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Three Part Question

In [cardiac arrest patients requiring defibrillation], can [performing hands-on defibrillation with an insulating barrier], [safely eliminate the need to interruption chest compressions to deliver a rescue shock]?

Clinical Scenario

A 60-year old man in the emergency department develops a shockable arrhythmia leading to cardiac arrest. As you prepare to deliver a rescue shock, you instructed everyone to clear away from the patient. Knowing that minimizing interruptions to chest compression has been shown to improve outcomes,(1,2) you wonder if there is a safe way to perform hands-on defibrillation and deliver rescue shocks without interrupting chest compressions.

Search Strategy

PubMed (MEDLINE), January 2000 through March 2020:
"Hands-on defibrillation"[All Fields]; "Defibrillators"[Mesh] AND "Electric Injuries"[Mesh]; "Heart Arrest"[Mesh] AND "Electric Injuries"[Mesh]; "Electric Injuries"[Mesh] AND "Electric Countershock"[Mesh]; "Gloves, Protective"[Mesh] AND "Electric Countershock"[Mesh]; "Heart Arrest"[Mesh] AND "Safety"[Mesh] AND "Electric Countershock"[Mesh]; "Health Personnel"[Mesh] AND "Electric Countershock"[Mesh] AND "Safety"[Mesh]; "Defibrillators"[Mesh] AND "Electric Countershock"[Mesh] AND "Safety"[Mesh]; Hands-on [All Fields] AND ("electric countershock"[MeSH Terms] OR ("electric"[All Fields] AND "countershock"[All Fields]) OR "electric countershock"[All Fields] OR "defibrillation"[All Fields]); "Defibrillators"[Mesh] AND "Personal Protective Equipment"[Mesh] AND "Heart Arrest"[Mesh].

Search Outcome

There were 494 unique articles found using the search strategy. Authors excluded 179 articles published prior to 2000 and 278 articles due to relevance based on title/abstract. The full texts of the remaining 37 articles were reviewed, including a manual hand search of the bibliographies, in order to identify original studies that provided quantitative data on hands-on defibrillation. Ultimately, 6 studies were included for analysis as shown in table 1.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Lloyd et al 2008 USA	4 healthcare providers simulating HOD with polyethylene medical gloves on 39 patients undergoing electrocardioversion. 43 shocks (4 at 100 J, 27 at 200 J, 8 at 360 J) using a biphasic defibrillator with self-adhesive pads in anteroposterior placement.	Prospective	Shocks detected by rescue	No shocks detectable	Blinding-study participants were investigators
			Shocks resulting in injury	No injuries
Yu et al 2010 USA	3 AHA BLS certified healthcare providers performed HOD with a resuscitation blanket on 15 porcine models. 274 shocks ranging from 30J-360J using a biphasic defibrillator with pads in apex-anterior placement.	Experimental	Shocks detected by rescuer	No shocks detectable	Use of porcine models
			Shocks resulting in injury	No injuries
Neumann et al 2012 Germany	Healthcare providers performed HOD with two pairs of polyethylene gloves on 20 porcine models. 37 shocks ranging from 92J-155J using a biphasic defibrillator with self-adhesive pads in ventrodorsal placement.	Experimental	Shocks detected by rescuer	No shocks detectable	Use of porcine models
			Shocks resulting in injury	No injuries
Deakin et al 2015 UK	Persons trained in BLS/ALS simulated HOD with Class 1 electrical insulating gloves on 61 live patients undergoing cardioversion. 61 shocks (32 at 150 J, 11 at 200 J, 18 at 360 J) using a biphasic defibrillator with self-adhesive pads in antero-lateral placement.	Experimental	Shocks detected by rescuer	No shocks detectable	Simulation study
			Shocks resulting in injury	No injuries
Wampler et al 2016 USA	Certified prehospital providers performed HOD with barehands, nitrile gloves, firefighter gloves, neoprene pad, on 2 fresh un-embalmed cadavers. 300 shocks (50 at 30 J for barehand trials, 250 at 360 J) using a biphasic defibrillator with self-adhesive pads in anterior-apex placement.	RCT	Shocks detected by rescuer	54 shocks detected (49/50 barehand, 1/50 single layer nitrile gloves, 3/50 double layer nitrile gloves, 1/50 neoprene pad)	No significant weaknesses
			Shocks resulting in injury	No injuries
Wight et al 2019 USA	Single investigator simulated HOD with a polyethylene drape on 23 live patients undergoing cardioversion. 10 shocks (8 at 200 J, 2 at 360 J) using a biphasic defibrillator with self-adhesive pads in anterior-posterior placement.	Prospective	Shocks detected by rescuer	No shocks detectable	Simulated CPR, no blinding
			Shocks resulting in injury	No injuries

Comment(s)

The six aforementioned studies capture all studies in the literature that provide original quantitative data on HOD since 2000. In extracting data from all six studies, a total of 721 biphasic shocks were delivered. All shocks ranged in energy from 30J to 360J. Studies examined HOD during CPR, with cadavers, using porcine models, and during electrocardioversion. Only 54/721 shocks were rated as perceptible, 49 of these were from a single study where rescuers performed CPR with bare hands and shocks were delivered at reduced energy of 30J. The remaining 5 detectable shocks were all reported while using nitrile gloves (4) or a neoprene pad (1). None of the 521 shocks delivered while rescuers utilized polyethylene gloves, electrical safety gloves, a resuscitation blanket, firefighter gloves, or a mechanical compression device were detected. No injuries were reported in any study, though it is possible that injuries could have occurred in the bare-hands experiment if energies of shocks had not been reduced to 30J. Of note, no study examined HOD in wet or rainy conditions. This literature review provides evidence that HOD can be performed safely with an insulating barrier in a controlled environment. Improvements in defibrillator technology such as the widespread implementation of biphasic devices and self-adhesive electrode pads may have eliminated the risks of HOD that informed current CPR protocols. Given that HOD can reduce interruptions to compressions, it has the potential to improve outcomes. In addition to reducing off-chest time during the actual delivery of shocks, eliminating the need to stop CPR would reduce the off-chest time associated with pre- and post-shock pauses.(9) Even for rescuers performing traditional CPR, this data provides further reassurance they are safe if they choose to perform compressions while the defibrillator charges.

Clinical Bottom Line

Hands-on defibrillation eliminates the need to interrupt compressions to deliver a rescue shock and has the potential to be performed safely if the rescuer uses appropriate electrical insulating barriers such as polyethylene gloves or class 1 electrical insulating gloves. The safety profile of nitrile gloves is unclear. Performing HOD with bare hands is not advisable. Since detection of shock was used as a proxy for safety, additional investigation is warranted before HOD becomes common practice.

References

1. Lloyd, M. S.; Heeke, B.; Walter, P. F.; Langberg, J. J. Hands-on defibrillation: An analysis of electrical current flow through rescuers in direct contact with patients during biphasic external defibrillation Circulation 2008
2. Yu, T.; Ristagno, G.; Li, Y.; Bisera, J.; Weil, M. H.; Tang, W. The resuscitation blanket: A useful tool for "hands-on" defibrillation Resuscitation 2010
3. Neumann, T.; Gruenewald, M.; Lauenstein, C.; Drews, T.; Iden, T.; Meybohm, P. Hands-on defibrillation has the potential to improve the quality of cardiopulmonary resuscitation and is safe for rescuers-a preclinical study Journal of the American Heart Association 2012
4. Deakin, C. D.; Thomsen, J. E.; Lofgren, B.; Petley, G. W. Achieving safe hands-on defibrillation using electrical safety gloves--a clinical evaluation Resuscitation 2015
5. Wampler, D.; Kharod, C.; Bolleter, S.; Burkett, A.; Gabehart, C.; Manifold, C. A randomized control hands-on defibrillation study-barrier use evaluation Resuscitation 2016
6. Wight, J. A.; Iravanian, S.; Haouzi, A. A.; Lloyd, M. S. Hands-on defibrillation with a safety barrier: An analysis of potential risk to rescuers Resuscitation 2019