1. Dallas 2015 TFQO: Michael Sayre COI #400 EVREV 1: Mohamud Daya COI #327 EVREV 2: Jan-Thorsten Gräsner COI #230 Taskforce: BLS BLS 363: CPR Prior to Defibrillation

2. Dallas 2015 COI Disclosure Mohamud Daya COI #327 Commercial/industry none Potential intellectual conflicts none Jan-Thorsten Gräsner COI #230 Commercial/industry none Potential intellectual conflicts none

3. Dallas 2015 2010 CoSTR There is inconsistent evidence to support or refute delay in defibrillation to provide a period of CPR (90 seconds to 3 minutes) for patients in non EMS witnessed VF/pulseless VT cardiac arrest.

4. Dallas 2015 C2015 PICO Population: Among adults and children who are in ventricular fibrillation or pulseless ventricular tachycardia in any setting (P), Intervention does a prolonged period of chest compressions before defibrillation (I), Comparison compared with a short period of chest compressions before defibrillation (C), Outcome change Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC, rhythm control (O)?

5. Dallas 2015 Inclusion/Exclusion & Articles Found Inclusions/Exclusions RCT, nRCT, Meta-Analyses included Case reports, animal studies excluded A literature review resulted in the retrieval of 13 articles on this topic. 5 randomized controlled trials (Baker 2008 p424, Jacobs 2006 p39, Ma 2012 p806, Stiell 2011 p787 and Wik 2003 p1389), 4 non-randomized trials (Bradley 2010 p155, Cobb 1999 p1182 Hayakawa 2009 p470, Koike 2011 p393), 3 meta-analyses (Huang 2014 p1, Meier 2010 p52, Simpson 2010 p925) 1 subgroup analysis of data reported in the RCT by Stiell et al. (Rea 2014 p1).

6. Dallas 2015 2015 Proposed Treatment Recommendations We suggest an initial period of CPR for 30- 60 seconds while the defibrillator is being applied.

7. Dallas 2015 Risk of Bias in studies

8. Dallas 2015 Risk of Bias in studies

9. Dallas 2015 Risk of Bias in studies

10. Dallas 2015 Risk of Bias in studies

11. Dallas 2015 Risk of Bias in studies

12. Dallas 2015 Evidence profile table(s)

13. Dallas 2015 Evidence profile table(s)

14. Dallas 2015 Evidence profile table(s)

15. Dallas 2015 C2015 PICO Population: Among adults and children who are in ventricular fibrillation or pulseless ventricular tachycardia in any setting (P), Intervention does a prolonged period of chest compressions before defibrillation (I), Comparison compared with a short period of chest compressions before defibrillation (C), Outcome change Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC, rhythm control (O)?

16. Dallas 2015 Proposed Consensus on Science statements For the critical outcome of survival to one year with good neurological function (CPC ≤ 2), we identified low quality evidence (downgraded for bias and imprecision) from a single trial (OR 1.18, 95% CI [0.522 to 2.667]) (Wik, 2003, 1389 For the critical outcome of survival to one year, we identified low quality evidence (downgraded for bias and imprecision) from 2 RCTs (OR 1.15, 95% CI [0.625 to 2.115]) (Jacobs, 2005, 39; Wik, 2003, 1389

17. Dallas 2015 Proposed Consensus on Science statements For the critical outcome of survival to hospital discharge with favorable neurological outcome (defined as CPC score of ≤ 2, MRS score ≤ 3), we identified low quality evidence (downgraded for inconsistency and imprecision) from 4 RCTs (OR 0.95, 95% CI [0.786 to 1.15]) (Stiel, 2011, 787; Wik, 2003, 1389 ; Baker, 2008, 424 ; Ma, 2012, 806). For the critical outcome of survival to hospital discharge, we identified low quality evidence (downgraded for bias and imprecision) from 4 RCTs (OR 1.095, 95% CI [0.695 to 1.725] (Jacobs, 2005, 39; Wik, 2003, 1389 ; Baker, 2008, 424 ; Ma, 2012, 806)

18. Dallas 2015 Proposed Consensus on Science statements With respect to ROSC, we identified low quality evidence (downgraded for bias and imprecision) from 4 RCTs (OR 1.193, 95% CI [0.871 to 1.634]) (Jacobs, 2005, 39; Wik, 2003, 1389 ; Baker, 2008, 424 ; Ma, 2012, 806)

19. Dallas 2015 Proposed Consensus on Science statements One subgroup analysis looked at enrollments based on EMS response time comparing those with times less than 4 to 5 minutes vs. those ≥ 4 to 5 minutes. Within this subgroup, one RCT (Wik 2003 1389) found a favorable relation with CPR for 180 seconds before defibrillation when response time was ≥ 5 minutes but this relationship was not confirmed in 3 other RCTs (Baker 2008 p424, Jacobs 2006 p39, Stiell 2011 p787 ) The second subgroup analysis (Rea 2014 p1) examined outcomes from early vs. late analysis based on baseline EMS agency VF/pVT survival rates. These authors reported that survival was better with early analysis and defibrillation for agencies in which low baseline survival to hospital discharge rate (defined as 20% for an initial rhythm of VF/pVT).

20. Dallas 2015 Proposed Consensus on Science statements Although no study has suggested harmful effects from up to 180 seconds of CPR prior to defibrillation, an exploratory analysis from one RCT (Stiell 2011 p787) suggested a decline in survival to hospital discharged from a prolonged period of CPR (180 seconds) with delayed defibrillation in patients with an initial rhythm of VF/pVT that had received bystander CPR compared to a shorter period of CPR (30-60 seconds) followed by defibrillation.

21. Dallas 2015 2015 Proposed Treatment Recommendations We suggest an initial period of CPR for 30- 60 seconds while the defibrillator is being applied.

22. Dallas 2015 Draft Values and Preferences Statement: We recognize that the evidence in support of these recommendations from RCTs of variable quality completed in different countries with varying EMS system configurations. The available evidence suggests a minimal effect size overall, while recognizing that it remains possible that when high quality CPR is delivered a longer period of CPR may be superior. In making these recommendations, we placed a higher value on the delivery of early defibrillation and a lower value on the as yet unproven benefits of performing CPR for a longer period of time. We placed a higher value on evidence from RCTs than NRCTs.

23. Dallas 2015 Knowledge Gaps System level characteristics Impact of response time unclear Quality of bystander CPR Characteristics of the ECG waveform Optimal duration of CPR if that strategy is selected (90 seconds, 120 seconds, and 180 seconds)?

24. Dallas 2015 Next Steps This slide will be completed during Task Force Discussion (not EvRev) and should include: Consideration of interim statement Person responsible Due date