane for randomized controlled trials (RCTs),5 Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 for studies of diagnostic accuracy,6 and GRADE for observational studies that inform both therapy and prognosis questions.7 GRADE evidence profile tables8 were then created to facilitate an evaluation of the evidence in support of each of the critical and important outcomes. Critical outcomes were defined as neurologically favorable outcome (level 9), survival (level 8), and return of spontaneous circulation (ROSC; level 7). Given the heterogeneity of time points evaluated in the studies related to BLS/AED, time intervals were pooled across outcomes. For neurologic outcome and survival, we considered the outcomes at discharge, 30 days, 60 days, 180 days, and/or 1 year. Important outcomes included physiologic and process end points.
The quality of the evidence (or confidence in the estimate of the effect) was categorized as high, moderate, low, or very low,9 based on the study methodologies and the 5 core GRADE domains of risk of bias, inconsistency, indirectness, imprecision, and other considerations (including publication bias).10 These evidence profile tables were then used to create a written summary of evidence for each outcome (the consensus on science statements). Whenever possible, consensus-based treatment recommendations were then created. These recommendations (designated as strong or weak) were accompanied by an overall assessment of the evidence and a statement from the task force about the values and preferences that underlie the recommendations. A strong recommendation typically contains the words “we recommend,” while a weak recommendation contains the words “we suggest.” Further details of the methodology that underpinned the evidence evaluation process are found in “Part 2: Evidence Evaluation and Management of Conflicts of Interest.”
The body of knowledge encompassed in this CoSTR comprises 23 individual systematic reviews with 32 treatment recommendations, derived from a GRADE evaluation of 27 randomized clinical trials and 181 observational studies of variable design and quality conducted over a 35-year period. The treatment recommendations in this Part are limited to recommendations for adults. Where there is overlap with pediatric topics, readers are referred to “Part 6: Pediatric Basic Life Support and Pediatric Advanced Life Support.”
The actions linking the victim of sudden cardiac arrest with survival are called the Chain of Survival and form the order of presentation of the systematic reviews in this publication, as follows:
Early Access and Cardiac Arrest Prevention
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Dispatcher recognition of cardiac arrest (BLS 740)
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Dispatcher instruction (BLS 359)
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Resuscitation care for suspected opioid-associated emergencies (BLS 811)
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Opioid overdose response education (BLS 891)
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Drowning (BLS 856)
Early, High-Quality CPR
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Starting CPR (BLS 661)
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Chest compression-only CPR vs conventional CPR (BLS 372)
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CPR before defibrillation (BLS 363)
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Hand position during compressions (BLS 357)
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Chest compression rate (BLS 343)
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Chest compression depth (BLS 366)
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Chest wall recoil (BLS 367)
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Minimizing pauses in chest compressions (BLS 358)
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Compression-ventilation ratio (BLS 362)
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Timing of CPR cycles (BLS 346)
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Check for circulation during BLS (BLS 348)
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Feedback for CPR quality (BLS 361)
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EMS chest compression-only versus conventional CPR (BLS 360)
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Passive ventilation technique (BLS 352)
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Harm from CPR to victims not in cardiac arrest (BLS 353)
Early defibrillation
Section snippets
Early access: emergency medical dispatch
The first contact with emergency medical services (EMS) is usually via a 9-1-1 or 1-1-2 emergency call. The correct and timely identification of cardiac arrest is critical to ensuring (1) the appropriate dispatch of a high-priority response, (2) the provision of telephone CPR instructions, and (3) the activation of community first responders carrying AEDs. In an observational study in the Netherlands, cases of cardiac arrest that were missed at initial telephone triage had much worse outcomes,
High-quality CPR
Early high-quality CPR saves lives. This section reviews the evidence surrounding how to start CPR, as well as optimal chest compression characteristics, compression-only CPR, pulse checks, and ventilation. Although the systematic reviews considered adult and pediatric data, treatment recommendations in this Part are limited to adult patients. The reader is referred to “Part 6: Pediatric Basic Life Support and Pediatric Advanced Life Support” for related pediatric recommendations.
In making
Early defibrillation
This section reviews (1) the evidence surrounding the clinical benefit of AEDs in the out-of-hospital setting by laypeople and healthcare providers, and (2) the complex choreography of care needed to ensure high-quality CPR and effective defibrillation. Collectively, we continue to place strong emphasis on the importance of rapid defibrillation as the treatment of choice for VF/pVT in the out-of-hospital and hospitalized settings.
2005 and 2010 topics not reviewed in 2015
The following topics were included in 2010 but not in this publication (deferred standardized reviews):
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Etiology of cardiac arrest
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Incidence of cardiac arrest
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Recognition of cardiac arrest
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Facedown victim
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Finding the right hand placement
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Lay rescuer compression-only versus no CPR
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Rescuer fatigue in chest compression-only CPR
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Alternative compression techniques
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Interposed abdominal compressions (IAC) CPR
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Harm to rescuers from CPR
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Opening the airway
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Foreign-body airway obstruction
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Barrier devices
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Oropharyngeal
Summary
This review comprises the most extensive literature search and evidence evaluation to date on the most important international BLS interventions, diagnostics, and prognostic factors for cardiac arrest victims. It reemphasizes that the critical lifesaving steps of BLS are (1) prevention, (2) immediate recognition and activation of the emergency response system, (3) early high-quality CPR, and (4) rapid defibrillation for shockable rhythms.
Highlights in prevention indicate the rational and
Disclosures
2015 CoSTR Part 3: Adult Basic Life Support and Automated External Defibrillation: Writing Group Disclosures.Writing Group Member Employment Research Grant Other Research Support Speakers’ Bureau/Honoraria Expert Witness Ownership Interest Consultant/Advisory Board Other Gavin D. Perkins Warwick Medical School and Heart of England NHS Foundation Trust None None None None None None None Andrew H. Travers Emergency Health Services, Nova Scotia None None None None None American Heart Association† None Robert A. Berg
Acknowledgments
We thank the following individuals (the Basic Life Support Chapter Collaborators) for their collaborations on the worksheets contained in this section:
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This article has been copublished in Circulation.
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Co-chairs and equal first co-authors.
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The members of the BLS Chapter Collaborators are listed in the Acknowledgments section.