- Email: [email protected]
Re: Editorial ‘Keep your hands on the chest’
Resuscitation 88 (2015) e11
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Re: Editorial ‘Keep your hands on the chest’ Sir, The Editorial ‘Keep your hands on the chest’ is correct in its title, but flawed in its contradictory conclusion.1 Although the editorial suggests that hands-on defibrillation (HOD) may be safe, there is clear evidence that this is not the case; several research groups have appropriately cautioned against this practice based on theoretical,2–4 laboratory5,6 and clinical7,8 data. Hands-on defibrillation using no more than clinical examination gloves risks burns, myalgia and possible nerve damage. Safe HOD will only be possible using appropriate protective insulating barriers and it is premature to recommend a technique that contravenes international safety standards. There are numerous papers demonstrating that minimizing interruptions to chest compressions improves outcome.9–11 The plateau at which an improved chest compression fraction provides no further survival benefit, is unknown, but the paper by Rea et al. discussed in the editorial concluded that there may be survival benefits of further limiting CPR interruptions even where median compression fraction exceeds 80%.12 No study has demonstrated that a plateau exists and the top of the curve has not yet been reached in any research. A major cause of interruptions to chest compressions is related to peri-shock pauses, particularly in relation to delivering the shock itself. Several studies have shown a clear and direct relationship between the peri-shock pause and resuscitation success.13–15 Any suggestion that there is no evidence to encourage the study of hands-on defibrillation is inconsistent with clear evidence to the contrary. With every additional chest compression appearing to contribute to a better outcome, hands-on defibrillation offers a real potential to improve compression fraction and subsequent patient outcome. References 1. Haig S. Keep your hands on the chest. Resuscitation 2014;85:847–8. 2. Petley GW, Cotton AM, Deakin CD. Hands-on defibrillation: theoretical and practical aspects of patient and rescuer safety. Resuscitation 2012;83: 551–6.
http://dx.doi.org/10.1016/j.resuscitation.2014.09.030 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
3. Sullivan JL. Hands-on defibrillation: an analysis of electrical current flow through rescuers in direct contact with patients during biphasic external defibrillation. Circulation 2008;118:e712. 4. Sullivan JL, Chapman FW. Will medical examination gloves protect rescuers from defibrillation voltages during hands-on defibrillation? Resuscitation 2012;83:1467–72. 5. Deakin CD, Lee-Shrewsbury V, Hogg K, Petley GW. Do clinical examination gloves provide adequate electrical insulation for safe hands-on defibrillation? I: Resistive properties of nitrile gloves. Resuscitation 2013;84:895–9. 6. Petley GW, Deakin CD. Do clinical examination gloves provide adequate electrical insulation for safe hands-on defibrillation? II: Material integrity following exposure to defibrillation waveforms. Resuscitation 2013;84:900–3. 7. Johnson T, Meersman J, Youngquist ST. Abstract 107: performing hands-on defibrillation in out-of-hospital cardiac arrest can result in the mild. Subjective perception of current to providers. Circulation 2012;126:A107. 8. Weingart SD. A note of caution on the performance of hands-on biphasic defibrillation. Resuscitation 2013;84:e53. 9. Christenson J, Andrusiek D, Everson-Stewart S, et al. Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation. Circulation 2009;120:1241–7. 10. Edelson DP, Abella BS, Kramer-Johansen J, et al. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation 2006;71:137–45. 11. Vaillancourt C, Everson-Stewart S, Christenson J, et al. The impact of increased chest compression fraction on return of spontaneous circulation for out-ofhospital cardiac arrest patients not in ventricular fibrillation. Resuscitation 2011;82:1501–7. 12. Rea T, Olsufka M, Yin L, Maynard C, Cobb L. The relationship between chest compression fraction and outcome from ventricular fibrillation arrests in prolonged resuscitations. Resuscitation 2014;85:879–84. 13. Berg RA, Hilwig RW, Berg MD, et al. Immediate post-shock chest compressions improve outcome from prolonged ventricular fibrillation. Resuscitation 2008;78:71–6. 14. Berg RA, Hilwig RW, Kern KB, Sanders AB, Xavier LC, Ewy GA. Automated external defibrillation versus manual defibrillation for prolonged ventricular fibrillation: lethal delays of chest compressions before and after countershocks. Ann Emerg Med 2003;42:458–67. 15. Cheskes S, Common MR, Byers PA, Zhan C, Morrison LJ. Compressions during defibrillator charging shortens shock pause duration and improves chest compression fraction during shockable out of hospital cardiac arrest. Resuscitation 2014;85:1007–11.
Charles D. Deakin ∗ Southampton University Hospital NHS Trust, Tremona Road, Southampton SO16 6YD, UK ∗ Corresponding
author. Tel.: +44 7973 430820. E-mail address: [email protected] 5 September 2014
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Re: Editorial ‘Keep your hands on the chest’ Sir, The Editorial ‘Keep your hands on the chest’ is correct in its title, but flawed in its contradictory conclusion.1 Although the editorial suggests that hands-on defibrillation (HOD) may be safe, there is clear evidence that this is not the case; several research groups have appropriately cautioned against this practice based on theoretical,2–4 laboratory5,6 and clinical7,8 data. Hands-on defibrillation using no more than clinical examination gloves risks burns, myalgia and possible nerve damage. Safe HOD will only be possible using appropriate protective insulating barriers and it is premature to recommend a technique that contravenes international safety standards. There are numerous papers demonstrating that minimizing interruptions to chest compressions improves outcome.9–11 The plateau at which an improved chest compression fraction provides no further survival benefit, is unknown, but the paper by Rea et al. discussed in the editorial concluded that there may be survival benefits of further limiting CPR interruptions even where median compression fraction exceeds 80%.12 No study has demonstrated that a plateau exists and the top of the curve has not yet been reached in any research. A major cause of interruptions to chest compressions is related to peri-shock pauses, particularly in relation to delivering the shock itself. Several studies have shown a clear and direct relationship between the peri-shock pause and resuscitation success.13–15 Any suggestion that there is no evidence to encourage the study of hands-on defibrillation is inconsistent with clear evidence to the contrary. With every additional chest compression appearing to contribute to a better outcome, hands-on defibrillation offers a real potential to improve compression fraction and subsequent patient outcome. References 1. Haig S. Keep your hands on the chest. Resuscitation 2014;85:847–8. 2. Petley GW, Cotton AM, Deakin CD. Hands-on defibrillation: theoretical and practical aspects of patient and rescuer safety. Resuscitation 2012;83: 551–6.
http://dx.doi.org/10.1016/j.resuscitation.2014.09.030 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
3. Sullivan JL. Hands-on defibrillation: an analysis of electrical current flow through rescuers in direct contact with patients during biphasic external defibrillation. Circulation 2008;118:e712. 4. Sullivan JL, Chapman FW. Will medical examination gloves protect rescuers from defibrillation voltages during hands-on defibrillation? Resuscitation 2012;83:1467–72. 5. Deakin CD, Lee-Shrewsbury V, Hogg K, Petley GW. Do clinical examination gloves provide adequate electrical insulation for safe hands-on defibrillation? I: Resistive properties of nitrile gloves. Resuscitation 2013;84:895–9. 6. Petley GW, Deakin CD. Do clinical examination gloves provide adequate electrical insulation for safe hands-on defibrillation? II: Material integrity following exposure to defibrillation waveforms. Resuscitation 2013;84:900–3. 7. Johnson T, Meersman J, Youngquist ST. Abstract 107: performing hands-on defibrillation in out-of-hospital cardiac arrest can result in the mild. Subjective perception of current to providers. Circulation 2012;126:A107. 8. Weingart SD. A note of caution on the performance of hands-on biphasic defibrillation. Resuscitation 2013;84:e53. 9. Christenson J, Andrusiek D, Everson-Stewart S, et al. Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation. Circulation 2009;120:1241–7. 10. Edelson DP, Abella BS, Kramer-Johansen J, et al. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation 2006;71:137–45. 11. Vaillancourt C, Everson-Stewart S, Christenson J, et al. The impact of increased chest compression fraction on return of spontaneous circulation for out-ofhospital cardiac arrest patients not in ventricular fibrillation. Resuscitation 2011;82:1501–7. 12. Rea T, Olsufka M, Yin L, Maynard C, Cobb L. The relationship between chest compression fraction and outcome from ventricular fibrillation arrests in prolonged resuscitations. Resuscitation 2014;85:879–84. 13. Berg RA, Hilwig RW, Berg MD, et al. Immediate post-shock chest compressions improve outcome from prolonged ventricular fibrillation. Resuscitation 2008;78:71–6. 14. Berg RA, Hilwig RW, Kern KB, Sanders AB, Xavier LC, Ewy GA. Automated external defibrillation versus manual defibrillation for prolonged ventricular fibrillation: lethal delays of chest compressions before and after countershocks. Ann Emerg Med 2003;42:458–67. 15. Cheskes S, Common MR, Byers PA, Zhan C, Morrison LJ. Compressions during defibrillator charging shortens shock pause duration and improves chest compression fraction during shockable out of hospital cardiac arrest. Resuscitation 2014;85:1007–11.
Charles D. Deakin ∗ Southampton University Hospital NHS Trust, Tremona Road, Southampton SO16 6YD, UK ∗ Corresponding
author. Tel.: +44 7973 430820. E-mail address: [email protected] 5 September 2014