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Three Part Question

[In adult patients in cardiac arrest requiring defibrillation for VF/VT] is [manual pressure augmention to the defib pads better than standard pad use] at [ improving survival and improving ROSC rates]

Clinical Scenario

You attend a cardiac arrest in a 48 year old female patient. The patient is in VF, and you follow the ALS algorithm but unfortunately you are unable to defibrillate the patient. You only have one defibrillator and so dual sequence defibrillation is not an option. Sadly, the patient never comes of VF, fading into asystole and then dies.

At the debrief a colleague tells you that applying pressure to the pads reduces thoracic impedance and might be a way of improving the success of defibrillation. You wonder if this is true.

Search Strategy

Ovid MEDLINE(R) ALL 1946 to March 05, 2025: 1 paper found

Embase 1980 to 2025 Week 09 8 papers found only 1 relevant.

((Ventricular tachycardia.mp. OR exp Tachycardia, Ventricular/) OR (VT.mp.) OR (VF.mp.) OR (ventricular fibrillation.mp. OR Ventricular Fibrillation/) OR ((ventricular.mp.) AND (tachycardia.mp. OR exp Tachycardia/)) OR ((ventricular.mp.) AND (fibrillation.mp.))) AND (manual pressure.mp. OR manual augmentation.mp.)

Search Outcome

Ovid MEDLINE(R) ALL 1946 to March 05, 2025: 1 paper found

Embase 1980 to 2025 Week 09 8 papers found only 1 relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Voskoboinik A et al. 2022 Australia	Single case report	Single case study of prehospital defibrillation	Success rate and clinical course	47 year old male. Manual pressure augmentation used with later shock (that was successful) showed 18% reduction in impedence as measured by defibrillator. Patient survived after coronary artery stenting in hospital.	Single case study. Success of manual pressure augmentation may be co-incidental.

Comment(s)

This single case report suggests that manual pressure augmentation may be achievable and may reduce impedance. As impedance is a barrier to successful defibrillation this might improve rates of ROSC (return of spontaneous circulation). Interestingly, before the use of pads for defibrillation, we used paddles that when applied to the chest required the operator to press down on the chest in ta similar way to manual pressure augmentation. So the practice is not new, rather a return to earlier methods. Further evidence would be required to change practice and a trial was planned in Australia (the AUGMENT- VA trial). However, this trial was stopped early following a shock to a health care worker. 1. The Augment-VA trial. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=381913 2. The Age newspaper. Ambulance Victoria suspends trial after paramedic receives shock while restarting patient�s heart. https://www.theage.com.au/national/victoria/ambulance-victoria-suspends-trial-after-paramedic-receives-shock-while-restarting-patient-s-heart-20230201-p5ch1s.htm. Accessed Jan 2024.

Clinical Bottom Line

Manual pressure augmentation may reduce impedance, but there is insufficient evidence to suggest using this in mainstream practice.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Voskoboinik A, Nehme Z, Kistler P. First time use of manual pressure augmentation for ventricular fibrillation arrest in the community. Resuscitation 2022:174:31-32