Defibrillation

Bra Removal Prior to Defibrillation

Last Full Review: ILCOR 2025

Should a woman’s bra be removed before providing cardiopulmonary resuscitation (CPR) or using an automated external defibrillator (AED)? Laypersons sometimes leave a bra in place to preserve the person’s modesty or for cultural reasons, while others hesitate to use an AED with a bra in place due to concerns that underwire bras pose a risk of burns during defibrillation. Men may be concerned about being accused of sexual assault or inappropriate touching. Others find it impossible to remove a bra without scissors, potentially causing a delay in starting CPR or using an AED. This question was addressed by the International Liaison Committee on Resuscitation (ILCOR) in a scoping review.

 

Evidence Summary

A 2025 ILCOR scoping review (Bray et al. 2024; Nørskov et al. 2025, 100885; Bray et al. 2025, S34) sought evidence for adverse events and outcomes associated with pad placement and/or defibrillation without removing the bra or brassiere (including those with metal components) from adults and children in cardiac arrest in any setting. The review identified a single animal study (Di Maio et al. 2015, 11) and two manikin studies (Kramer et al. 2015, 82; O’Hare et al. 2014, S49). No studies were identified reporting patient outcomes. The animal study (Di Maio et al. 2015, 11) was published as a conference abstract, and the study was supported by an AED manufacturer. Four pigs with self-adherent AED pads that were in direct contact with the metal of an underwire bra received multiple shocks at 200 joules for induced ventricular fibrillation. No redirection of the current, arcing, scorching or burning of the skin or bra was reported, and there was 100% first-shock success. The pad placement was reported to not pose a risk to the operator.

A second study (O’Hare et al. 2014, S49), also published as a conference abstract and with the same group of authors as the animal study (Di Maio et al. 2015, 11) and employed by an AED manufacturer, assessed 78 randomly selected untrained AED users in a resuscitation scenario with “female” manikins dressed in a front-opening hooded sweater with a bra or a “male” manikin without a bra. Removal of clothing and bra from the manikin was prompted by the AED. There was no difference in time to placement of AED pads or time to first shock for female versus male manikins, and 88.5% of participants correctly placed pads and delivered a shock.

The final manikin study (Kramer et al. 2015, 82), published as a peer-review article, used 69 randomly assigned undergraduate students in a simulation of out-of-hospital cardiac arrest with CPR and AED use on male or female manikins. The female manikins were dressed in a wig, makeup, silicone breasts, front-opening brassiere and women’s clothing. A voice prompt from the AED provided guidance for activation of the AED, positioning of pads, shock delivery and providing CPR. This study reported that female manikins were significantly less likely to be disrobed than the male manikins (42.4% versus 91.7%), and male participants were significantly less likely to completely disrobe the female manikins than the female participants (13.3% versus 66.7%).

Based on the studies identified in this review and known inequality in AED application in women, ILCOR (Bray et al. 2024; Bray et al. 2025, S34) made several good practice statements that prioritize placing AED pads in the right place rather than routine bra removal, and that if implemented may reduce inequity, address an important problem, may benefit society and are likely to be acceptable and feasible.

• There is insufficient evidence to guide the routine removal of a bra, but it may not always be necessary to remove a bra for defibrillation. Pads must be placed on bare skin in the correct position, which may be possible by adjusting the bra’s positioning rather than removing it.
• Manufacturers should develop realistic manikins that reflect different body sizes that can impact pad placement.
• Where possible, CPR training should cover defibrillation for patients wearing bras, focusing on correct pad placement and minimizing pauses in compressions

 

Insights and Implications

This is the first review by ILCOR on the topic of bra removal before defibrillation, and it is timely. Studies show that women are less likely to receive CPR and defibrillation by the public (Perman et al. 2019, 1060; Grunau et al. 2020, 17). This inequity is likely multifactorial, but there appear to be divergent opinions on whether or not to remove a bra before pad placement and defibrillation. There is little evidence to support either position. The focus needs to be on minimizing delays to starting or interrupting CPR and minimizing delays to defibrillation. By simply adjusting the position of a bra, an AED electrode pad can be placed in the correct location on bare skin without delaying care to remove a bra. This review did not look for studies of bra removal before providing chest compressions. This may be necessary for establishing landmarks for proper hand positioning over the lower chest, but studies are needed to determine if hand position or compression depth are compromised when a person receiving CPR is wearing a bra, as well as if bra removal would cause any potential delay in starting compressions.

Defibrillator Electrode Pad Size and Placement

Last Full Review: ILCOR 2025
Last Update: 2023

Standard manufacturer defibrillator electrode pads for adults are typically greater than 8 centimeters (cm) in diameter and may vary in shape The proper positioning of automated external defibrillator (AED) or defibrillator pads should anatomically encompass the heart, while ensuring good skin contact. An anterolateral position on the chest (avoiding breast tissue) or an anteroposterior position have been recommended in past guidelines for adults. New studies have since been published, triggering an updated systematic review by the International Liaison Committee on Resuscitation (ILCOR).

 

Evidence Summary

A 2025 ILCOR systematic review (Ristagno et al. 2024) and Consensus on Science with Treatment Recommendations (CoSTR) (Ristagno et al. 2025, 101030; Bray et al. 2025, S34) sought evidence with clinical outcomes for the use of any specific pad size or orientation and position in adults and children in cardiac arrest in any setting and with a shockable rhythm at any time during cardiopulmonary resuscitation (CPR), compared with use of reference-standard pad size or orientation and position. No studies were identified for pediatric cardiac arrest or in-hospital cardiac arrest. For pad size, one observational pre-post implementation study (Yin et al. 2023, 109754) did not find a significant difference in defibrillation success with a large pad size (113 cm₂) compared with a small (65 cm₂) pad size.

Two observational studies were identified studying different pad positions for out-of-hospital cardiac arrest (OHCA). The cohort study by Lupton et al. (Lupton et al. 2024, e2431673) was performed by a single emergency medical services agency with a protocol that initially placed pads in the anteroposterior position, if feasible, with a change to the anterolateral position after three consecutive failed shocks. For the outcomes of favorable neurological outcome at hospital discharge and survival to hospital discharge, among 255 OHCAs, no significant benefit was shown from the initial anteroposterior pad position compared with the initial anterolateral position. The same study found significant benefit for the outcome of return of spontaneous circulation (ROSC) from an initial anteroposterior pad position compared with an initial anterolateral position (74.1% versus 50.5%; aOR, 2.64; 95% CI, 1.50–4.65) (Lupton et al. 2024, e2431673).

A before-after study by Steinberg et al. (Steinberg et al. 2022, 16) used recorded defibrillator data from OHCAs with initial ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) to evaluate defibrillation success with anteroposterior pad placement (207 patients, 1,024 shocks) and subsequently with anterolateral pad placement (277 patients, 1,020 shocks). There was no significant difference in defibrillation success between the two pad positions.

Vector change was evaluated in a cluster randomized controlled trial (RCT) (Cheskes et al. 2022, 1947) for refractory VF (persistent VF after three consecutive anterolateral defibrillations) or pVT. Vector change was defined as defibrillation with a new set of pads placed in the anteroposterior position for refractory VF. The trial compared vector change defibrillation with standard anterolateral defibrillation in 280 adult OCHAs and was stopped early due to the coronavirus disease 2019 (COVID-19) pandemic. No significant difference was found for ROSC or survival to hospital discharge with favorable neurological outcome between the two groups. However, improved survival to discharge (21.7% versus 13.3%) and a higher rate of termination of VF (79.9% versus 67.6%; aRR, 1.18; 95% CI, 1.03–2.36) were both shown with vector change to anteroposterior pad position compared with anterolateral pad position (Cheskes et al. 2022, 1947).

The International Liaison Committee on Resuscitation released a good practice statement that there is insufficient evidence to recommend a specific pad or paddle size for optimal external defibrillation in adults (Ristagno et al. 2024; Bray et al. 2025, S34).

Additional good practice statements directed towards manufacturers of defibrillators included:

• Manufacturers should standardize adult pad or paddle placement in the anterolateral position. One pad or paddle should be placed below the right clavicle, just to the right of the upper sternal border, and the other with its center in the left mid-axillary line, below the armpit.
• Manufacturers should provide clear instructions to ensure proper contact between the pad or paddle and the skin, along with diagrams that accurately show the ILCOR-recommended pad and paddle positions.

 

Additional good practice statements for CPR providers using an AED included:

• A statement that advises following the manufacturer’s AED guidance and instructions for adult pad placement.

 

Additional good practice statements for CPR providers trained in manual defibrillation included:

• A statement that advises for adults, place defibrillator pads or paddles in the anterolateral position to optimize placement speed and minimize interruptions to chest compressions. One pad/paddle should be positioned below the patient’s right clavicle, just to the right of the upper sternal border. The other pad/paddle should be placed on the patient’s left mid-axillary line, below the armpit.
• A statement that advises for adults, if the initial anterolateral position is not feasible, consider using the anteroposterior pad position if trained. Place the anterior pad of the left side of the chest, between the midline and the nipple. For female patients, place the anterior pad to the left of the lower sternum, ensuring it avoids breast tissue as much as possible. The posterior pad should be placed on the left side of the patient’s spine, just below the scapula.

 

Additional good practice statements for healthcare professionals trained in vector change included:

For adults in refractory VF (persistent VF after three defibrillations), consider changing pads to the anteroposterior pad position. Place the anterior pad on the left side of the chest, between the midline of the chest and the nipple. For female patients, place the anterior pad to the left of the lower sternum, ensuring it avoids breast tissue as much as possible. The posterior pad should be placed on the left side of the patient’s spine, just below the scapula. This recommendation does not replace the existing ILCOR treatment recommendation on vector change and double sequential defibrillation for advanced life support providers (Berg et al. 2023, e187).

The ILCOR review provided several points justifying the good practice statements provided (Ristagno et al. 2024; Bray et al. 2025, S24). First, about 20% of patients in cardiac arrest will stay in a shockable rhythm despite standard resuscitation efforts. Because transthoracic impedance varies with pad size and position, this may impact success of defibrillation. All studies were at serious risk of bias, and only one was an RCT, limiting the certainty of evidence for making recommendations. Multiple studies reporting on transthoracic impedance differences with pad size, including some that were not included in the systematic review, are discussed in the section on justifications in the ILCOR review:

• A secondary analysis of the DOSE VF trial (Cheskes et al. 2019, 223) showed that vector change defibrillation compared to standard pad placement was not superior for VF termination, ROSC, or survival for shock-refractory VF, but for recurrent VF, vector change defibrillation was superior to standard pad placement for VF termination.
• The study by Yin et al. (Yin et al. 2013, 1248) showed transthoracic impedance was higher for smaller electrodes than for larger electrodes, but defibrillation success was equivalent.
• Two observational studies in adults (Kerber et al. 1981, 676; Yin et al. 2013, 1248) and three in children (Atkins and Kerber 1994, 90; Atkins et al. 1988, 914; Samson et al. 1995, 544) showed significantly higher transthoracic impedance with small pads than large pads. Lower transthoracic impedance results in higher current flow and may allow for higher defibrillation success.
• An observational study of transthoracic impedance in volunteers measured lower transthoracic impedance in the anteroposterior pad positions compared to the anterolateral position (Krasteva et al. 2006, 1009).
• An observational study of 123 cardiac arrests (Dalzell et al. 1989, 741) reported on small, intermediate and large pad diameters and transthoracic impedance. Impedance decreased significantly with increasing pad size. The study used monophasic defibrillators and showed that a single shock of 200 joules (J) was successful in 8/26 (31%) of arrests with small pads, 40/63 (63%) with intermediate pads, and in 28/34 (82%) with large pads. This study has not been replicated using biphasic, impedance-compensated defibrillation waveforms.

 

Insights and Implications

This topic was last reviewed by ILCOR in 2010, with evidence updates and a scoping review in the interim. For pad size, there were no studies comparing sizes for outcomes of ROSC or other critical outcomes, and only one study looked at defibrillation success rates for AEDs with large versus small pad sizes. In practice, healthcare providers and lay responders will typically not have an option for pad sizes beyond what is provided for adults or children by the manufacturer or healthcare organization. For pad position, the only studies available looked at refractory shockable rhythms and had a serious risk of bias. The observational studies for pad size discussed by ILCOR outside of the evidence valuation address the surrogate outcome of transthoracic impedance and suggest that impedance may be less with the anteroposterior position than the anterolateral position. More studies are needed to know if this translates to improved clinical outcomes. For now, the priority is speed of pad placement without disrupting CPR. This is best accomplished with the anterolateral pad position in adults. The suggestion for healthcare professionals to consider vector change defibrillation for refractory VF is based primarily on the study by Cheskes et al. (Cheskes et al. 2024, 110186) in which a secondary analysis of the DOSE VF trial found vector change defibrillation was superior to standard pad placement for VF termination.

Pad Size and Placement in Infants and Children

Last Full Review: ILCOR 2025

Standard manufacturer defibrillator electrode pads for adults are typically 8 to 12 centimeters (cm) in diameter, while for children and infants they measure around 7.0 cm x 11.2 cm. Pad sizes can vary by manufacturer, and some pads are the same size as adult pads but have an attenuator on the cord to step down the voltage applied to the pad. The proper position of automated external defibrillator (AED) or defibrillator pads should anatomically encompass the heart while ensuring good skin contact. An anterolateral position on the chest (avoiding breast tissue) or an anteroposterior position have been recommended in past guidelines for adults, while for children and infants, an anteroposterior position has been recommended. New studies have been published, triggering an updated systematic review by the International Liaison Committee on Resuscitation (ILCOR).

 

Evidence Summary

A 2025 ILCOR systematic review (Ristagno et al. 2025, 101030) and Consensus on Science with Treatment Recommendations (CoSTR) (Lopez-Herce et al. 2024; Scholefield et al. 2025, S116), conducted with the ILCOR Basic and Advanced Life Support Task Forces, sought evidence with clinical outcomes for the use of any specific pad size/orientation and position in adults and children in cardiac arrest in any setting and with a shockable rhythm at any time during cardiopulmonary resuscitation (CPR), compared with use of reference-standard pad size/orientation and position. No studies were identified for pediatric cardiac arrest. Studies from the adult population were used as indirect evidence.

For pad size, one observational pre-post implementation study (Yin et al. 2023, 109754) in adults did not find a significant difference in defibrillation success with large pad size (113 cm₂) compared with a small (65 cm₂) pad size.

For pad position, two observational studies (Lupton et al. 2024, e2431673; Steinberg et al. 2022, 16) were identified studying different pad positions for adult out-of-hospital cardiac arrest (OHCA). The cohort study by Lupton et al. (Lupton et al. 2024, e2431673) was performed by a single emergency medical services agency with a protocol that initially placed pads in the anteroposterior position, if feasible, with a change to the anterolateral position after three consecutive failed shocks. For the outcomes of favorable neurological outcome at hospital discharge and survival to hospital discharge, among 255 OHCAs, no significant benefit was shown from the initial anteroposterior pad position compared with the initial anterolateral position. The same study found significant benefit for the outcome of return of spontaneous circulation (ROSC) from an initial anteroposterior pad position compared with an initial anterolateral position (74.1% versus 50.5%; aOR, 2.64; 95% CI, 1.50–4.65) (Lupton et al. 2024, e2431673).

A before-after study by Steinberg (Steinberg et al. 2022, 16) used recorded defibrillator data from OHCAs with initial ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) to evaluate defibrillation success with anteroposterior pad placement (207 patients, 1,024 shocks) and subsequently with anterolateral pad placement (277 patients, 1,020 shocks). There was no significant difference in defibrillation success between the two pad positions.

For vector change, indirect evidence from studies in adults were evaluated from a cluster randomized controlled trial (Cheskes et al. 2022, 1947) for refractory VF (persistent VF after three consecutive anterolateral defibrillations) or pVT. Vector change was defined as defibrillation with a new set of pads placed in the anteroposterior position for refractory VF. The trial compared vector change defibrillation with standard anterolateral defibrillation in 280 adult OCHAs and was stopped early due to the coronavirus disease 2019 (COVID-19) pandemic. No significant difference was found for ROSC or survival to hospital discharge with favorable neurological outcome between the two groups. However, improved survival to discharge (21.7% versus 13.3%) and a higher rate of termination of VF (79.9% versus 67.6%; aRR, 1.18; 95% CI, 1.03–2.36) were both shown with vector change to anteroposterior pad position compared with anterolateral pad position (Cheskes et al. 2022, 1947).

The International Liaison Committee on Resuscitation released good practice statements (Lopez-Herce et al. 2024; Scholefield et al. 2025, S116) directed towards manufacturers of defibrillators including:

• Manufacturers should consider the standardization of pad size for infants, children and adults.
• Manufacturers of AEDs should standardize pad placement in an anteroposterior position for infants and young children, with one pad anteriorly, over the left precordium and the other pad posteriorly to the heart just inferior to the left scapula.
• Manufacturers should include instructions to ensure proper contact between the pad and the skin and to ensure that their pad position diagrams clearly indicate the ILCOR-recommended pad positions.

 

For CPR providers using an AED:

• A good practice statement advises to follow the AED’s specific guidance and instructions for pad placement in infants and children (Lopez-Herce et al. 2024; Scholefield et al. 2025, S116).

 

For CPR providers trained in manual defibrillation:

• A good practice statement from ILCOR (Lopez-Herce et al. 2024; Scholefield et al. 2025, S116) advises that for infants and children, place pads in an anteroposterior position as described above.

 

A recommendation could not be made for or against the use of vector change for the treatment of refractory VF or pVT in infants and children.

Insights and Implications

The Red Cross recommendation for use of an anteroposterior pad position in infants and children is unchanged and informed by the ILCOR treatment recommendations and the indirect evidence from adults that this pad position may improve ROSC. Placing pads in an anteroposterior position is easier in infants and children than in adults, so there should be little or no delay in defibrillation and providing chest compressions. Pads are often used as real-time feedback devices in pediatric cardiac arrest for assessment of the quality of chest compressions, and they typically require an anteroposterior position for metric measurement. Vector change is currently not possible for children and infants due to difficulty fitting two sets of pads on a child’s thorax. In addition, the incidence of refractory VF in children and infants is not known.

Single Versus Stacked Shocks in Pediatric Cardiac Arrest

Last Full Review: ILCOR 2025
Last Update: 2010

Since 2010, the International Liaison Committee on Resuscitation (ILCOR) has recommended a single-shock strategy in pediatric patients with ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) followed by immediate chest compressions. The previous three-shock strategy was recommended as older monophasic defibrillators had a low rate of conversion with the first shock, and it was thought that transthoracic impedance was reduced after each shock. This topic has not undergone a systematic review by ILCOR since 2010.

 

Evidence Summary

A 2024 ILCOR systematic review and Consensus on Science with Treatment Recommendations (CoSTR) (Tiwari et al. 2024; Scholefield et al. 2025, S116) sought evidence to support the use of more than one (stacked) shock(s) for the initial or subsequent defibrillation attempt(s) in infants and children who are in VF or pVT during in- or out-of-hospital cardiac arrest, compared with a single shock for each defibrillation attempt. Survival outcomes and return of spontaneous circulation (ROSC) were selected outcomes of interest for this review. The search failed to identify any pediatric trials, observational studies or case series comparing single versus stacked shock in children with cardiac arrest with VF or pVT in any setting. The previous 2005 ILCOR recommendation for delivery of stacked shocks was withdrawn for 2025, and a new good practice statement was made for infants and children with out-of-hospital or in-hospital cardiac arrest in VF or pVT that suggests a single-shock strategy followed by immediate CPR beginning with chest compressions (Tiwari et al. 2024; Scholefield et al. 2025, S116).

Insights and Implications

In discussion, the scoping review authors note that there is a first-shock success rate of up to 90% with current biphasic defibrillators, and that a stacked, three-shock sequence results in a delay of up to 37 seconds between the first shock and the first post-shock chest compression (Tiwari et al. 2024; Scholefield et al. 2025, S116). By using a single-shock strategy, if the initial shock fails, chest compressions may be provided, allowing delivery of oxygen to the myocardium and making the next shock more likely to result in defibrillation. The Red Cross guidelines continue to recommend a single-shock strategy for children and infants in cardiac arrest with a shockable rhythm and resuming CPR with chest compressions immediately following delivery of the shock and between any subsequent shocks.

Automated External Defibrillator Use for Infants

Last Full Review: ILCOR 2022; American Red Cross Scientific Advisory Council 2008
Last Update: 2023

Out-of-hospital cardiac arrest is rare in infants and children, and unlike adults, is less likely to be due to a primary cardiac event and more likely to be the result of a respiratory issue or trauma. Is there evidence to support the use of automated external defibrillators (AEDs) on infants in cardiac arrest?

 

Evidence Summary

The use of AEDs in infants (i.e., younger than 1 year of age) was first evaluated by the American Red Cross Scientific Advisory Council in 2008 and has been updated triennially since, with the last update in 2023 (American Red Cross Scientific Advisory Council: Resuscitation 2023a). Since the previous update, only two case reports have been identified describing the successful use of an AED, both in 1-month-old infants (Hoyt et al. 2019, 2599; Aoki 2018, 670). A 2022 study (Holgersen et al. 2022, 58) of pediatric out-of-hospital cardiac arrests over a 4-year period included data from 173 children under 17 years of age identified in a Danish registry and by review of prehospital medical records. A presumed reversible cause of cardiac arrest was reported in 48.6% of cases, with hypoxia being the primary cause of out-of-hospital cardiac arrest. Thirty-day overall survival was 40%, with the lowest survival rate (26.9%) found in infants. Defibrillator use was more frequent among survivors in all age groups (16% of survivors defibrillated by bystanders versus 1.9% in nonsurvivors). For infants, 98.1% of cardiac arrests occurred in a private home—compared with 65.9% in the 1- to 5-year age group and just over 42% in the 6- to 12-year and 13- to 16-year age groups respectively. No infants had defibrillation by a bystander, and only 5.8% had defibrillation by emergency medical services. The initial rhythm in infants was shockable in 21.2% of cases.

A 2022 International Liaison Committee on Resuscitation (ILCOR) systematic review (Atkins et al. 2022b, 100283) and Consensus on Science with Treatment Recommendations (CoSTR) (Atkins et al. 2022a) of lay responder use of AEDs in infants, children and adolescents found limited data on infants. Automated external defibrillator use was analyzed using raw data supplied by the Cardiac Arrest Registry to Enhance Survival (CARES) registry from three studies that included data from children who experienced a cardiac arrest/had an AED applied by a lay responder and survival outcomes. The relative risk (RR) of survival was calculated from the supplied data. For infants, the RR of survival with favorable neurological status at hospital discharge or at 30 days was 1.82 (95% CI, 0.28–11.96). Data from the analysis did support the use of an AED by lay responders for children over 1 year of age; however, data was only available for 12 infants who had an AED applied, and only one was discharged with a favorable neurological status. The ILCOR CoSTR concluded that there was insufficient data to provide a recommendation for AED application by a lay responder to infants in cardiac arrest (Atkins et al. 2022a; Atkins et al. 2022b, 100283).

Insights and Implications

Ventricular fibrillation (VF) is the primary cause of sudden cardiac death in adults. Although VF is less common in children, up to one-fourth of pediatric out-of-hospital cardiac arrests are due to VF (Mogayzel et al. 1995, 484; Hickey et al. 1995, 495). Up to 14% of cases of VF in children occur in those under 1 year of age (i.e., infants) (Rossano et al. 2006, 80). Prompt CPR and defibrillation is key to survival of patients in cardiac arrest, and AEDs have been shown to improve time-to-defibrillation and survival in different settings. The most recent review of pediatric out-of-hospital cardiac arrests from the Danish registry (Holgersen et al. 2022, 58) reports the lowest survival, and lowest use of AEDs in the under 1 year of age group. This may simply reflect the fact that compared with other pediatric age groups, cardiac arrests in infants occur most frequently at home, where an AED is not readily available.

Despite the lack of evidence in the ILCOR review to support the use of AEDs by lay responders for infants with out-of-hospital cardiac arrest, the American Red Cross Scientific Advisory Council review notes that there is no evidence to suggest harm from their use. The application of an AED may cause a slight pause in CPR, but that determinant is outweighed by the lifesaving benefit in both infants and children with shockable rhythms.

 

Ultra-Portable Automated External Defibrillators

Last Full Review: ILCOR 2024

Compact or ultra-portable automated external defibrillators (AEDs) are designed to be small, lightweight and portable, making them suitable for use in a variety of settings. They may weigh less than 3 pounds, be packaged in a carrying case that is easy to grab, and they have a user interface that makes them simple and intuitive for both lay responders and healthcare professionals to use effectively. Their size, ease of use, affordability and portability make them attractive for use at home and potentially in other strategic locations where having a readily available defibrillator is important. However, their effectiveness in practice is uncertain, and some devices are limited in the number of shocks and maximum energy they will deliver.

 

Evidence Summary

The International Liaison Committee on Resuscitation (ILCOR) prioritized this topic for a scoping review because early defibrillation is associated with a large increase in survival from out-of-hospital cardiac arrests (OHCAs), there is growing interest in the use of these devices to improve AED availability, and this topic has not been previously reviewed. The scoping review (Debaty et al. 2024, 100739; Debaty et al. 2024; Greif et al. 2024) included one economic analysis of simulated patients at risk of sudden cardiac arrest (Shaker et al. 2022, 771679), a study protocol of a cluster randomized controlled trial (RCT) (Todd et al. 2023a, 100466) and an abstract (Todd et al. 2023b, S88) with preliminary findings from the same cluster RCT. The health-economic analysis was based on a simulated database and suggested that a small AED for rapid treatment of sudden cardiac arrest strategy is a cost-effective approach for patients with an increased risk of sudden cardiac arrest. The study protocol of ultra-portable AED use described the planned study of first responders equipped with an ultra-portable, single-use AED and activated by smartphone for OHCA with 30-day survival outcomes. There is a clear lack of research in this area, and evidence of device performance in real-life settings is needed.

Insights and Implications

Early defibrillation saves lives. This review recognizes the development of a novel, single-use ultra-portable defibrillator that is the size of a large cellphone and can be easily applied. The device is not yet available nor approved by the US Food and Drug Administration, but the potential impact of this type of device for OHCA is substantial. Because successful defibrillation is related to shock energy, transthoracic impedance, pad size and multiple other factors, research is needed to show clinical efficacy of ultra-portable, single-use AEDs.