Recent discussions
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Ken Tegtmeyer
There's a least one other paper in pediatric telemedicine support for code response that compares to in person response: Pediatr Crit Care Med 2019 Feb;20(2):172-177.
doi: 10.1097/PCC.0000000000001796.
(I am an author on this paper, as well as co-author with Dr. Lauridsen on some papers)
IF the point is purely to discuss structure of the team, is there a reason that discussion specifically of staffing costs was not a specific topic of consideration, particularly with team size discussions and use of a “dedicated” team. It may be that there is zero literature on it as well.
I also think it's very important if you are discussing team size and structure to also include some discussion of qualifications, which are mentioned a little, but more specifically ongoing training of the team specifically. Not the requirement for periodic ALS training and certification, but whether the team needs or benefits from team specific training, whether via mock codes, or other simulation based training.
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Steven Andrews
You acknowledge your recommendation is weak but it is still a recommendation. I recommend wording “There currently is insufficienct evidence to suggest a preference of a Large Bag (1500-1700 mL) or Smaller Bag (1000 mL) for the ventilation of adults during cardiopulmonary resuscitation” . I think your initial wording is based on the Snyder study which you acknowledge has many weaknesses. The Snyder study broke down outcomes by years to try to understand if COVID had an effect. When they looked at that data they said there were still worse outcomes after there change in practice excluding COVID time period. When I look at that data, I see that in 2018 (first year after the change, compared to 2015 and 2016) the survival was the same as before the change and it was actually worse in 2019 and later (Surivival to discharge: 2015- 10%, 2016- 13%, 2018- 12%, 2019- 9%, 2020- 10%, 2021 -10%; from page 7 of Supplement Appendix 1). I also see they stopped using LUCAS devices at the same time as they adopted the smaller 1000 ml bags (they document their previous bags gave 1685 ml ventilation at max). This same data suggests you shouldn't stop using LUCAS devices.
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Gavin Perkins
A nice scoping review.
A couple of friendly amendments
- It would be useful to situate this work in the context of the ILCOR Scientific Statement - 10 Steps to Improving In-hospital Cardiac Arrest. There is synergy between this review and Step 6: Develop and Deploy an Effective Resuscitation Response System.
- The article citation lacks clarity as to whether this review focuses on all arrest teams or is limited to PLS / NLS teams. The review is described as involving EIT, PLS, NLS but it is listed as being posted as an ALS question. If recommendations are made for adults, the ALS TF should be involved.
Lindkvist-Viggers S, Carballo-Fazanes A, Riis DN, Cheng A, Hogeveen M, Kawakami MD, Myburgh M, Lauridsen KG on behalf of the International Liaison Committee on Resuscitation Task Forces on Neonatal Life Support, Pediatric Life Support, and Education, Implementation, and Teams.
Best Practices for In-hospital Cardiac Arrest Team Composition: A Scoping Review. [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 2025 December X Available from: http://ilcor.org
Declaration of interests - ILCOR Board, Grant applicant (on behalf of ILCOR) for 10 steps IHCA programme. ERC and RCUK Leadership roles.
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Brian Walsh
Making weak recommendations of VT of 400-600 mls or 6-10 ml/Kg IBW will lead to confusion as we have known for years that tidal volume if you are going to set or measure it should be individualized to ml/kg. Height estimators and even most identification (drivers license, etc.) have heights listed. Additionally, many new generation ventilators now require a height at startup configuration to allow for the setting and measuring of tidal volumes in ml/Kg.
Most current recommendations for tidal volumes are 6-8 ml/kg, so I find it interesting that 10 appears in your recommendations. For conciseness I would recommend you picking only tidal volume per kg IBW/PBW and forgo the use of the tidal volume range of 400-600 for those equipped to measure and/or set tidal volumes.
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Brian Walsh
Evidence evaluated by BVM total resuscitator volume is misleading. It is so much more the technique than the device. The stroke volume is more important than the resuscitator volume. All manufacturers provide this information for a reason. Often 1 and 2 hand stroke volumes are also presented. Below is an example of three commonly available adult BVM with 1 and 2 hand stroke volumes. Your recommendations eliminate 2 of the three.
Brand. Resuscitator Volume. 1 Hand 2 Hand
VT Select. 1200 ml 530 ml 690 ml. Could not be used.
Ambu 1547 ml. 600 ml. 1000 ml. Can be used.
Smart Bag. 1700 ml no info 900. Could not be used.
BVM have not changed in 60-70 years, yet tidal volumes have dramatically decreased. Manufacturers trying to move the ball to more lung protective and efficient ventilation while avoiding hyperventilation, have just been eliminated from trying to move the science forward. While 1 hand stroke volumes slightly higher than the required tidal volume of roughly 500 ml is helpful in a small leak scenario, mask resealing should be the first line of correction, not squeezing the bag harder. 2 hand technique in all BVM produce extremely high tidal volumes, yet your review is absent on those characteristic.
Respectfully, your recommendations should state a standard size adult BVM and not list a total volume of the resuscitator in the face of such little evidence and no evaluation of stoke volume per breath.
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Gavin Perkins
Thanks for summarising the evidence on terminology relating to individuals or teams attending patients in cardiac arrest. It is interesting to see how terminology has evolved over time.
The most recent (2024) Utstein statements represents ILCOR's consensus approved definitions for individuals / teams attending out of hospital cardiac arrest. These were developed through an iterative consensus process with global input. Given the 2024 updates were approved by ILCOR such a short time ago it seems premature to revisit before there has been an opportunity for them to bed in.
Consider shifting emphasis to exploring the barriers and facilitators that could enable effective implementation of the 2024 definitions beyond research and registries into educational frameworks and beyond. This could improve the current situation and provide evidence for the next updates to the ILCOR Utstein definitions.
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Janet Bray
Doesn't it make sense to use the same language in implementation, education, or legal frameworks as in research and registries? Otherwise, the current confusion will be perpetuated. The ILCOR OHCA Utstein definitions were discussed at length by the writing group and international consensus was reached. The writing group included clinicians (physicians, nurses, paramedics), researchers, registry experts and EMS leadership. These definitions are used by the BLS Task Force in treatment recommendations.
ILCOR OHCA Utstein definitions are:
A bystander* is someone on scene (includes off duty health care professionals)
A volunteer community responder is someone alerted to the scene with no duty to respond (ie via text message or Apps)
First responders are responders dispatched as part of the emergency response without the ability to transport the patient to hospital(eg, fire, police)
EMS are responders dispatched as part of the emergency responses with the ability to transport the patient to hospital
Dispatched responders are dispatched as part of the emergency responses (e.g. first responders and EMS)
*For the purpose of bystander CPR and AED use -bystander is someone on scene o
Implementation, education, and legal frameworks could add the level of training in front: untrained, BLS-trained, ALS-trained.
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Dorothy Igharo
i am in agreement with either case. Activation of EMS is the right way to go especially if unsure
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Dorothy Igharo
We deal with the public as BLS provider. My guess is that when a person comes in contact with this substance, there’s an urgent need to water flush, call for help and send to the emerge as the investigation itself indicates several victims end up in a facility such as hospital.