Recent discussions
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Janet Bray
Thank you for your comment. There is another PICOST that addresses checking for circulation during CPR. Janet Bray (BLS Chair)
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Remi Garceau
Good day,
I was wondering if you have any clinical data that would indicate if the resuscitation that occured, if the providers was trained with QCPR feed back or not. We are telling groups like the Heart and stroke foundation that this should be impleted and yet, they are imposing it in the instructor guidelines.
Would it not be more concluent to have the QCPR feedback mandatory on all health care provider AED or manual AED? This would have a direct impact not on a dummy, but on a real person.
A provider is trained once per year with a QCPR, but all resuscitation could be done with a QCPR device and improve the quality on a real life person.
Thanks
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Anwar Adil Mithwani
Video laryngoscopy provides an enhanced and magnified view of vocal cards on a screen which is particularly helpful in difficult intubation.This method shows intubation process in real time and guide the tranee.process may take longer due to need to focus and manipulate the blade, superior in visualizing the airway anomalies (craniofacial abnormalties)
Lower rates of mucosal trauma.
Less effective in emergency situation
Traditional Laryngoscopy requires direct line of sight which can be challenging sometimes in Neonates.,success rates depends upon training and needs more experiences. process is quicker for experienced.In less experienced person high risk of trauma.
Often preferred in emergency to save life.
In conclusion : Choice between VL & TL for neonatal intubation depends upon provider"s expertise ,avaiable resources and clinical scenario. video laryngoscopy is good for teaching,training and managing difficult airways.
TL remains indispensable in low source settings and emergencies .
An integrated approach using VL as a training adjunct and TL as a fallback, might provide the best outcomes in neonatal airway management.
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Sheldon Cheskes
The use of a Good Practice Statement (GPS) to recommend anterior-lateral pads as a starting pad position for CPR providers trained in manual defibrillation seems inappropriate given the lack of new evidence supporting this pad position compared to an anterior-posterior pad position. In general “Panels should consider making good practice statements when they have high confidence that indirect evidence undoubtedly supports net benefit and when, in addition, it would be an onerous and unproductive exercise and thus a poor use of the panel’s limited resources to collect this evidence”1. In the case of anterior-lateral vs anterior-posterior initial pad position for defibrillation, I do not believe such indirect evidence exists. The statement specifically, notes a preference for the anterior-lateral position on the assumption of optimizing placement speed while minimizing interruptions to chest compressions. Regarding the assumption of optimizing placement speed one only looks at the recent trials assessing the impact of IO or IV in OHCA where the assumption was that IO would be faster than IV vascular access.2,3 The trials both demonstrate that such assumptions are often erroneous when placed under the scrutiny of a randomized controlled trial. As well, in defibrillation one must balance speed vs defibrillation efficacy which is directly related to current applied to the myocardium. While the study from Lupton et al. is observational in nature, it does raise the possibility of increase shock efficacy for pads place in an initial anterior-posterior position for patients in ventricular fibrillation/pulseless ventricular tachyardia.4 Regarding the assumption of minimizing interruptions in chest compressions, it was noted in the DOSE VF RCT that regardless of whether the patient received standard, vector change or double sequential external defibrillation, there was no difference in CPR quality, all of which were guideline compliant regardless of randomization arm.5 Given these uncertainties it seems inappropriate to make a GPS supporting one pad position over another for initial pad placement when the required indirect evidence does not exist. Given no new evidence exists, a recommendation supporting either pad position similar to the ILCOR statement of 2021 seems more appropriate (It is reasonable to place pads on the exposed chest in an anterior-lateral position. An acceptable alternative position is anterior-posterior).6
References above available upon request
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Jana Djakow
The CoSTR report raises critical concerns about the shift from the ABC sequence to CAB in pediatric resuscitation. While it questions the significance of delays in ventilations, it does not apply the same scrutiny to delays in chest compressions. This inconsistency is particularly concerning given the lack of pediatric-specific data to justify prioritizing compressions over ventilations.
Goh et al., suggested that delayed chest compressions can have serious consequences. However, this study excluded children and relied on "time of arrest," a variable prone to errors. Additionally, their data showed no significant difference in survival outcomes within one minute of delay, raising doubts about the robustness of their conclusions.
CO-CPR vs. RB-CPR: Risks for Pediatric Patients
A major concern is the potential rise in compression-only CPR (CO-CPR) rates at the expense of rescue breaths (RB-CPR). Naim et al. (2021) reported an increase in CO-CPR rates in the U.S. following the adoption of CAB, without a corresponding rise in bystander CPR rates. This trend is troubling for infants, the largest group of pediatric cardiac arrests, where CO-CPR offers no significant advantage over no CPR. This raises doubts about whether CAB truly benefits pediatric patients or risks reducing survival rates.
Importance of Initial VentilationsHolgersen et al. (2022) analyzed outcomes in Denmark, where ABC remains the standard. They reported a 30-day survival rate of 40% for pediatric out-of-hospital cardiac arrests (OHCA). While neurological outcomes were not detailed, Denmark’s consistent use of the ABC sequence, supported by comprehensive training, suggests that ABC is not inferior to CAB and highlights the importance of system-level education rather than sequence change.
The shift to CAB in peds BLS lacks evidence showing differences in critical or important outcomes in real patients as defined in P-COSCA. The potential risks, including increased CO-CPR rates and reduced survival in infants, argue for caution. Studies like those by Skrisovska et al. and Holgersen et al. emphasize the value of initial ventilations and the benefits of system-wide training.
The ILCOR should focus on evidence-based, patient-centered outcomes when revising guidelines. In the absence of pediatric-specific data demonstrating CAB's superiority, overhauling an entire function system of education, clinical practices, and lay rescuer protocols—may compromise safety and effectiveness in achieving good outcomes. -
Diminique Biarent
The CoSTR report raises critical concerns about the shift from the ABC sequence to CAB in pediatric resuscitation. While it questions the significance of delays in ventilations, it does not apply the same scrutiny to delays in chest compressions. This inconsistency is particularly concerning given the lack of pediatric-specific data to justify prioritizing compressions over ventilations.
Goh suggested that delayed CC can have serious consequences. However, this study excluded children and relied on "time of arrest," a variable prone to estimation errors. Additionally, their data show no significant difference in survival outcomes within one minute of delay, raising doubts about the robustness of their conclusions.
A major concern is the potential rise in compression only (CO) CPR rates at the expense of rescue breaths (RB)CPR. Naim (2021) reported an increase in CO-CPR rates following the adoption of CAB, without a rise in bystander CPR rates. This trend is troubling for infants, the largest group of pediatric CA where CO-CPR offers no significant advantage over no CPR. This raises doubts about whether CAB truly benefits pediatric patients or risks reducing survival rates
Holgersen et al. (2022) analyzed outcomes in Denmark, where ABC remains the standard. They reported a 30-day survival rate of 40% for pediatric out-of-hospital cardiac arrests (OHCA). While neurological outcomes were not detailed, Denmark’s consistent use of the ABC sequence, supported by comprehensive training, suggests that ABC is not inferior to CAB and highlights the importance of system-level education rather than sequence changes.
The shift to CAB in pediatric resuscitation lacks robust evidence, particularly in children. The potential risks, including increased CO-CPR rates and reduced survival in infants, argue for caution. Studies like those by Skrisovska et al. and Holgersen et al. emphasize the value of initial ventilations and the benefits of system-wide training.
The ERC should focus on evidence-based, patient-centered outcomes when revising guidelines. In the absence of pediatric-specific data demonstrating CAB's superiority, overhauling an entire system—including education, clinical practices, and lay rescuer protocols—may compromise safety and effectiveness in achieving favorable outcomes in pediatric resuscitation.
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Cibele Lebrao
The use of the video laryngoscopy device will be useful in assisting premature babies and difficult airways. However, this is not the current practice in most services.
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Silvia Heloisa Moscatel Loffredo
I agree with the proposed recommendation and consider it a promising practice for reducing the neonate’s exposure to adverse events associated with traditional laryngoscopy intubation. It will also be beneficial for training in endotracheal intubation.
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Jesus López-Herce
The initiation sequence of basic CPR is a controversial topic with important implications for CPR training. There is no solid scientific evidence but making a recommendation can have a great relevance for CPR training.
As the authors of this systematic review acknowledge, no studies in humans have been identified, and no new study has been found that provides significant evidence to make a recommendation on what is the best sequence for starting CPR. Only 5 studies with simulation with mannequins have been found in which, the overall certainty of evidence was rated as very low for all outcomes, downgraded for a very serious risk of bias and indirectness.
The results indicate, as is logical, that with the CAB sequence that begins with chest compressions, the start of chest compressions is done earlier than with the ABC sequence. On the contrary, with the ABC sequence ventilation starts earlier than with the CAB sequence. These results are common sense and no scientific studies are needed to deduce them. Regarding the other results there were differences between the studies.
These results do not at all support the recommendation made “In adults and children in cardiac arrest, we suggest commencing CPR with compressions rather than ventilations. This is a personal opinion of the researchers, very respectable, but not based of the results.
In our opinion, starting CPR with the CAB or ABC sequence probably does not make any relevant clinical difference because both sequences only differ in starting one manoeuvre or the other a few seconds earlier, the rest of the resuscitation being the same.
The 2020 pediatric recommendations concluded that there was insufficient evidence to make a recommendation. Resuscitation. 2020 Nov;156:A120-A155.
Furthermore, and most importantly, although the current recommendation is only a suggestion with a very low level of evidence, it can have an important impact on teaching since it can be interpreted by teaching groups as an obligation to change their recommendations, which involves an enormous teaching effort without any clinical benefit.
For these reasons, we consider that the recommendation on this subject should be “There is currently insufficient scientific evidence to recommend an initial sequence of CAB or ABC CPR in adults or children”.
Ignacio Manrique and Jesús López-Herce
Representing the Spanish Group of Pediatric and Neonatal CPR
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David Dillon
Fantastic summary of the current data and well supported recommendations for ongoing clinical practice. My only minor comment is that the name author name for the reference Dillon 2024 is misspelled as Dhillon 2024 throughout the document.