Table 1.
BLS Topics Reviewed by EvUps
| Topic/PICO | Year(s) last updated | Existing treatment recommendation | RCTs since last review, n | Observational studies since last review, n | Sufficient data to warrant SysRev? |
|---|---|---|---|---|---|
| Paddle size and placement for defibrillation (new) | 2010 CoSTR; 2020 ScopRev | It is reasonable to place pads on the exposed chest in an anterior-lateral position. An acceptable alternative position is anterior-posterior. In large-breasted individuals, it is reasonable to place the left electrode pad lateral to or underneath the left breast, avoiding breast tissue. Consideration should be given to the rapid removal of excessive chest hair before the application of pads, but emphasis must be on minimizing delay in shock delivery. There is insufficient evidence to recommend a specific electrode size for optimal external defibrillation in adults. However, it is reasonable to use a pad size >8 cm. | 0 | 0 | No |
| CPR before call for help (BLS 1527) | 2020 CoSTR | We recommend that a lone bystander with a mobile phone should dial EMS, activate the speaker or other hands-free option on the mobile phone, and immediately begin CPR with dispatcher assistance, if required (strong recommendation, very low–certainty evidence). | 0 | 0 | No |
| Barrier devices (BLS 342) | 2005 CoSTR | Providers should take appropriate safety precautions when feasible and when resources are available to do so, especially if a victim is known to have a serious infection (eg, HIV, tuberculosis, HBV, or SARS). | 0 | 4 | No |
| Chest compression rate (BLS 343) | 2015 CoSTR; 2020 ScopRev | We recommend a manual chest compression rate of 100–120/min (strong recommendation, very low–quality evidence). | 0 | 0 | No |
| Rhythm check timing (BLS 345) | 2020 CoSTR | We suggest against the checking of cardiac rhythm immediately after defibrillation (weak recommendation, very low–certainty evidence). | 0 | 0 | No |
| Timing of CPR cycles (2 min vs other) (BLS 346) | 2020 CoSTR | We suggest pausing chest compressions every 2 min to assess the cardiac rhythm (weak recommendation, low-certainty evidence). | 0 | 0 | No |
| Public-access AED programs (BLS 347) | 2020 CoSTR | We recommend the implementation of public-access defibrillation programs for patients with OHCAs (strong recommendation, low-certainty evidence). | 0 | 2 | No |
| Check for circulation during BLS (BLS 348) | 2015 CoSTR; 2020 EvUp | Outside of the ALS environment where invasive monitoring is available, there are insufficient data on the value of a pulse check while performing CPR. We therefore do not make a treatment recommendation on the value of a pulse check. | 0 | 0 | No |
| Rescuer fatigue in chest compression–only CPR (BLS 349) | 2010 CoSTR | No treatment recommendation | 3 (simulation) | 1 (simulation) | No |
| Harm from CPR to victims not in cardiac arrest (BLS 353) | 2020 CoSTR | We recommend that laypersons initiate CPR for presumed cardiac arrest without concerns of harm to patients not in cardiac arrest (strong recommendation, very low–certainty evidence). | 0 | 2 | No |
| Harm to rescuers from CPR (BLS 354) | 2010 CoSTR; 2020 ScopRev | Evidence supporting rescuer safety during CPR is limited. The few isolated reports of adverse effects resulting from the widespread and frequent use of CPR suggest that performing CPR is relatively safe. Delivery of defibrillator shock with an AED during BLS is also safe. The incidence and morbidity of defibrillator-related injuries in the rescuers are low. | 0 | 0 | No |
| Hand position during compressions (BLS 357) | 2020 CoSTR | This treatment recommendation is unchanged from 2015: We suggest performing chest compressions on the lower half of the sternum on adults in cardiac arrest (weak recommendation, very low–certainty evidence). | 0 | 2 | No |
| Dispatcher instructions in CPR (BLS 359) | 2019 CoSTR | We recommend that emergency medical dispatch centers have systems in place to enable call handlers to provide CPR instructions for adult patients in cardiac arrest (strong recommendation, very low–certainty evidence). We recommend that emergency medical call takers provide CPR instructions (when deemed necessary) for adult patients in cardiac arrest (strong recommendation, very low–certainty evidence). | 0 | 8 | No |
| EMS chest compression–only vs conventional CPR (BLS 360) | 2017 CoSTR | We recommend that EMS providers perform CPR with 30 compressions to 2 breaths (30:2 ratio) or continuous chest compressions with PPV delivered without pausing chest compressions until a tracheal tube or supraglottic device has been placed (strong recommendation, high-certainty evidence). We suggest that when EMS systems have adopted minimally interrupted cardiac resuscitation, this strategy is a reasonable alternative to conventional CPR for witnessed shockable OHCA (weak recommendation, very low–certainty evidence). | 0 | 0 | No |
| Feedback for CPR quality (BLS 361) | 2020 CoSTR | We suggest the use of real-time audiovisual feedback and prompt devices during CPR in clinical practice as part of a comprehensive quality improvement program for cardiac arrest designed to ensure high–quality CPR delivery and resuscitation care across an EMS system (weak recommendation, very low–certainty evidence). We suggest against the use of real-time audiovisual feedback and prompt devices in isolation (ie, not part of a comprehensive quality improvement program) (weak recommendation, very low–certainty evidence). | 0 | 3 | Yes |
| CV ratio (BLS 362) | 2017 CoSTR | We suggest a CV ratio of 30:2 compared with any other CV ratio in patients with cardiac arrest (weak recommendation, very low–quality evidence). | 0 | 0 | No |
| CPR before defibrillation (BLS 363) | 2020 CoSTR | We suggest a short period of CPR until the defibrillator is ready for analysis or defibrillation in unmonitored cardiac arrest (weak recommendation, low-certainty evidence). | 0 | 0 | No |
| Chest compression depth (BLS 366) | 2015 CoSTR | We recommend a chest compression depth of ≈5 cm (2 in) (strong recommendation, low–quality evidence) while avoiding excessive chest compression depths (>6 cm [>2.4 in] in an average adult) (weak recommendation, low–quality evidence) during manual CPR. | 0 | 0 | No |
| Chest wall recoil (BLS 367) | 2015 CoSTR | We suggest that rescuers performing manual CPR avoid leaning on the chest between compressions to allow full chest wall recoil (weak recommendation, very low–quality evidence). | 0 | 0 | No |
| Removal of FBAO (BLS 368) | 2020 CoSTR | We suggest that back slaps are used initially in adults and children with an FBAO and an ineffective cough (weak recommendation, very low–certainty evidence). We suggest that abdominal thrusts are used in adults and children (>1 y of age) with an FBAO and an ineffective cough when back slaps are ineffective (weak recommendation, very low–certainty evidence). We suggest that rescuers consider the manual extraction of visible items in the mouth (weak recommendation, very low–certainty evidence). We suggest against the use of blind finger sweeps in patients with an FBAO (weak recommendation, very low–certainty evidence). We suggest that appropriately skilled health care providers use Magill forceps to remove an FBAO in patients with OHCA from FBAO (weak recommendation, very low–certainty evidence). We suggest that chest thrusts be used in unconscious adults and children with an FBAO (weak recommendation, very low–certainty evidence). We suggest that bystanders undertake interventions to support FBAO removal as soon as possible after recognition (weak recommendation, very low–certainty evidence). We suggest against the routine use of suction-based airway clearance devices (weak recommendation, very low–certainty evidence). | 0 | 4 | No |
| Firm surface for CPR (BLS 370) | 2020 CoSTR | We suggest performing manual chest compressions on a firm surface when possible (weak recommendation, very low–certainty evidence). During IHCA, we suggest that when a bed has a CPR mode that increases mattress stiffness, it should be activated (weak recommendation, very low–certainty evidence). During IHCA, we suggest against moving a patient from a bed to the floor to improve chest compression depth (weak recommendation, very low–certainty evidence). The confidence in effect estimates is so low that the task force was unable to make a recommendation about the use of a backboard strategy. | 0 | 1 | No |
| Analysis of rhythm during chest compression (BLS 373) | 2020 CoSTR | We suggest against the routine use of artifact-filtering algorithms for analysis of electrocardiographic rhythm during CPR (weak recommendation, very low–certainty evidence). We suggest that the usefulness of artifact-filtering algorithms for analysis of electrocardiographic rhythm during CPR be assessed in clinical trials or research initiatives (weak recommendation, very low–certainty evidence). | 0 | 2 | Yes |
| Alternative compression techniques (cough CPR, precordial thump, fist pacing) (BLS 374) | 2020 CoSTR | We recommend against the routine use of cough CPR for cardiac arrest (strong recommendation, very low–certainty evidence). We suggest that cough CPR may be considered only as a temporizing measure in exceptional circumstance of a witnessed, monitored IHCA (eg, in a cardiac catheterization laboratory) if a nonperfusing rhythm is recognized promptly before loss of consciousness (weak recommendation, very low–certainty evidence). We recommend against fist pacing for cardiac arrest (strong recommendation, very low–certainty evidence). We suggest that fist pacing may be considered only as a temporizing measure in the exceptional circumstance of a witnessed, monitored IHCA (eg, in a cardiac catheterization laboratory) attributable to bradyasystole if such a nonperfusing rhythm is recognized promptly before loss of consciousness (weak recommendation, very low–certainty evidence). We recommend against the use of a precordial thump for cardiac arrest (strong recommendation, very low–certainty evidence). | 0 | 0 | No |
| Tidal volumes and ventilation rates (BLS 546) | 2010 CoSTR | For mouth-to-mouth ventilation for adult victims using exhaled air or bag-mask ventilation with room air or oxygen, it is reasonable to give each breath within a 1-s inspiratory time and with an approximate volume of 600 mL to achieve chest rise. It is reasonable to use the same initial tidal volume and rate in patients regardless of the cause of the cardiac arrest. | 0 | 0 | No |
| Lay rescuer chest compression–only vs standard CPR (BLS 547) | 2017 CoSTR | We continue to recommend that bystanders perform chest compressions for all patients in cardiac arrest (good practice statement) We suggest that bystanders who are trained, able, and willing to give rescue breaths and chest compressions do so for all adults in cardiac arrest (weak recommendation, very low–certainty evidence). | 2 (simulation) | 4 | No |
| Starting CPR (C-A-B vs A-B-C) (BLS 661) | 2020 CoSTR | We suggest starting CPR with compressions rather than ventilation (weak recommendation, very low–certainty evidence). | 0 | 0 | No |
| Dispatch diagnosis of cardiac arrest (BLS 740) | 2020 CoSTR | We recommend that dispatch centers implement a standardized algorithm or standardized criteria to determine immediately if a patient is in cardiac arrest at the time of emergency call (strong recommendation, very low–certainty evidence). We suggest that dispatch centers monitor and track diagnostic capability. We suggest that dispatch centers look for ways to optimize sensitivity (minimize false-negatives). We recommend high-quality research that examines gaps in this area. | 1 | 6 | Yes |
| Resuscitation care for suspected opioid-associated emergencies (BLS 811) | 2020 CoSTR | We suggest that CPR be started without delay in any unconscious person not breathing normally and that naloxone be used by lay rescuers in suspected opioid-related respiratory or circulatory arrest (weak recommendation based on expert consensus). | 0 | 0 | No |
| Drowning (BLS 856) | 2020 CoSTR | We recommend that submersion duration be used as a prognostic indicator when making decisions on search and rescue resource management/operations (strong recommendation, moderate-certainty evidence). We suggest against the use of age, EMS response time, water type (fresh or salt), water temperature, and witness status when making prognostic decisions (weak recommendation, very low–certainty evidence. We acknowledge that this review excluded exceptional and rare case reports that identify good outcomes after prolonged submersion in icy water. | 0 | 0 | No |
| Dispatcher-assisted continuous chest compressions vs conventional CPR (new) | 2017 CoSTR | We recommend that dispatchers provide chest compression–only CPR instructions to callers for adults with suspected OHCA (strong recommendation, low–quality evidence). | 0 | 0 | No |
A-B-C indicates airway-breaths-compressions; AED, automated external defibrillator; ALS, advanced life support; BLS, basic life support; CoSTR, Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; C-A-B, compressions-airway-breaths; CPR, cardiopulmonary resuscitation; CV, compression-to-ventilation; EMS, emergency medical services; EvUps, evidence updates; FBAO, foreign body airway obstruction; HBV, hepatitis B virus; IHCA, in-hospital cardiac arrest; OHCA, out-of-hospital cardiac arrest; PICO, population, intervention, comparator, outcome; PPV, positive-pressure ventilation; RCT, randomized controlled trial; SARS, severe acute respiratory syndrome; ScopRev, scoping review; and SysRev, systematic review.
CoSTR documents are available at https://costr.ilcor.org/.