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## Complete Summary

#### GUIDELINE TITLE

Defibrillation: 2005 International Consensus Conference on
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
with Treatment Recommendations.

#### BIBLIOGRAPHIC SOURCE(S)

Defibrillation. In: 2005 International Consensus Conference on
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
with Treatment Recommendations. Circulation 2005 Nov 29;112(22
Suppl):III17-24. \[126 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Cardiac arrest\
Ventricular fibrillation

#### GUIDELINE CATEGORY

Treatment

#### CLINICAL SPECIALTY

Cardiology\
Emergency Medicine\
Family Practice\
Internal Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Emergency Medical Technicians/Paramedics\
Health Care Providers\
Hospitals\
Nurses\
Physician Assistants\
Physicians\
Public Health Departments

#### GUIDELINE OBJECTIVE(S)

To provide guidance on defibrillation including the sequence of shock
delivery and the use and effectiveness of various waveforms and energies
during defibrillation

#### TARGET POPULATION

Individuals experiencing cardiac arrest or ventricular fibrillation

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Treatment**

1.  Strategies before defibrillation

    -   Precordial thump

    -   Cardiopulmonary resuscitation

2.  Use of automatic external defibrillators (AEDs)

    -   Ensuring quality and maintenance of AED programs

    -   AED use in hospitals

    -   Electrode pad/paddle position and size

    -   Use of paddles vs. self adhesive defibrillation pads

    -   Biphasic vs. monophasic waveforms for ventricular defibrillation

    -   Energy levels for defibrillation

    -   Second and subsequent shocks (fixed vs. escalating energy, one
        shock 3-shock sequences)

    -   Defibrillator data collection

    -   Prevention of oxygen related fire during defibrillation

#### MAJOR OUTCOMES CONSIDERED

-   Return of spontaneous circulation

-   Resuscitation success

-   Survival rate

-   Long-term clinical outcome

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

All reviewers were instructed to search their allocated questions
broadly. Reviewers documented their search strategies to ensure
reproducibility of the search. The minimum electronic databases searched
included the Cochrane database for systematic reviews and the Central
Register of Controlled Trials (<http://www.cochrane.org/>), MEDLINE
(<http://www.ncbi.nlm.nih.gov/PubMed/>), EMBASE
([www.embase.com](http://www.embase.com/)), and the master reference
library collated by the American Heart Association (AHA). To identify
the largest possible number of relevant articles, reviewers were also
encouraged to perform hand searches of journals, review articles, and
books as appropriate.

The reviewers documented the mechanism by which studies relevant to the
hypothesis were selected. Specific study inclusion and exclusion
criteria and study limitations were documented. Inclusion of all
relevant evidence (from animal and manikin/model studies as well as
human studies) was encouraged.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**Level 1**: Randomized clinical trials or meta-analyses of multiple
clinical trials with substantial treatment effects

**Level 2**: Randomized clinical trials with smaller or less significant
treatment effects

**Level 3**: Prospective, controlled, nonrandomized cohort studies

**Level 4**: Historic, nonrandomized cohort or case-control studies

**Level 5**: Case series; patients compiled in serial fashion, control
group lacking

**Level 6**: Animal studies or mechanical model studies

**Level 7**: Extrapolations from existing data collected for other
purposes, theoretical analyses

**Level 8**: Rational conjecture (common sense); common practices
accepted before evidence-based guidelines

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

A worksheet template was provided with step-by-step directions to help
the experts document their literature review, evaluate studies, and
determine levels of evidence. When possible, 2 expert reviewers were
recruited to undertake independent evaluations for each topic.

**Assessing the Quality of Evidence**

In this step reviewers were asked to determine the level of evidence of
relevant studies (Step 2A), assess the quality of study research design
and methods (Step 2B), determine the direction of results (Step 2C), and
cross-tabulate assessed studies (Step 2D).

The levels of evidence used for the 2005 consensus process were modified
from those used in 2000. In many situations summary conclusions were
based on lower levels of evidence because human clinical trial data was
not available. The reviewers assessed the quality of research design and
methods and allocated each study to 1 of 5 categories: excellent, good,
fair, poor, or unsatisfactory. Studies graded as poor or unsatisfactory
were excluded from further analysis.

Reviewers evaluated the direction of the study results as supportive,
neutral, or opposed and then depicted the data in 1 of 2 grids. The
grids were 2-dimensional, showing quality and levels of evidence. The
reviewers completed a Supporting Evidence grid and a Neutral or Opposing
Level of Evidence grid.

**Controversies Encountered**

*Studies on Related Topics (Level of Evidence \[LOE\] 7)*

Many reviewers identified studies that answered related questions but
did not specifically address the reviewer\'s initial hypothesis.
Examples include the extrapolation of adult data for pediatric
worksheets and extrapolation of the results of glucose control in
critically ill patients to the postresuscitation setting. Worksheet
reviewers were instructed to clearly designate evidence that represented
extrapolations. Reviewers could designate such studies as LOE 7, or they
could assign a level of evidence based on the study design but include
terms such as \"extrapolated from\" with specific relevant details in
the draft consensus on science statements to indicate clearly that these
were extrapolations from data collected for other purposes.

*Animal Studies and Mechanical Models*

Animal studies can be performed under highly controlled experimental
conditions using extremely sophisticated methodology. Irrespective of
methodology, all animal studies and all studies involving mechanical
models (e.g., manikin studies) were classified as LOE 6. Specific
details about these studies (including methodology) are included in the
summary of science where appropriate.

*Studies Evaluating Diagnosis or Prognosis*

The default levels of evidence used for the 2005 consensus process were
not designed for the review of studies that evaluate diagnosis or
prognosis. For these studies other methods of assigning levels of
evidence were considered (such as those proposed by the Oxford Centre
for Evidence-Based Medicine \[<http://www.cebm.net/>\]). Worksheet
reviewers planning to include alternative levels of evidence were asked
to define such levels clearly and to retain the default levels of
evidence.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus\
Expert Consensus (Consensus Development Conference)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Worksheet reviewers created a summary of the science. In the summary
format reviewers were encouraged to provide a detailed discussion of the
evidence, including the outcomes evaluated and the strengths and
limitations of the data.

The final step in the science summary process was the creation of draft
consensus on science statements and treatment recommendations. Statement
templates were provided to standardize the comprehensive summary of
information. Elements of the consensus on science statement template
included the specific intervention or assessment tool, number of
studies, levels of evidence, clinical outcome, population studied, and
the study setting. Elements of the treatment recommendation template
included specific intervention or assessment tool, population and
setting, and strength of recommendation.

The statements drafted by the reviewers in the worksheets reflect the
recommendations of the reviewers and may or may not be consistent with
the conclusions of the 2005 Consensus Conference.

All 380 participants at the 2005 Consensus Conference received a copy of
the worksheets on CD-ROM. Expert reviewers presented topics in plenary,
concurrent, and poster conference sessions. Presenters and participants
then debated the evidence, conclusions, and draft summary statements.
Each day the most controversial topics from the previous day, as
identified by the task force chairs, were presented and debated in one
or more additional sessions. The International Liaison Committee on
Resuscitation (ILCOR) task forces met daily during the conference to
discuss and debate the experts\' recommendations and develop interim
consensus science statements. Each science statement summarized the
experts\' interpretation of all the relevant data on a specific topic.
Draft treatment recommendations were added if a consensus was reached.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Completed worksheets were posted on the Internet for further review. The
initial process involved posting the worksheet to a password-protected
area of the American Heart Association Intranet (accessible to worksheet
reviewers). In December 2004 the completed worksheets were posted on an
Internet site that could be accessed by the public for further review
and feedback before the 2005 Consensus Conference in Dallas
([www.C2005.org](http://www.c2005.org/)).

Wording of science statements and treatment recommendations was refined
after further review by International Liaison Committee on Resuscitation
(ILCOR) member organizations and the international editorial board. This
format ensured that this final document represents a truly international
consensus process.

The manuscript was ultimately approved by all ILCOR member organizations
and by an international editorial board. The American Heart Association
(AHA) Science Advisory and Coordinating Committee and the editor of
*Circulation* obtained peer reviews of this document before it was
accepted for publication. The document is being published simultaneously
in *Circulation* and *Resuscitation*, although the version in
*Resuscitation* does not include the sections on stroke and first aid.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Strategies Before Defibrillation**

**Precordial Thump**

One immediate precordial thump may be considered after a monitored
cardiac arrest if an electrical defibrillator is not immediately
available.

**Cardiopulmonary Resuscitation (CPR) before Defibrillation**

A 1-1/2 to 3-minute period of CPR before attempting defibrillation may
be considered in adults with out-of-hospital ventricular fibrillation
(VF) or pulseless ventricular tachycardia (VT) and Emergency Medical
Services (EMS) response (call to arrival) intervals \>4 to 5 minutes.
There is no evidence to support or refute the use of CPR before
defibrillation for in-hospital cardiac arrest.

**Use of Automatic External Defibrillators (AEDs)**

**AED Programs**

Use of AEDs by trained lay and professional responders is recommended to
increase survival rates in patients with cardiac arrest. Use of AEDs in
public settings (airports, casinos, sports facilities, etc.) where
witnessed cardiac arrest is likely to occur can be useful if an
effective response plan is in place. The response plan should include
equipment maintenance, training of likely responders, coordination with
local EMS systems, and program monitoring. No recommendation can be made
for or against personal or home AED deployment.

**AED Program Quality Assurance and Maintenance**

AED programs should optimize AED function (rhythm analysis and shock),
battery and pad readiness, operator performance, and system performance
(e.g., mock codes, time to shock, outcomes).

**AED Use in Hospitals**

Use of AEDs is reasonable to facilitate early defibrillation in
hospitals.

**Electrode-Patient Interface**

**Electrode Pad/Paddle Position and Size**

Paddles and electrode pads should be placed on the exposed chest in an
anterolateral position. Acceptable alternative positions are
anteroposterior (paddles and pads) and apex posterior (pads). In
large-breasted patients it is reasonable to place the left electrode pad
(or paddle) lateral to or underneath the left breast. Defibrillation
success may be higher with 12-cm electrodes than with 8-cm electrodes.
Small electrodes (4.3 cm) may be harmful; myocardial injury can occur.

**Self-Adhesive Defibrillation Pads Versus Paddles**

Self-adhesive defibrillation pads are safe and effective and are an
acceptable alternative to standard defibrillation paddles.

**Initial Shock Waveform and Energy Levels**

**Biphasic Versus Monophasic Waveforms for Ventricular Defibrillation**

Biphasic waveform shocks are safe and effective for termination of VF
when compared with monophasic waveform shocks.

**Energy Level for Defibrillation**

There is insufficient evidence for or against specific selected energy
levels for the first or subsequent biphasic shocks. With a biphasic
defibrillator it is reasonable to use 150 J to 200 J with biphasic
truncated exponential (BTE) waveforms or 120 J with the rectilinear
biphasic waveform for the initial shock. With a monophasic waveform
defibrillator, an initial shock of 360 J is reasonable.

**Second and Subsequent Shocks**

**Fixed Versus Escalating Energy**

Nonescalating- and escalating-energy biphasic waveform defibrillation
can be used safely and effectively to terminate VF of both short and
long duration.

**1-Shock Protocol Versus 3-Shock Sequence**

Priorities in resuscitation should include early assessment of the need
for defibrillation (see National Guideline Clearinghouse \[NGC\] summary
for the American Heart Association guideline [Adult Basic Life
Support](http://www.guideline.gov/summary/summary.aspx?doc_id=8480&nbr=004731)),
provision of CPR until a defibrillator is available, and minimization of
interruptions in chest compressions. Rescuers can optimize the
likelihood of defibrillation success by optimizing the performance of
CPR, timing of shock delivery with respect to CPR, and the combination
of waveform and energy levels. A 1-shock strategy may improve outcome by
reducing interruption of chest compressions. A 3-stacked shock sequence
can be optimized by immediate resumption of effective chest compressions
after each shock (irrespective of the rhythm) and by minimizing the
hands-off time for rhythm analysis.

**Related Defibrillation Topics**

**Defibrillator Data Collection**

Monitor/defibrillators modified to enable collection of data on
compression rate and depth and ventilation rate may be useful for
monitoring and improving process and outcomes after cardiac arrest.

**Oxygen and Fire Risk During Defibrillation**

Rescuers should take precautions to minimize sparking (by paying
attention to pad/paddle placement, contact, etc) during attempted
defibrillation. Rescuers should try to ensure that defibrillation is not
attempted in an oxygen-enriched atmosphere.

#### CLINICAL ALGORITHM(S)

The International Liaison Committee on Resuscitation (ILCOR) Universal
Cardiac Arrest Algorithm is provided in the \"Introduction\" section of
the original guideline document (see \"Availability of Companion
Documents\" field).

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is not specifically
stated.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate application of cardiopulmonary resuscitation and
defibrillation techniques to increase the chance of successful
intervention

#### POTENTIAL HARMS

-   Potential complications of the precordial thump include rhythm
    deteriorations, such as rate acceleration of ventricular tachycardia
    (VT), conversion of VT into ventricular fibrillation (VF), complete
    heart block, and asystole.

-   The use of small electrodes (4.3 cm) may be harmful to patients;
    myocardial injury can occur.

-   There is the potential of fire risk during defibrillation in the
    presence of an oxygen enriched atmosphere.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This document summarizes current evidence for the recognition and
response to sudden life-threatening events, particularly sudden cardiac
arrest in victims of all ages. The broad range and number of topics
reviewed and the inevitable limitations of journal space require
succinctness in science statements and, where recommendations were
appropriate, brevity in treatment recommendations. This is not a
comprehensive review of every aspect of resuscitation medicine; some
topics were omitted if there was no evidence or no new information.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Defibrillation. In: 2005 International Consensus Conference on
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
with Treatment Recommendations. Circulation 2005 Nov 29;112(22
Suppl):III17-24. \[126 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2005 Nov 29

#### GUIDELINE DEVELOPER(S)

American Heart Association - Professional Association

#### SOURCE(S) OF FUNDING

American Heart Association

#### GUIDELINE COMMITTEE

International Liaison Committee on Resuscitation (ILCOR)

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Not stated

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

A robust conflict of interest policy was developed to ensure full
disclosure of potential conflicts and to protect the objectivity and
credibility of the evidence evaluation and consensus development
process. This policy is described in detail in an editorial companion
document (see \"Availability of Companion Documents\" field).
Representatives of manufacturers and industry did not participate in
this conference.

Potential conflicts of interest of the editorial board are listed in
Appendix 3 of the original guideline document (see \"Availability of
Companion Documents\" field). Potential conflicts of interest of the
worksheet authors are noted in the worksheets and can be accessed
through the links to the worksheets contained in the original guideline
document. All 380 attendees were required to complete forms in order to
document their potential conflicts of interest. Most attendees were also
worksheet authors. The information from the conflict of interest forms
completed by all conference attendees, including worksheet authors, can
also be accessed at the website
<http://circ.ahajournals.org/content/vol112/22_suppl/#APPENDIX>. Readers
of the print version can also access the statements at the American
Heart Association website: [www.C2005.org](http://www.c2005.org/).

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American Heart Association Web
site](http://circ.ahajournals.org/cgi/content/full/112/22_suppl/III-17).

Print copies: Available from the American Heart Association, Public
Information, 7272 Greenville Ave, Dallas, TX 75231-4596; Phone:
800-242-8721

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Introduction. 2005 International Consensus Conference on
    Cardiopulmonary Consensus Conference on Cardiopulmonary
    Resuscitation and Emergency Cardiovascular Care Science with
    Treatment Recommendations. Circulation 2005 Nov 29;112(22
    Supplement):III-1-III-4.

-   The evidence evaluation process for the 2005 International Consensus
    Conference on Cardiopulmonary Resuscitation and Emergency
    Cardiovascular Care Science with Treatment Recommendations.
    Circulation 2005 Nov 29;112(22 Supplement):III-128-III-130.

-   Conflict of interest management before, during, and after the 2005
    International Consensus Conference on Cardiopulmonary Resuscitation
    and Emergency Cardiovascular Care Science with Treatment
    Recommendations. Circulation 2005 Nov 29;112(22
    Supplement):III-131-III-132.

-   Controversial topics from the 2005 International Consensus
    Conference on Cardiopulmonary Resuscitation and Emergency
    Cardiovascular Care Science with Treatment Recommendations.
    Circulation 2005 Nov 29;112(22 Supplement):III-133-III-136.

-   Appendix 1: Worksheet topics and authors. Circulation 2005 Nov
    29;112(22 Supplement):B1-B14.

-   Appendix 3: Conflict of interest for editors, editorial board,
    special contributors and reviewers, and honorees. Circulation 2005
    Nov 29;112(22 Supplement):B16-B18.

-   Interdisciplinary topics: 2005 International Consensus Conference on
    Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
    Science with Treatment Recommendations. Circulation 2005 Nov
    29;112(22 Supplement):III-100-III-108.

Electronic copies: Available from the [American Heart Association Web
site](http://circ.ahajournals.org/content/vol112/22_suppl/).

Print copies: Available from the American Heart Association, Public
Information, 7272 Greenville Ave, Dallas, TX 75231-4596; Phone:
800-242-8721

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on February 2, 2006. The
information was verified by the guideline developer on March 7, 2006.

#### COPYRIGHT STATEMENT

Copyright to the original guideline is owned by the American Heart
Association, Inc. (AHA). Reproduction of the AHA Guideline without
permission is prohibited. Single reprint is available by calling
800-242-8721 (US only) or writing the American Heart Association, Public
Information, 7272 Greenville Ave., Dallas, TX 75231-4596. Ask for
reprint No. 71-0276. To purchase additional reprints: up to 999 copies,
call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies,
call 410-528-4121, fax 410-528-4264, or email <kgray@lww.com>. To make
photocopies for personal or educational use, call the Copyright
Clearance Center, 978-750-8400.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
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All guidelines summarized by NGC and hosted on our site are produced
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Guidelines represented on the NGC Web site are submitted by guideline
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Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008