Review

. 2025 Jul 14:25:101030.

doi: 10.1016/j.resplu.2025.101030. eCollection 2025 Sep.

Pad size, orientation, and placement for defibrillation during basic life support: A systematic review

Giuseppe Ristagno^{1

2}, Federico Semeraro³, Violetta Raffay⁴, Giuseppe Stirparo⁵, Ileana Lulic⁴, Charles D Deakin⁶, Ian R Drennan^{7

8

9

10

11}, Jimena Del Castillo¹², Jason Acworth^{13

14}, Peter T Morley¹⁵, Gavin D Perkins¹⁶, Micheal Smith¹⁶, Theresa M Olasveengen¹⁷, Janet E Bray^{18

19}; International Liaison Committee on Resuscitation Basic Life Support Task Force Members; Advanced Life Support Task Force Members; Pedriatic Life Support Task Force Members

Collaborators, Affiliations

Collaborators

International Liaison Committee on Resuscitation Basic Life Support Task Force Members:
Anthony Lagina, Baljit Singh, Julie Considine, Sung Phil Chung, Vihara Dassanayake, Katie Dainty, Guillaume Debaty, Maya Dewan, Bridget Dicker, Fredrik Folke, George Lukas, Carolina Malta Hansen, Nicholas J Johnson, Rebecca Cash, Takanari Ikeyama, Siobhan Masterson, Ziad Nehme, Tatsuya Norii, Aloka Samantaray, Anastasia Spartinou, Christopher M Smith, Christian Vaillancourt
Advanced Life Support Task Force Members:
Markus Skrifvars, Katherine M Berg, Ari Moskowitz, Asger Granfeldt, Brian Grunau, Carolyn Zelop, Helen Pocock, Karen G Hirsch, Keith Couper, Mathias J Holmberg, Nikolaos Nikolaou, Shannon M Fernando, Shinichiro Ohshimo, Sonia D'Arrigo, Tommaso Scquizzato, Yew Woon Chia, Carrie Leong, Conor Crow, Neville Lok, Bernd Bottiger, Brian O'Neil, Jasmeet Soar, Michael Parr, Michelle Welsford, Peter Kudenchuk, Robert W Neumar, Tonia Nicholson, Jerry P Nolan, Eric J Lavonas, Claudio Sandroni
Pedriatic Life Support Task Force Members:
Kee-Chong Ng, Barnaby R Scholefield, Alexis Topjian, Jesus Lopez-Herce, Andrea Christoff, Ryan W Morgan, Arun Bansal, James M Gray, Hiroshi Kurosawa, Leandra Rech, Joseph Rossano, Lokesh Kumar Tiwari, Michelle Myburgh, Monica Kleinman, Ravi Thiagarajan, Stephan Katzenschlager, Tia T Raymond, Anne-Marie Guerguerian, Janice A Tijssen, Gabrielle Nuthall, Steve Schexnayder, Thomaz Bittencourt Couto, Vinay Nadkarni, Yong-Kwang Gene Ong Dianne Atkins, Allan de Caen

Affiliations

¹ Department of Pathophysiology and Transplantation, University of Milan, Italy.
² Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
³ Department of Anaesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy.
⁴ Department of Medicine, School of Medicine, European University Cyprus, Nicosia, Cyprus.
⁵ Agenzia Regionale Emergenza Urgenza - AREU, Milan, Italy.
⁶ University Hospital Southampton, UK.
⁷ Sunnybrook Research Institute and Department of Emergency Services, Sunnybrook Health Science Centre, Toronto, Ontario, Canada.
⁸ Department of Family and Community Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada.
⁹ First60, St. Michaels Hospital, Toronto, ON, Canada.
¹⁰ Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
¹¹ Ornge Critical Care Transport, Toronto, ON, Canada.
¹² Hospital Maternoinfantil Gregorio Marañón, Madrid, Spain.
¹³ Emergency Department, Queensland Children's Hospital, Brisbane, Australia.
¹⁴ Faculty of Medicine, University of Queensland, Australia.
¹⁵ Royal Melbourne Hospital Clinical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Victoria, Australia.
¹⁶ Warwick Medical School, University of Warwick, UK.
¹⁷ Department of Anaesthesia and Intensive Care Medicine, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway.
¹⁸ Monash School of Public Health and Preventive Medicine, Melbourne, Australia.
¹⁹ Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Australia.

PMID: 40741375
PMCID: PMC12309583
DOI: 10.1016/j.resplu.2025.101030

Review

Pad size, orientation, and placement for defibrillation during basic life support: A systematic review

Giuseppe Ristagno et al. Resusc Plus. 2025.

. 2025 Jul 14:25:101030.

doi: 10.1016/j.resplu.2025.101030. eCollection 2025 Sep.

Authors

Collaborators

International Liaison Committee on Resuscitation Basic Life Support Task Force Members:
Anthony Lagina, Baljit Singh, Julie Considine, Sung Phil Chung, Vihara Dassanayake, Katie Dainty, Guillaume Debaty, Maya Dewan, Bridget Dicker, Fredrik Folke, George Lukas, Carolina Malta Hansen, Nicholas J Johnson, Rebecca Cash, Takanari Ikeyama, Siobhan Masterson, Ziad Nehme, Tatsuya Norii, Aloka Samantaray, Anastasia Spartinou, Christopher M Smith, Christian Vaillancourt
Advanced Life Support Task Force Members:
Markus Skrifvars, Katherine M Berg, Ari Moskowitz, Asger Granfeldt, Brian Grunau, Carolyn Zelop, Helen Pocock, Karen G Hirsch, Keith Couper, Mathias J Holmberg, Nikolaos Nikolaou, Shannon M Fernando, Shinichiro Ohshimo, Sonia D'Arrigo, Tommaso Scquizzato, Yew Woon Chia, Carrie Leong, Conor Crow, Neville Lok, Bernd Bottiger, Brian O'Neil, Jasmeet Soar, Michael Parr, Michelle Welsford, Peter Kudenchuk, Robert W Neumar, Tonia Nicholson, Jerry P Nolan, Eric J Lavonas, Claudio Sandroni
Pedriatic Life Support Task Force Members:
Kee-Chong Ng, Barnaby R Scholefield, Alexis Topjian, Jesus Lopez-Herce, Andrea Christoff, Ryan W Morgan, Arun Bansal, James M Gray, Hiroshi Kurosawa, Leandra Rech, Joseph Rossano, Lokesh Kumar Tiwari, Michelle Myburgh, Monica Kleinman, Ravi Thiagarajan, Stephan Katzenschlager, Tia T Raymond, Anne-Marie Guerguerian, Janice A Tijssen, Gabrielle Nuthall, Steve Schexnayder, Thomaz Bittencourt Couto, Vinay Nadkarni, Yong-Kwang Gene Ong Dianne Atkins, Allan de Caen

Affiliations

¹ Department of Pathophysiology and Transplantation, University of Milan, Italy.
² Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
³ Department of Anaesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy.
⁴ Department of Medicine, School of Medicine, European University Cyprus, Nicosia, Cyprus.
⁵ Agenzia Regionale Emergenza Urgenza - AREU, Milan, Italy.
⁶ University Hospital Southampton, UK.
⁷ Sunnybrook Research Institute and Department of Emergency Services, Sunnybrook Health Science Centre, Toronto, Ontario, Canada.
⁸ Department of Family and Community Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada.
⁹ First60, St. Michaels Hospital, Toronto, ON, Canada.
¹⁰ Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
¹¹ Ornge Critical Care Transport, Toronto, ON, Canada.
¹² Hospital Maternoinfantil Gregorio Marañón, Madrid, Spain.
¹³ Emergency Department, Queensland Children's Hospital, Brisbane, Australia.
¹⁴ Faculty of Medicine, University of Queensland, Australia.
¹⁵ Royal Melbourne Hospital Clinical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Victoria, Australia.
¹⁶ Warwick Medical School, University of Warwick, UK.
¹⁷ Department of Anaesthesia and Intensive Care Medicine, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway.
¹⁸ Monash School of Public Health and Preventive Medicine, Melbourne, Australia.
¹⁹ Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Australia.

PMID: 40741375
PMCID: PMC12309583
DOI: 10.1016/j.resplu.2025.101030

Abstract

Aim: To evaluate the impact of defibrillation pad size, orientation, and position on clinical outcomes in adult and paediatric cardiac arrest with a shockable rhythm through a systematic review of available evidence.

Methods: A systematic review was registered with PROSPERO (CRD42024512443). Searches were performed across PubMed, EMBASE, and the Cochrane Library up to March 31st, 2025. Studies involving adults or children with cardiac arrest and comparing pad sizes or positions were included. Risk of bias was assessed using the RoB 2.0 and ROBINS-I tools, and the certainty of evidence was evaluated using GRADE methodology.

Results: Of 7855 screened studies, four met inclusion criteria, e.g. 1 randomized clinical trial (RCT) and 3 observational studies in adults, covering 1334 adult cardiac arrest patients. Evidence on pad size, deriving from an observational study enrolling 314 patients, was sparse and inconclusive, with no significant differences in defibrillation success between large and small pads (OR 0.82[0.42-1.60]). For pad orientation, no evidence was found. For pad placement, one RCT including 280 patients suggested a potential survival benefit from vector-change defibrillation using anterior-posterior (AP) pad placement in refractory ventricular fibrillation (VF), compared to the standard anterior-lateral (AL) placement (adj. RR 1.71[1.01-2.88]). Data from two observational studies including 739 patients were conflicting and limited by high risk of bias.

Conclusion: Evidence remains inconclusive to support the superiority of any specific pad size, orientation or position for improving survival or neurological outcomes in cardiac arrest. However, vector-change to the AP position may offer benefit in cases of refractory VF. High-quality RCTs are needed to further inform clinical practice.

Keywords: Anterior-lateral; Anterior-posterior; Defibrillation; Outcome; Pads position; Vector.

PubMed Disclaimer

Conflict of interest statement

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: GR, PT, TMO, GDP, and JEB are Editorial Board Members of Resuscitation Plus. GDP is Editor in Chief of Resuscitation Plus. JEB is an Associate Editor of Resuscitation Plus. IRD was a co-investigator on the DOSE VF Trial. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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References

1. Soar J., Böttiger B.W., Carli P., et al. European resuscitation council guidelines 2021: adult advanced life support. Resuscitation. 2021;161:115–151. - PubMed
1. Koster R.W., Walker R.G., Chapman F.W. Recurrent ventricular fibrillation during advanced life support care of patients with prehospital cardiac arrest. Resuscitation. 2008;78:252–257. - PubMed
1. Berg K.M., Bray J.E., Ng K.C., et al. 2023 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations: summary from the basic life support; advanced life support; pediatric life support; neonatal life support; education, implementation, and teams; and first aid task forces. Resuscitation. 2024;195 - PubMed
1. Moulton C., Dreyer C., Dodds D., et al. Placement of electrodes for defibrillation - a review of the evidence. Eur J Emerg Med. 2000;7:135–143. - PubMed
1. Rea T.D., Kudenchuk P.J. The details matter for defibrillator pad placement and cardiac arrest resuscitation. JAMA Netw Open. 2024;7 - PubMed

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Pad size, orientation, and placement for defibrillation during basic life support: A systematic review

Collaborators

Affiliations

Pad size, orientation, and placement for defibrillation during basic life support: A systematic review

Authors

Collaborators

Affiliations

Abstract

Conflict of interest statement

Figures

References

Publication types

LinkOut - more resources

Full Text Sources

Miscellaneous