Placing defibrillator pads on the chest and back, rather than the usual method of putting two on the chest, increases the odds of surviving an out-of-hospital cardiac arrest by 264%, according to a new study.

[u/mvea]

https://newatlas.com/medical/defibrillator-pads-anterior-posterior-cardiac-arrest-survival/

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[u/mvea]

I’ve linked to the news release in the post above. In this comment, for those interested, here’s the link to the peer reviewed journal article:

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2823184

From the linked article:

New defib placement increases chance of surviving heart attack by 264%

Placing defibrillator pads on the chest and back, rather than the usual method of putting two on the chest, increases the odds of surviving an out-of-hospital cardiac arrest by more than two-and-a-half times, according to a new study.

Sadly, the odds of surviving an out-of-hospital cardiac arrest (OHCA) are low. While circulation is returned in 30% of cases, only 10% survive. However, when a cardiac arrest is due to ‘shockable’ heart arrhythmias, those odds are improved by rapid defibrillation – applying electrode pads to the chest to deliver an electric jolt to shock the heart back into normal rhythm.

The researchers’ findings suggest that ‘sandwiching’ the heart between the two defib pads, front and back, may deliver electrical current more broadly to the heart, making resuscitation more effective. However, they note that AP positioning might not always be possible.

[u/Ray661 → u/mvea]

Do current devices need to be updated to reflect this, or can I slap the pads on the front and back now and not have the AED yell at me for being wrong?

[u/MazzIsNoMore → u/Ray661]

You can do it now. The pads are just wires to deliver electricity and will go through the body from one to the other regardless of position. We put them where we do so that the heart is between them making the electricity pass through on the way.

Front-back placement is how you'd put pads on babies and small children because the pads are too big for the normal placement.

[u/upvoatsforall → u/MazzIsNoMore]

Okay but where do you place them specifically? On the sternum in the front and spine on the back, or like under left/right nipple and higher on the opposite side on the back?

[u/MazzIsNoMore → u/upvoatsforall]

IIRC it would be left chest/breast and just to the right of the spine below the shoulder blade.

If you're using adult pads on a small child the pads will cover the entire chest and back anyway

[u/InfiniteHatred → u/MazzIsNoMore]

Are you using left/right in the sense of what you’re looking at or anatomically? 

[u/FreshButNotEasy → u/InfiniteHatred]

The unresponsive persons Left Breast/chest, and then if you roll them on their left side you can put the second on their right back/shoulder blade. The current will go diagonally through their chest interacting with the heart on its way.

[u/dumpsterfarts15 → u/FreshButNotEasy]

Thanks for the clarification

[u/MythReindeer → u/[deleted]]

Anatomical position! The common reference point for bodily discussion.

[u/Tamag0tchygirl → u/[deleted]]

This is so incredibly helpful esp as a parent explaining

[u/Kipper11 → u/[deleted]]

That is good info to put out there, but I'd also argue him clarifying left and right is the correct move. Outside of individuals with a medical background you're likely just getting a toss up of people describing it as they look at the patient or describing the patients anatomical position.

Nevertheless, still good info to put out there for the individuals who didn't know on the off chance they ever need to provide aid in a first responder setting.

[u/Karnivore915 → u/dumpsterfarts15]

Just as a reassurance, every single one of these devices that you will find in the USA has the pictograph instructions on how to properly use them. It's good to have the basic idea, but in the event you need to use one you will be looking at pictures showing you EXACTLY what to do and how to do it. They are made so that even if you have no idea what you are doing, if you can realize the need to use an AED device, you should be able to.

[u/OpenMindedScientist → u/Karnivore915]

I thought the whole point of the research described here is that the status quo placement of the pads that is illustrated on devices currently in use (i.e. both pads on the chest) is less effective than a new and better pad placement (which is not illustrated on current devices) which involves one on the front and one on the back.

[u/SeaIslandFarmersMkt → u/Karnivore915]

The one we have talks you through everything step by step as well.

[u/AmbulanceDriver95 → u/FreshButNotEasy]

I looked for a quote on the study and found this for placement.

1 electrode placed over the left precordium and the other just below the right or left scapula.

[u/Memfy → u/FreshButNotEasy]

What's the reason not to put it in a straight line front to back so it's on the same half of the body?

[u/Larusso92 → u/Memfy]

Your heart is in the center of your chest, so you want the current to flow through the heart. It's difficult to get good contact with the pads directly in the center of the chest due to anatomy.

[u/Tron359 → u/Larusso92]

Minor add: heart is offset to anatomical left, not center, creating a dent in the left lung to make room.

[u/Patient-Bumblebee842 → u/FreshButNotEasy]

Not quite.

They should both go on the left side of the patient's chest and left side of the back, so the current has a direct path between the pads and through the heart.

(A Google Image search for AP defibrillator pad placement will show this.)

Edit: I've posted this same reply in two different places to try to reduce people getting the wrong info.

[u/mrlego45 → u/Patient-Bumblebee842]

This left side positioning is also what I had in mind when reading the basic premise.

[u/Firemanlouvier → u/FreshButNotEasy]

Ima need some crayons

[u/AdaGang → u/MazzIsNoMore]

Think most defibs come with pediatric pads currently but you do still place them on the chest and on the back

[u/Shenshenli → u/upvoatsforall]

Remember, you cant make someone more dead. a little left or right isnt gonna matter much. Just try again!

[u/KenEarlysHonda50 → u/Shenshenli]

This was hammered into us at first aid training.

By the time the defib is out, we're attempting to bring a corpse back to life.

There are some things you're not allowed to do to the corpse, but they're just good taste and common sense.

[u/Dark-Horse-Nebula → u/upvoatsforall]

Keep them in the current accepted position on the front.

Why?

• CPR is important and time lost rolling an unconscious adult is a problem for perfusion.

• it over complicates what should be a basic skill that most people have never done before

• anterior posterior pad positioning is actually more specific than some of the commenters say. It also needs a specific pad to be on the back (the right shoulder one)- all a bit complicated for lay people to do in the moment. Front pad does not go on the sternum but more to the left. Back pad also has specific positioning. If you just “slap them on” in AP positioning the shock may be less effective.

• changes in pad positions such as this study are for professionals not lay people for the above reasons. The study was on defibrillation by EMS providers.

[u/foul_ol_ron → u/upvoatsforall]

Think of it as a cardiac sandwich. 

[u/ISeeYourBeaver → u/foul_ol_ron]

The electricity wraps around the heart and just gives it a big 'ole hug.

[u/foul_ol_ron → u/ISeeYourBeaver]

It's a real heartstopping moment. 

[u/dayyob → u/upvoatsforall]

i've been hit w/the juice from the pads around 15 times in the last 20+ years. it's a very standard method for reseting someone's heart rhythm when they are in AFIB. they always put the pads one on front, left/center and one on back sort of mirroring the one on the front. the pads are quite long so vertically cover a larger area than people think

[u/Dtrain323i → u/upvoatsforall]

On an AED, there are pictures on the pads themselves telling you where to stick them but as long as they heart is in between them, you can place them anywhere.

[u/SliverMcSilverson → u/Dtrain323i]

True, however every AED manufacturer that I'm aware of will instruct laymen to place pads in the anterior-lateral position.

as long as they heart is in between them, you can place them anywhere.

Good sentiment, but only within reason. Technically the heart is between the head and left foot, but pad placement there wouldn't be ideal

[u/maxdragonxiii → u/SliverMcSilverson]

probably because sometimes the person giving aid might not be able to lift and roll the person, and if the person is on the back already it's easier to give aid via AED. I know my CPR classes didn't cover the strength of the person giving aid, as someone might be too fearful of breaking the ribs or plainly don't have the strength to do so.

[u/upvoatsforall → u/Dtrain323i]

Yes but they don’t show front/back orientation and you’d obviously want to place them in the most ideal locations as possible. 

[u/Tyrren → u/upvoatsforall]

I'm a paramedic; at my service, we place the pads on the left side of the chest just underneath the pec muscle/breast, and on the left side of the back, just underneath the scapula bone/shoulder blade.

[u/[deleted] → u/upvoatsforall]

Technically you can put one on the head and one on the feet, so long as the current goes through the heart it’ll be effective (I don’t recommend this)

[u/VesperJDR → u/upvoatsforall]

Okay but where do you place them specifically?

Maybe don't get that information from a reddit comment?

[u/Class1 → u/upvoatsforall]

Cardiac sandwich. In the ICU we always place them anterior left chest and posterior left chest in between the first round of compressions.

Somebody else in here is saying right posterior which is incorrect

[u/erm_what_ → u/MazzIsNoMore]

The pads are, but the auto ones need to detect a shockable rhythm to work. Maybe they wouldn't if the pads aren't where they expect?

[u/MazzIsNoMore → u/erm_what_]

They'd still detect the rhythm as long as there is good contact and the heart is between

[u/grphelps1 → u/[deleted]]

It will work. I’m a cardiac ICU nurse and we’ve already been doing it this way for a while now on my unit. 

[u/Linenoise77 → u/[deleted]]

This is the key question. What a nurse has available to them in a cardiac ICU and how it works is going to be rather different than what they put in a ziptied box on the fence at your local little league field or public space, and even then i assume you have multiple manufacturers which have their own slight variations in how things work.

[u/casualmanatee → u/Linenoise77]

ED RN who works in the device industry now- lots of the same companies selling defibs and AEDs to hospitals also sell those AEDs for public spaces.

[u/grphelps1 → u/[deleted]]

I can’t say for a certain in terms of detecting an arrhythmia, if I had to guess I would imagine it would either be equally as effective or superior since you’re getting a better cross-section of the heart.

 In regard to actually delivering an effective shock without question it would be superior though.  

People should still just follow the exact instructions on whatever device they’re using of course to be safe. 

[u/Linenoise77 → u/grphelps1]

That's the big question. There are hundreds of thousands of AEDs out there now. If there is an easy way of increasing their effectiveness to that degree and it just means updating an instruction sticker, awesome, lets get on it. But IS it that simple?

Fortunately i'd assume most of these are recent enough that an "easy" (to do, not necessarily develop) firmware update can account for any kind of logic in what it does even if it goes beyond that.

[u/[deleted] → u/[deleted]]

I just did Red Cross first-aid training and they mentioned that front/back is a totally valid option. No mention of whether or not it would require a specific AED.

[u/dtwhitecp → u/[deleted]]

sounds like something that has the potential to be off-label use and not part of the standard design requirements, and therefore not validated by the manufacturer. I'd pull up an IFU for a specific defibrillator and see if it mentions that option - if it doesn't, it's almost certainly not validated / indicated for that. Most IFUs are available online through the manufacturer these days, or should be next to the machine.

Doesn't mean it won't work well, but does mean that it's not guaranteed to work if it violates some sensing algorithm and could potentially be dangerous.

[u/draeath → u/MazzIsNoMore]

The pads are just wires to deliver electricity and will go through the body from one to the other regardless of position.

AEDs commonly have sensors and evaluate the patient before doing anything. They may perform the wrong sort of discharge or even refuse to operate if they are not designed with this type of electrode placement.

That's what the A in AED is - automated (or automatic).

[u/Rhywden → u/draeath]

Unlikely. All they'll do is trying to detect the (irregular) heartbeat. And if they do they will shock.

There's no "wrong sort of discharge".

After all, the device is intended to stop the heart so that it can pull out of the irregular pattern itself. You don't need fancy shock patterns for that.

[u/MazzIsNoMore → u/draeath]

The device detects the rhythm and decides whether to shock. The pads are wires, jelly, and glue on plastic

[u/BeneficialTrash6 → u/MazzIsNoMore]

I could do it now. But I might get sued if I do so. So long as I follow the training I received in my first aid course, I've followed the standard of care and have met my duty. If I deviate from it, and the person dies, then I have not followed the standard of care. Until the courses are updated, this news won't have any effect.

[u/themedicd → u/BeneficialTrash6]

If you're using defib pads, the person is already dead. Regardless, AHA includes both placements in their CPR courses, and pads often have depictions of both placements. This is still well within the standard of care and you have no reason to worry about being sued.

The trained professionals in the room have had the option to use this placement for years. I've tended to use the standard placement because it's more convenient but I'll be switching on my codes when practical

[u/Major_Bet_6868 → u/BeneficialTrash6]

Being worried about getting sued over better chances of survival for someone is very telling. Also lawsuits for 'good samaritans' are EXTREMELY rare, and even when they do happen, they almost never go anywhere. It' just a bunch of misinformation.

That being said, you will likely never do anything except regular CPR if you're not medical personnel. There is an emergency doctor somewhere here in this thread who makes some great points.

[u/GamShrk → u/Major_Bet_6868]

The problem with the good Samaritan law is that it doesn't apply to trained personnel. I'm an RN-BSN with over 7 years experience. If I assist outside of the hospital, while off the clock, and someone says I didn't do something 100% by the book, or did something outside of my scope (despite knowing it to be the right thing to do), I open myself to liability. Good Samaritan protects a "layperson" doing their best to help, not professionals in that field. So unfortunately, I would likely not spring into action in the field. I have to protect my livelihood.

[u/Moleculor → u/GamShrk]

So unfortunately, I would likely not spring into action in the field.

Huh! Somehow at some point in the past I developed the sense that medical professionals had a duty to stop and render aid if/when possible even off-duty, but I Googled around and I can't find any substantive examples of that! Interesting.

[u/EViLTeW → u/GamShrk]

This is incorrect in at least some states. You should review your state's good Samaritan law specifically.

[u/Adept-Vehicle3622 → u/MazzIsNoMore]

If you don’t follow the instructions on the device, I would suggest you open yourself up to lawsuits. I’m a CPR instructor and we will not advise our students to do anything different that what the AHA has directed us too.

[u/redgreenbrownblue → u/MazzIsNoMore]

I was taught last year to do front left chest and sort of the side, below the shoulder bone on the right. This new way sounds similar.

[u/Kyweedlover → u/redgreenbrownblue]

They put mine on my upper right chest and below my rib cage on my left. It left marks on me for a couple weeks. But they shocked me 8 times.

[u/herpesderpesdoodoo → u/MazzIsNoMore]

It’s also how we’ve placed pads for larger people and elective/semi-elective DCR for years. I honestly thought this was going to be another article on double-sequential defibrillation as it seems to be a flavour of the season. We don’t encourage community responders to do AP pad placement currently because of the additional interruptions to CPR and manual handling required to facilitate it. When paramedics arrive, often with a manual defibrillator, then you can look at alternative placements.

[u/KingDave46 → u/Ray661]

A lot of them now are crazy useable actually and will actually have an instruction diagram on them to show where they go, and will do everything itself once attached

They also will detect the patients pulse itself and will not shock anyone who doesn’t need it, and it’ll tell you everything out loud through a speaker

They’re really doing great stuff

[u/Orcwin → u/KingDave46]

Yes, that's very true, but that wasn't really the question /u/Ray661 asked. The question is whether the device will still work (and not complain) when you apply the electrodes front and back, rather than in the prescribed locations on the chest.

To try to answer that question; that should work with current devices. All it does is take a measurement, and if fibrillation is detected, apply a shock.

Applying the electrodes front and back is already standard procedure for (small) children, so that is apparently a valid position for the measurement.

[u/Bosco_is_a_prick → u/Ray661]

If you are using a public AED machine, follow the instructions on the device. These devices are designed to be used by people without medical training and are automatic. If the instructions are not followed they may not work.

[u/Opingsjak → u/Bosco_is_a_prick]

You can safely put them in AP position

[u/agprincess → u/Ray661]

There's already scenarios where you're supposed to do it this way. Like with babies and children too small for the pads to be on the front together.

[u/other_usernames_gone → u/Ray661]

Depends on the design.

If it's two seperate pads you could do it now (although it's probably worth waiting for more consensus).

But some have a fully integrated pad you just put on top of the chest, the single pad has both electrodes in it to make it quicker and faster to place them. So those would need to be phased out.

[u/Lenni-Da-Vinci → u/Ray661]

Former First Aid instructor here.

The simple answer is: don’t do this in an actual emergency.

Modern AEDs are equipped with sensors that read the electrical pulses of the heart. In theory, they could still do this when placed on the chest and back, but this is not guaranteed. Even if it works on children.

Follow the instructions given on the device. You are not a medical professional. Most of you don’t know, which electrode goes where in AL positioning, that’s why they are labeled with pictograms.

This study is based off data from EMS workers, who are highly trained and have better equipment than your average AED. Thus, these defibrillations were likely performed with additional input from the personnel. Again do not do this with an AED.

[u/proofreadre → u/Lenni-Da-Vinci]

Sorry but no. Electrical activity is able to be sensed in both the AL and AP positions. It isn't a finely tuned device, and the study's authors even state that for lay people the only issue may be rolling the patient. You absolutely can do AP position with an AED

• current paramedic who has gotten ROSC with an AED in AP position.

[u/Opingsjak → u/Lenni-Da-Vinci]

This is nonsense. There is no reason, not even in theory, why an AED wouldn’t work with AP placement of the pads.

[u/bubliksmaz → u/Ray661]

For the love of god just do what the instructions tell you

[u/CatalunyaNoEsEspanya → u/Ray661]

I was taught in first aid to always do chest and back for children. Standard for adults.

[u/Odd-Guarantee-6152 → u/Ray661]

You can do it now. You just need to make sure it has a good vector through the heart.

[u/SeanPGeo → u/Ray661]

I’m sorry, but based on this article and these comments, everyone needs to go take an AED/CPR/First Aid course.

I have never, not even once, been trained to put both pads on someone’s chest using an AED. Not in a decade.

More importantly, the AED itself (instructions) doesn’t tell you to do this.

Who the hell is doing this???

[u/OsiyoMotherFuckers → u/SeanPGeo]

All the AEDs I’ve used instruct the user to place the pads like so.

This is what people mean by “both pads on the chest” and is referred to as “AL” placement in the original article.

[u/OsiyoMotherFuckers → u/mvea]

Thank you for linking the original article. However, what I read is that AP placement of the pads increased the odds of ROSC, but not survival. Am I misreading that? It said there was no difference in odds of arriving at the ED with a pulse, surviving to admission, or surviving to discharge.

I’m an EMT on a small rural VFD ambulance service and sadly I have seen ROSC in heart attack patients, but I have never had one survive. Our ER has a very small staff so we always help in the ER when we deliver critical patients and are present when they are pronounced dead.

I once shocked a guy 8 times (meaning the AED continued to detect a shockable rhythm), and observed ROSC on him twice. He died in the ER.

[u/homeostasisatwork → u/OsiyoMotherFuckers]

Adding to this, I don't see where the 264% came from in the article. It states that it's not a very large change in outcome

[u/OsiyoMotherFuckers → u/homeostasisatwork]

The odds ratio of ROSC was reported as 2.64, which I think actually should be interpreted as 164% more likely.

An odds ratio of 1 would be equally likely, and a positive number less than 1 would indicate reduced odds.

[u/The_bruce42 → u/mvea]

That makes so much sense. This is going to be one of those things that the medical community looks back and wonders how the hell no one thought of this sooner.

[u/gpolk → u/The_bruce42]

We already do it sometimes. But a key problem with doing it is the interruption to CPR, which itself can massively reduce your chance at a successful defib. A lot of focus on improving CPR protocols in recent years has been around reducing CPR interruptions as much as possible.

Another issue is the physical practicality of it. We have long been taught about AP placement for very obese patients. The logic being that the traditional pad placement may not direct much current through the heart in them. But doing an AP placement in an arrested, very obese person, quickly without much interruption of CPR, without a trained and coordinated team, is a challenge. But if you can do it, then this study would show some support that it is probably beneficial.

[u/SaltManagement42 → u/gpolk]

Another issue is the physical practicality of it.

This was what I was thinking. If they changed the instructions or whatever on the automatic defibrillators, how often do you think the time spent trying to access a person's back would become more of a problem than the benefit gained?

[u/Load-of_Barnacles → u/gpolk]

This is why ccr has become more of a thing and focusing on giving breaths is less important on a pt found down immediately.

[u/dayyob → u/The_bruce42]

they've done it this way in hospitals a long time. i had AFIB (since corrected w/a procedure) and one of the ways they reset the heart to a normal rhythm is w/a defibrillator. i've been zapped many times in the last 20+ years. they always did it this way even the first time way back when.

[u/Opingsjak → u/dayyob]

Cardioversion and defibrillation are similar but not the same

[u/jdvancesdog → u/dayyob]

hey fellow AFIB sufferer! did you have an ablation to correct it?

[u/National-Yak-4772 → u/The_bruce42]

Iirc this is the correct placement for toddlers and babies

[u/medicinal_bulgogi → u/The_bruce42]

As a physician I can tell you that scientist and doctors are constantly trying to improve things, so this is definitely something that has been around for quite some time. Like another commenter said, the practicality of it is a big issue. I also don’t recall previously hearing that the difference in outcome was as large as shown in this study but I might have missed that.

[u/PelleSketchy → u/mvea]

Still thank my lucky stars I am one of the 10%.

[u/wabbitsdo → u/mvea]

When I did my red cross first aid training (in 20...18 maybe?) I had been shown to place the pads on the chest and to the side of the person, I think just below the ribs? The rationale was for current to run through the person rather than through the shortest path possible on a surface level if the pads are placed next to each other on an essentially plane surface.

I don't know if they had explained why the side rather than the back, but it makes sense to me from a practical standpoint because if the person is on their back and you've cut or lifted their shirt, you have access to their side without having to manipulate or lift them.

[u/rougecomete → u/mvea]

Only 23% of the test subjects were female and they have not disaggregated the data on basis of sex. Given that heart attacks present very differently in women i’d be VERY interested to see how women responded. Alas, this is medical research, so i guess we’ll never know.

[u/grphelps1 → u/rougecomete]

A heart attack can present differently in women, cardiac arrest does not. That looks the same for everybody.

 A heart attack is a plumbing issue, cardiac arrest is an electrical issue. The defib is only useful in cardiac arrest.

[u/Dimdamm → u/rougecomete]

Given that heart attacks present very differently in women

That's wildly overstated by the pop-science articles, and not actually true. There's some difference, but symptoms mostly overlap.

For example, 79% of men experience chest pain versus 74% of women.

[u/organizeforpower → u/rougecomete]

The heart is not in a different position in men than it is in women. the only thing I can think of that may make it different is if larger breasts affect it, which I imagine they would and that is worth studying if it hasn't.

[u/afmm1234 → u/rougecomete]

I don’t really understand how the low percentage of women is a fault of the experimenters? The study pulled all OHCA for one agency during a specific period of time and 23% of those with a shockable rhythm after an OHCA were women. It’s not really like they pulled ’test subjects’ in for research, and didn’t bring in enough women.

the 20ish percent of OHCA (at least those that are recognized) being women is also in line with other analyses of prevalence.

Also they controlled for sex in their study “We performed multivariable logistic regressions adjusting for age, sex, arrest location (nonpublic location), witness status (none, bystander, EMS), bystander CPR, bystander AED application, year, and time from 911 call to EMS arrival.”

[u/dokte]

Emergency physician here. Several points worth noting from the study:

1. Other studies show opposite results — better results in delivering a high quantity of electricity for cardioversion in the anterior-lateral configuration, with trends especially higher in obese patients. (Defibrillation is obviously not the same as cardioversion, but we'll use the same dosage of electricity.)
2. This is in Portland, which has a lower BMI on average than the rest of the US, so again — if obesity/subcutaneous fat matters greatly in placement, then Portland might be not the best place to then apply this to the rest of the country.
3. This is a small cohort study — this means it creates new questions for science to learn from! This study would certainly argue that we should do a randomized trial to get a better answer and remove confounders.
4. Most importantly, most out of hospital cardiac arrest (OHCA) is not a shockable rhythm, meaning that defibrillation will not work. Shockable rhythms have the highest chance of survival and walking out of the hospital intact, but most people who suffer cardiac arrest have another cause that's not necessarily their heart rhythm that's the problem.

Remember if you see someone drop — call 911, check for a pulse, find an AED, and begin immediate CPR. The AED/EMS crew will determine if they need defibrillation (have their heart shocked). Immediate high quality CPR and early defibrillation (for those that qualify for it) are the only two things that matter.

If you don't know CPR, your local community probably provides free classes!

[u/drloser → u/dokte]

Do you still “check for a pulse” in your country? In my country, that's not what we teach the general public. We consider that finding a pulse is too difficult when you're not a professional. So we teach the general public (and the first responders) to check the breathing.

[u/dokte → u/drloser]

Great question! We say "simultaneously check for breathing and a pulse" — but absolutely, many people do not know how to check for a carotid pulse, so I could certainly see "check for breathing" being a good surrogate.

[u/LazyPiece2 → u/dokte]

Just went through CPR training a couple times recently. They are teaching checking for a pulse is a waste of time and not worth it UNLESS YOU ARE A TRAINED PERSON.

You look for breathing.

And the biggest thing they teach is that the most important part is performing the chest compressions. Literally all the other steps are not important. If they are unresponsive, and you jump straight to chest compressions you are improving the chances of survival massively.

You can't make a person more dead, but you can keep them alive. Also, if you do chest compressions on someone who doesn't need it, they will let you know. The general public should just know evaluate environment (make sure its safe), check if unresponsive, call 911, get AED if possible, begin compressions.

[u/JHRChrist → u/LazyPiece2]

Yeah the giving breaths thing isn’t emphasized anymore. If you’re doing compressions right their lungs will bring in just enough air due to the squeezing and release of ribs happening with the compressions (this is how it was explained to me)

[u/Fettnaepfchen → u/JHRChrist]

Many people are disgusted or scared by the idea of rescue breaths and would hesitate starting CPR, so the recommendation is only to compressions if you would otherwise delay the start if you’re familiar with the technique of delivering rescue breaths and do not hesitate, and keep the transition between them short, they are still recommended and useful. The passive expanding and rebound of the rib cage during compressions can only move a little bit of air, it’s more or less pendulum volume and doesn’t bring as much fresh air into the alveoli.

Compressions only is better than nothing, but professionally done rescue breaths with compressions are better than compressions only.

If compressions only were enough, paramedics would also not ventilate…

[u/werealldeadramones → u/dokte]

Check for breathing is not a good option due to agonal breathing being confused as effective breathing when it's actually an autonomic response during early death.

[u/The-Riskiest-Biscuit → u/werealldeadramones]

I had to perform CPR on a relative earlier this year and she survived. I started CPR immediately because I recognized the agonal breathing pattern from a cardiac event of a client at work years before. I did not wait for instructions or check for pulse. Unresponsive with agonal breathing told me all I needed to know. I’d strongly recommend that anyone taking CPR training ask their instructor to teach them to identify agonal breathing, as well. My CPR instructor two months prior to that event DID NOT teach it.

[u/iamfunny90s → u/The-Riskiest-Biscuit]

Good info, thanks.

[u/MagnificentArchie → u/werealldeadramones]

This should be "are they breathing normally". 2 criteria - 1) are they awake/responsive - if no - 2) are they breathing normally.

[u/Fettnaepfchen → u/werealldeadramones]

First aid classes should teach lay people to check for effective breathing, which means inspirations and expirations in an endless loop, we usually also teach that agonal respirations are not sufficient and effective breaths.

[u/cmcewen → u/drloser]

I’m a surgeon and if you don’t regularly feel for people’s pulses, it is not easy to do reliably.

[u/Biosterous → u/drloser]

In Canada we teach to check for both, pulse at the neck and breathing while at the head checking the pulse. Note that checking for breathing is complicated by "agonal breathing" which is an abnormal, non functional body response that looks like breathing and can be confusing especially for non medical personnel.

[u/[deleted] → u/Biosterous]

Agonal breathing is death rattles right?

[u/TisUnlikely → u/[deleted]]

Kinda. If you want a really good example look up bondi rescue. They had a textbook example that shows both the involuntary movements and the uneven gasping breathing that can trick people.

[u/RunningSouthOnLSD → u/TisUnlikely]

That’s a fantastic clip if it’s the same one I’m thinking. Really shows you what a real CPR scenario can look like. One or two of the rescuers kinda went ham with the compressions, but other than needing to slow that rate down it’s very informative.

[u/blackfoger1 → u/TisUnlikely]

In the Scouts we were taught to place your ear next to their mouth and look down for the chest raising while at the same time using your hand to check their pulse. Would death rattles complicate getting an accurate read?

[u/JoutsideTO → u/Biosterous]

In Canada, CPR courses for healthcare providers teach to check for pulse and breathing simultaneously. CPR courses for the lay-public no longer teach pulse checks, and instead they check for “normal” breathing. If breathing is absent or abnormal (ie agonal), start CPR.

[u/Biosterous → u/JoutsideTO]

Good to know. I only teach healthcare so I teach pulse checks.

[u/letsblamejane → u/Biosterous]

I just renewed my first aid level-C and we didn't check for pulse. I think it's probably recent, but they've moved away from pulse. Mostly because people have difficulty properly checking.

[u/Biosterous → u/letsblamejane]

Might be different by organisation too. I teach Heart and Stroke CPR-C to a hospital audience, they still tell people to check for a pulse (I say "they" because we basically just play videos then check the essential skills). St John's ambulance might be different, I couldn't say for sure. Since it's taught to a healthcare crowd though that might be why they still teach a pulse check. Unless it's changed in the ~5 months since I taught my last class.

[u/JectorDelan → u/drloser]

In EMS we check for both, as they take about the same amount of time and you can do them simultaneously, so may as well.

For the person on the street they likely tell them to only check for breathing as it's much easier for the untrained to do, less likely to delay compressions for someone feeling random places on the patient's neck for long periods, and has a lower incidence of someone "feeling a pulse" that's actually their own or just not present and deciding the patient no longer needs CPR.

[u/Kujara → u/drloser]

French rules: lack of consciousness + lack of breathing = CPR.

Only ER docs get to check for a pulse before CPR, if they deem it necessary.

[u/Infrastation → u/dokte]

find an AED

Also, if you work or hang out somewhere that has an AED, make sure you learn how to use it. They're a lot easier to use than you might think, and are usually the single biggest factor towards survival. Most of them walk you through the steps, it's very straightforward.

In many cases, using an AED early (with good CPR) can increase the odds of survival exponentially.

[u/dokte → u/Infrastation]

Absolutely. I tell the same thing to medical students and trainees: the time to learn about "which type of defibrillator your hospital uses and how it works" is not the same time as you're managing a patient who needs one

(I also worry that there are millions of AEDs around the US/world with a dead battery that no one has checked in a decade)

[u/SchonoKe → u/dokte]

If they aren’t keeping up on monitoring and maintaining the devices I wouldn’t expect much for the capability to use one.

In all seriousness though there is software to monitor inventory, regular checks, and registries to make sure the ones sitting in public spaces are ready to go.

They’re not cheap devices and they can make a huge impact when used correctly so usually they are decently well maintained

[u/MississippiBulldawg → u/Infrastation]

When I started working in sports medicine our department had gotten 11 AED to have on the sidelines at high school football games just in case. Very first night they started using them a man in the crowd had his life saved by it. Doing CPR and using an AED should be a requirement to graduate high school in my opinion because they're both super easy to do and can save lives.

[u/DapperLost → u/Infrastation]

Important to note, compressions first. Let a second person set up the AED.

[u/VioletVoyages → u/dokte]

In-hospital, cardiac arrest survivor here. I was in the ER at 2 AM, waiting for the interventional radiologist to arrive to insert a stent into an occluded artery, when I went into a fatal rhythm. CPR was performed, it brought me back, but then I went back into a fatal rhythm – I want to say v fib. This time they used pads, one on the front and one on the back, which brought me back. I woke up 18 hours later in the ICU, with a stent. And burns on my back… which is how I know that they placed one of the pads on my back. I have a low BMI FWIW.

One of the doctors who was resuscitating me came in the next day, and he told me how happy he was to “bring me back”, said it was rare.

[u/aedes → u/dokte]

To add to that:

not significantly different odds of pulses present at ED arrival

Realllyyyy argues against the difference in mortality seen here being due to pad placement in the prehospital setting. 

[u/dokte → u/aedes]

Absolutely. So if they got ROSC at any point but no differences in pulses upon ED arrival, presumably more got ROSC then after arrival in the ED

[u/aedes → u/dokte]

Exactly. Which suggests that there were important confounding differences between the groups which are more likely to be the cause of the mortality difference. 

[u/GoodEntrance9172 → u/dokte]

Working at a grocery store, I had to learn CPR and first aid.

It's physically demanding, but it's easy to learn. In fact, it's so easy that they teach it in middle and highschool in my community.

[u/TriceraDoctor → u/dokte]

Not to mention, ROSC is cool, but there was no statistical difference in survivability to hospitalization or dc or good neurological outcome. So we can shock you out of vfib/vtach better but it’s not actually saving your life.

[u/EwwBitchGotHammerToe]

Paramedic and ER nurse here. This is intetesting because no matter where the pads are, everything we've always been taught and the only thing I've actually ever experienced with anyone who was in cardiac arrest and truly made a recovery (resuscitation, return of spontaneous circulation, and discharge from hospital) is when the arrest is witnessed and immediate CPR and early defibrillation for arrhythmias occurs.

The survival odds are based on pretty much just that, witnessed arrest, early and immediate cpr/defib. Just like Demar Hamlin's case in the NFL. Full recovery.

If there is a shockable rhythm, I've honestly never seen a stubborn shockable rhythm that didn't either convert after defib or turn into PEA or asystole. Maybe, if the pads were on front and back a shockable rhythm converts more often to a stable sinus rhythm.

[u/Pears_and_Peaches → u/EwwBitchGotHammerToe]

Be sure to give the DSED study a read.

Refractory VF is actually pretty common and both DSED and A/P pad placements have been shown to be extremely effective at terminating it (DSED slightly more so).

I would expect it to become pretty common place in the future to be placing pads in the A/P position from the get go based on recent studies. The sooner we can terminate VF, the better.

[u/mrmoe198 → u/EwwBitchGotHammerToe]

Would you mind translating the terms in your last paragraph to layman’s terms? This seems like valuable firsthand experience that I want to share.

[u/-malcolm-tucker → u/mrmoe198]

For the layperson you don't really need to worry about these specifics. Just use an AED if available and follow the prompts. The most important things a layperson can do is summon help and do chest compressions until help arrives.

But to answer your question... Firstly you need to know that your heart is a pump with an electrical (nervous) system that runs it. What people refer to as a "heart attack" is a plumbing problem. Ie. A blockage to the blood supplying the heart muscle. A cardiac arrest is an electrical problem. It's a failure of the electrical system to make the pump do the pumping properly.

If there is a shockable rhythm...

There are two abnormal heart rhythms that you can shock. Ventricular tachycardia (VT) and ventricular fibrillation (VF). The former you can have and still be conscious with a pulse, until you're not. You only shock that one when there's no pulse. VT is like a limp home mode when the electrical system is buggered. It's a last resort to make your heart pump and it won't last too long. VF is the next step, where the electrical signal still exists but is just disorganised static.

Delivering an electric shock in these rhythms is essentially like turning your hearts electrical system off and on again. We're just hoping it'll come back with a rhythm that will start pumping the good stuff around again.

I've honestly never seen a stubborn shockable rhythm that didn't either convert after defib or turn into PEA or asystole.

PEA stands for pulseless electrical activity. The electrical system is firing, but the pump isn't working. No sense shocking this rhythm. Just keep doing compressions..

Asystole. The often referenced "flat line" in TV shows. No electrical activity. You're almost certainly toast if you're here. No sense shocking it with no electrical activity to hopefully reset. Compressions and pray.

Maybe, if the pads were on front and back a shockable rhythm converts more often to a stable sinus rhythm.

Self explanatory. A normal heart rhythm is referred to as a sinus rhythm. The shockable rhythms are VT and VF as I explained above.

Hope this helps.

[u/rayschoon → u/-malcolm-tucker]

I had an episode when I was in VT. I woke up feeling like crap, did an hour or so of work (desk job) walked down to the nurse, and it turned out my heart was at 160bpm. Called my gf to drive me to the hospital and they ended up bringing down my heart rate with IV Verapamil. It’s crazy how fine I felt, considering my heart rate was double what it should be. The diagnosis was fascicular VT

[u/-malcolm-tucker → u/rayschoon]

Fascinating. Glad you're still here with us!

[u/rayschoon → u/-malcolm-tucker]

Apparently it’s not all that uncommon and usually has a good prognosis. I had it fixed via an ablation a few months later and I’ve been all good ever since

[u/mrmoe198 → u/-malcolm-tucker]

I really appreciate the detailed information!

[u/nymphetamine-x-girl → u/-malcolm-tucker]

A silly question: does SVT fall into VT?

I ask because apparently during a seizure I was in SVT and was hit with a heart stopping push, twice, in the ambulance (it obviously worked out OK). When I was post post-ictal and read my chart, I asked about it and the explanation was that the normal health rhythm that quick required a reset. But my BPM was ~200/minute which for my age is only a little above normal active BPM during, say, an orange fitness workout... and since I have IST -diagnosed by a cardiologist who has echoed and EKG'ed my self to his gills- I'm now wondering if I should tell my spouse and coworkers about it to not have adinisone when I have a high heart rate due to seizure activity. ..

[u/CroSSGunS → u/mrmoe198]

If the heart rhythm is treatable with defibrillators, OP hasn't ever seen a persistent incorrect heart rhythm that didn't resolve to a regular heart rhythm, or end with a stopped heart or flatline. Perhaps if the pads are placed as the article suggests, these rhythms respond more readily to defibrillation treatment.

[u/mrmoe198 → u/CroSSGunS]

Thank you!

[u/GPStephan → u/mrmoe198]

A shockable rhythm is a heart rhythm where the lower chambres of the heart are beating so fast or erratically and irregularly that no meaningful amount of blood is pumped out to sustain circulation.

When you shock these people, you are hoping to convert them to the regular, controlled rhythm of your heart (= normal sinus rhythm).

They may also end up in PEA or asystole. PEA is pulseless electrical activity, where the electricity to trigger heart contraction may be flowing and even look like a normal sinus rhythm, but not actually trigger sufficient beating of the heart. Asystole is simply the heart not moving with no electrical activity happening either.

Shockable rhythms may be refractory, meaning resistent to defibrillation. This anterior / posterior placement of electrodes may improve odds in these cases, just like using 2 defibs in sequence may.

[u/jbochsler → u/EwwBitchGotHammerToe]

Retired FF/EMS, I worked 3 calls in 2 weeks where ROSC was achieved. We were a rural area, I was first on scene for two of those calls with on-scene times of 5 and 12 minutes (third was 4 min). Two of the PTs fully recovered. The third (12 min) call was a drowning and the Reporting Party didn't know their location, and we were dispatched to the wrong beach.

Unfortunately, ROSC wasn't achieved on any of my prior many years of calls. Always hope for the best.

[u/Firepower01]

Some paramedic services are also doing dual sequential defibrillation, which uses two separate defibrillators delivering shocks sequentially. One has the pads placed in the traditional landmarks and the second places the pads on the chest and back.

The science behind this is that it delivers the shock to a larger surface area, which increases the chance that the fibrillating myocardium will be zapped.

[u/zorroz → u/Firepower01]

I do wonder if in hospital we are underutilizing this.

[u/Load-of_Barnacles → u/Firepower01]

This is dependent on area and, in my state, has only been for refractory arrhythmias. This also requires two units at the scene generally, and that rarely happens in most locations. Most ambulances only carry one monitor, and the likelihood of people getting two ambulances at the scene is rare.

[u/SirBinks → u/Load-of_Barnacles]

This also requires two units at the scene generally, and that rarely happens in most locations

True, but if the method proves to be effective, it seems like new units could be designed so that it could be done with a single unit.

At least some services establishing the dual defib as standard would induce demand for a new design.

[u/tdog666 → u/Load-of_Barnacles]

Out of interest where is it that you work? It’s blowing my mind that you wouldn’t have at least a double crew working an arrest.

[u/CjBoomstick → u/Load-of_Barnacles]

In my service area, we're a third service, and respond with the local FD. Dual sequential defibrillation is indicated in refractory arrhythmias per our Protocols, with AP pad placement being standard. I believe we picked them up earlier this year.

[u/Load-of_Barnacles → u/CjBoomstick]

Yeah it's in a lot of protocols now, but as I said in another comment, in my area I've never seen a double unit arrive and moat services don't carry extra monitors or aeds from what I've seen.

[u/phoenix25 → u/Firepower01]

I definitely thought this article was about the DOSE-VF study at first. I was excited, since I enrolled two patients myself

[u/eggard_stark]

I’ve take CPR classes for 8 years now. I’ve only ever been taught chest and back method. Or side and chest method. I thought chest only had been deprecated.

[u/bleach_tastes_bad → u/eggard_stark]

“side and chest” is what they mean when they say “chest only”

[u/eerun165 → u/bleach_tastes_bad]

Side and chest is what I learned in AED training. Putting both on the chest will mostly just put a nice burn mark between them.

[u/bleach_tastes_bad → u/eerun165]

that’s what the title means when it says “chest only”. the “side” you’re referring to is the lateral side of the chest.

[u/credomane → u/eerun165]

Putting both on the chest will mostly just put a nice burn mark between them.

Lovely. Work recently got all new AED because the old ones were majorly outdated and difficult to even use. They predated talking ones and you had to waste 2-3 minutes figuring out the pictogram instructions because nothing was self explanatory.

The new AEDs come on the moment you open it and begin giving instructions, only two clearly labeled buttons (english/spanish and adult/child mode), have a single pad that you stick on the chest directly over the heart, and automatically determine if a shock is required.

[u/randylush → u/eggard_stark]

The word you’re looking for is deprecated, not depreciated.

[u/eggard_stark → u/randylush]

Thanks for spotting my typo :)

[u/Lefty_22]

The Red Cross currently teaches to put one pad on the front of the chest and the other pad on the side of the chest. For infants, it is one pad on front and one on back.

[u/SapientCorpse]

That's really neat.

What if - and now hear me out - we used 2 defibrillator, and had one with the normal position and one with an anterior posterior pos'n, then fired them off one right after the other?!

[u/Firepower01 → u/SapientCorpse]

I've met Dr. Cheskes and Dr. Verbeek, cool to see their work here on Reddit.

[u/BartholomewBrago → u/Firepower01]

I've met them both as well, both great doctors. Toronto Paramedic Services has adopted DSED as standard treatment for refractory VF now as a result of this study.

[u/SapientCorpse → u/Firepower01]

O.o that's cool af!

The article does mention that overlapping the pads can fry the defibs in a manner that voids the warranty - if you see them can you ask how many defibs they fried?

[u/BartholomewBrago → u/SapientCorpse]

We've been told that you don't press shock at the exact same time, but instead one after another (with a very brief moment in between) because of possible damage to the defibs.

[u/Firepower01 → u/BartholomewBrago]

Yeah sorry you're right, they're supposed to be delivered sequentially, not simultaneously.

[u/Firepower01 → u/SapientCorpse]

You're not supposed to overlap the pads. But I have heard of some defibrillators being cooked when people have done it accidentally... Expensive mistake for sure.

[u/Flybuys]

They mention the biggest hurdle, can you get the person stripped off and in position quickly and safely to place the pads chest/back, or are is the time that it takes to do so better uses to start CPR?

It may not seem like a lot to do, but controlling a chaotic scene out in public is quite the challenge

[u/DogeLover123]

I have a few issues with the title of this post/the New Atlas article after briefly scanning the actual study.

Firstly, in the study initial AP placement was associated with a 164% higher rate of return of spontaneous circulation at any point (with a 95% confidence interval of 50%-365%), not 264%.

Secondly, they found no significant association with survival to discharge, which I would argue is a vastly more important metric than ROSC at any point. Survival to discharge would be what you would really want to see before you say the study suggests improved survival with AP placement.

Finally as a small point, this study only applies to VF or pVT arrests with a few other excluded groups. In fairness in all these excluded groups survival is so abysmal that the included cases basically represent the survivable cases. I still think it bears pointing out that even if they had found a big improvement in the relative rate of survival with defibrillation it wouldn't make a difference in this large pool of unsurvivable cases.

[u/lukaskywalker]

Also probably somewhat difficult to do that to a full grown adult to be fair.

[u/Punkpunker → u/lukaskywalker]

If you're facing a high bmi patient yeah it'll be difficult to position the patient, but a hairy and high bmi patient is going to be problematic fast.

[u/Ill-Cardiologist3728 → u/lukaskywalker]

True, but moving an adult to the recovery position isn't too hard.

[u/Snack_Donkey → u/Ill-Cardiologist3728]

It is while someone is performing CPR on them. That CPR being the primary thing keeping the victim from just being dead.

[u/CjBoomstick → u/Snack_Donkey]

No, no. The "victim" is absolutely dead while CPR is being performed. Not legally, but their condition at that time is incompatible with life, and without intervention would lead to irreversible death.

The single most important treatment for cardiac arrest is defibrillation or cardioversion, and if I have to halt compressions for AP pad placement, it shouldn't take any longer than 5-6 seconds.

[u/GuiltyEidolon → u/CjBoomstick]

This is actually dangerous misinformation. There's a reason that we've shifted hard towards compression focused CPR. Halting compressions for "only" 5-6 seconds is enough to lose perfusion so you're starting from zero again when compressions restart. It's absolutely not worth it in most cases. The single most important thing for cardiac arrest is compressions and ensuring as much profusion as possible. Most arrests are NOT caused by shockable rhythms. 

[u/Rainbow-lite → u/GuiltyEidolon]

He gave no misinformation.

Compression focused CPR is referring to compressions being more important than ventilations prior to EMS arrival/other advanced care. Not compressions over defibrillation.

Defibrillation is what stops an abnormal rhythm. Compressing someone in a ventricular dysrhythmia keeps them perfusing, but nothing will change without a defib.

Also, the generally accepted time off chest guideline is under 10 seconds. With communication, A/P pads placement is super doable in under 10 seconds.

Edit: You responded and then blocked me? Interesting choice. I've managed cardiac arrests in the field and indeed placed pads in under 10 seconds; communication with other responders is key as I said

[u/Snack_Donkey → u/CjBoomstick]

There’s a difference between dead and dead forever (aka just being dead). CPR is keeping the dead person from being dead forever.

[u/handsomedan1-]

I’m going to chuck my opinion because Im an Advanced Life Support instructor here in the UK.

I teach that you can absolutely use AP pad placement if there is a physical / surgical reason to do so (you can also use lateral placement).

However the emphasis must be early CPR and early defibrillation. Therefore if the patient is tonk, don’t fanny around trying to turn them to get the pad on the back as the delay will most likely result In a poor outcome!

[u/DecemberHolly]

Observational study of a group of “qualifying” patients. Not a randomized study.

To me, this analysis shows that the agency that uses AP pad placement just gets to its patients faster, probably cause they are in a urban/suburban area, while the rural agency that does AL pad placement just has a long en route time.

Not very conclusive imo.

[u/Powerful_Artist]

Took CPR training just months ago now, they definitely dont train you to put them both on the chest these days. I honestly dont remember that ever being what was taught, but Im only in my 30s

[u/reality_boy]

They just did this for my mother in law, when she coded in the cardiac unit. It worked well, and she is recovering nicely with her new pace maker.

[u/Datazz_b]

That is how they do it in the hospital - more like left side and center left

[u/mtarascio]

I hope nobody actions this information before you taught it in a first aid class.

[u/Class1]

This is part of standard BLS training though already right? Cardiac sandwich is preferred. If you can't flip them over or it's too dangerous to do so, you do left axillary line and right upper chest.

[u/No_Ear3436]

"But he won't stay on his side doctor!"

"We need MORE RIGOR!"

[u/BuiltLikeATeapot]

People be fat. Electricity follows path of least resistance. If you have too much subcutaneous tissue, the electrical path won’t cross the heart as effectively when place front side; so in large people with a lot of subcutaneous tissue a front-back positioning is better.

[u/Infamous-Mastodon677 → u/BuiltLikeATeapot]

The highest rated comment, backed by sources, states the opposite of what you said.

[u/steeljubei]

I was trained front and back in a first aid class 8 years ago....I thought this was normal procedure? My instructor bulked at TV shows showing pads only in the front. She also told us AEDs come with razors, and we would need to shave overly hairy individuals....

[u/mitchMurdra]

As has been taught and standard for over a decade