In a 14‑year‑old female with diphenhydramine overdose presenting anticholinergic toxicity, is it justified to remove her clothing to place automated external defibrillator (AED) pads, exposing her breasts, given the risk of sudden cardiac arrest?

Yes, removing clothing to expose the chest for AED pad placement is absolutely justified in life-threatening situations, including in a 14-year-old female with diphenhydramine overdose at risk for sudden cardiac arrest.

AED pads must be placed directly on bare skin for effective defibrillation, and this requirement takes precedence over privacy concerns when cardiac arrest is imminent or has occurred. 1

Critical Technical Requirements

The 2025 AHA Guidelines explicitly state that defibrillation requires direct contact with the skin to ensure proper electrical conduction to the myocardium 1. Pregelled pads improve this conduction, but they must contact bare skin—clothing or undergarments between the pad and skin can:

• Block energy delivery to the heart
• Cause inadequate pad adhesion
• Result in failed defibrillation attempts
• Delay life-saving treatment

The Bra Question: Recent Evidence Update

The 2025 ILCOR guidelines provide nuanced guidance on this specific issue 2:

• There is insufficient evidence to mandate routine bra removal
• It may be possible to place pads correctly by adjusting the bra's position rather than completely removing it
• One animal study showed 100% first-shock success even with pads placed over metal underwire bras, with no arcing or burns 1

However, the critical caveat is this: pads must be placed on bare skin in the correct position. If the bra prevents proper pad placement, it must be removed without hesitation 2.

Specific Context: Diphenhydramine Overdose

In your 14-year-old patient with diphenhydramine overdose, the risk of sudden cardiac arrest is very real and documented:

• Diphenhydramine causes sodium channel blockade leading to QRS prolongation and ventricular dysrhythmias 3, 4
• Multiple case reports document cardiac arrest from diphenhydramine overdose, including in adolescents 5, 6, 4
• Torsade de pointes and ventricular fibrillation can occur suddenly, even hours after initial stability 5, 4
• One case report describes a patient who developed torsade de pointes 2 hours after arrival with initially stable vital signs 4

Practical Algorithm for This Situation

1. Prepare for cardiac arrest by having the AED immediately available at bedside
2. Expose the chest by removing the patient's top and bra if necessary
3. Attempt to preserve dignity by:
   • Using sheets/blankets to cover areas not needed for monitoring
   • Limiting personnel in the room to essential staff only
   • Explaining actions to the patient if conscious
4. Place pads in correct position (anterolateral or anteroposterior) directly on bare skin 1, 7
5. If using anterolateral placement, the lateral pad goes in the midaxilla, which requires moving breast tissue aside 1, 7

Common Pitfalls to Avoid

• Do not delay defibrillation to preserve modesty—every minute without defibrillation decreases survival by 7-10% in VF/pVT
• Do not place pads over clothing or bras if it compromises skin contact or correct positioning
• Do not place lateral pads too anteriorly—they must be in the midaxilla 1
• Do not assume stability means safety in diphenhydramine overdose—delayed cardiac events are well-documented 5, 4

Legal and Ethical Justification

The life-threatening nature of the condition provides clear justification:

• Diphenhydramine overdose carries documented risk of fatal dysrhythmias 5, 6, 3, 4, 8
• Early defibrillation is the single most important determinant of survival in VF/pVT 1
• The principle of beneficence (preventing death) outweighs privacy concerns in emergency situations
• Standard of care requires proper AED pad placement, which necessitates bare skin contact 1, 2

Age-Specific Considerations

While the patient is a minor, this does not change the medical necessity. If time permits and parents are present, briefly inform them of the need for chest exposure for monitoring and potential defibrillation. However, do not delay life-saving interventions to obtain consent in an emergency.

The 2025 guidelines acknowledge that the need to expose the chest may contribute to lower rates of public defibrillation in females 1, but they do not suggest compromising proper pad placement. Instead, they call for better training and public education to overcome this barrier 2.

In summary: Remove all clothing necessary to place AED pads correctly on bare skin. The patient's survival depends on it, and the anticholinergic toxicity from diphenhydramine creates genuine risk of sudden lethal dysrhythmias that require immediate defibrillation capability.