Recent discussions
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Emily Oliver
Thank you for this rapid and important review. The British Red Cross is providing this response in the context of eventually using the recommendations to shape its own communications, clinically and educationally, to lay responders and first aid volunteers. The paper addresses questions asked on the assumption that cardiac arrest is already confirmed. It does not refer to earlier aspects of the BLS algorithm of safety, checking for response, opening the airway and checking breathing which we understand could present the greatest risk to the lay rescuer given the proximity to the patient's nose and mouth. These aspects also have COVID-19 related considerations. Whilst recognising that this was not the focus of the paper, acknowledgement of considerations regarding infection risk at the assessment stage of the process from the lay rescuer perspective would be helpful, particularly with regard to moving the patient to their back, exposing their chest etc. It is also important to note that considerations regarding both touching the patient and use of PPE are necessarily different for lay responders living with the patient requiring CPR (and therefore already exposed to coronavirus if it is present amongst inhabitants), versus professional responders, particularly regarding the skill set involved in recognising the need for CPR and having adequate PPE available. The writing group has done a laudable job in acknowledging the circumstances of likely need for lay responder CPR (i.e. in the home, with members of a household who are necessarily occupying the same space already during this pandemic). However, it would be helpful if advice which is more specific for lay versus professional responders could be explicit. Messaging which implies a similar level of danger to both lay responders living with the patient and incoming professional responders could be misconstrued. Re-enforcement of the role that compression-only CPR can play in reducing infection risk during adult CPR to the lay responder is helpful. Acknowledgement that retention of ventilations for child CPR appears justified based on the stated consideration of the writing group -
Daniel Jost
I can contribute by bringing our experience as professional first responders (firefighters) to our homes. When they arrive at the bedside of an unconscious patient, to validate the absence of ventilation and, therefore the cardiac arrest, they use of the "Hands-on belly" method (Derkenne et al. 2020) that we use systematically since several years for OHCA detections by telephone by lay rescuers. The Firefighters put their hands on the chest or stomach to detect any movement. If this movement (eventually gasp) is more than 7 seconds apart, they start chest compressions and put the defibrillator on. They do not need to approach the victim's face to recognize the cardiac arrest formally. -
Andy Davies Resuscitation Coordinator
New , current New Zealand guidelines are as follows If you have access to personal protective equipment (PPE) (e.g. appropriate face mask, disposable gloves, eye protection), these should be worn. Lay a piece of clothing or a towel over the person’s mouth. The cloth is not PPE but may prevent some droplets/cough spray. Check for Response Check to see if the person is responding. Call for Help Call for an Ambulance. Advise operators if the person is in isolation because of possible COVID- 19. Remember, the Ambulance personnel responding will be wearing PPE. Recognise Cardiac Arrest Open the person’s airway with a head tilt, chin lift. Look for the absence of normal breathing. Do not listen or feel for breathing by placing your face next to theirs. If in doubt, commence compressions. Commence Chest Compressions Push in the centre of the chest, hard and fast Adults and Children Mouth-to-Mouth In many cases the person in cardiac arrest is a loved one or known to you. In that situation you may be willing to do mouth-to-mouth. This gives the best chance of survival, particularly for children. Without treatment, people in cardiac arrest will die. Defibrillators Get a defibrillator as quickly as possible. Follow the instructions to defibrillate shockable rhythms rapidly. The early restoration of circulation may prevent the need for airway and ventilatory support. We know that MOST people who have COVID , under the age of 60, don't die, but everyone in cardiac arrest- without intervention, does. The risk of contracting COVID from a CA victim without symptoms would be low, and the risk of a rescuer under 60 dying, also low. We should try to avoid mixing layperson CPR with guidelines for Health professionals. There needs to be 3 clear parthways 1- Chart for CPR on the street (Non-symptomatic ) 2- COVID 19 +ve or suspected at home. 3-COVID 19 +ve or suspected in hospital . Most COVID19 deaths we assume are PEA and end of life events . -
Justin Morgenstern
I made a previous comment after completely misreading the recommendations being made here. I think the key point in my comment that we need to be asking whether there is evidence that it is safe to do procedures, rather than asking whether there is evidence that such procedures are clearly dangerous, is correct. However, the criticism of the guideline was entirely unfounded and based entirely on my misinterpretation. I apologize for any confusion. I think this is tremendous work and appreciate everything your group does trying to make this complex literature usable for all of us. (I don't see the comment yet, so maybe it never even made it through, and I will be saved the embarrassment.) -
Timothy Ellender
Our simulation team did a small study with residents 6 months prior to COVID where we looked at resident exposure risk in multi-task procedures. We use fluorescent tracer and looked at room/personnel spread. Wow! Spread was reduced by 1/2 when we used a simple cotton cover sheet-separating patient and personnel. -
Justin Morgenstern
I think the conclusion around CPR and transmission made here is entirely inappropriate based on the data. You cite 2 studies that were not statistically significant, but one of those studies had a total of 3 people who gave CPR. (Loeb2004) That is clearly not enough to conclude the practice is safe. The problem is that you have framed the question wrong. The question should not and cannot be "is there evidence that CPR increases transmission?" The question needs to be, "Is there evidence that CPR can be done safely without full airborne precautions?" In other words, if you were designed this as a trial right now, you must be designing it as a non-inferiority trial. Common sense tells us that CPR is incredibly high risk. Basic science tells us it is incredibly high risk. The number of healthcare workers who have become ill (with SARS and COVID19) tells us that it is high risk. We would need strong proof to move away from that position. When you combine the data from the 3 available studies, the point estimate for for the odds ratio is on the side of CPR being dangerous (OR 2.3) and the 95% confidence interval goes all the way to an odds ratio of 22. You absolutely cannot use that data to make the statement that CPR is safe. It is not accurate, and will lead to significant harm in the healthcare community. -
Johannes Heymer
We conducted a study on aerosol spread during cpr. A preprint short report can be found here: https://zenodo.org/record/3739498 Recent research revealed, that a supraglottic airway is at least non inferior to other methods of airway management and ventilation in the context of cardiac arrest. We conclude that, especially in the prehospital environment and in the context of limited PPE, the immediate insertion of a laryngeal tube with an airway filter may reduce aerosol spread during chest compressions. -
Johannes Heymer
We conducted a study on aerosol spread during cpr. A preprint short report can be found here: https://zenodo.org/record/3739498 Recent research revealed, that a supraglottic airway is at least non inferior to other methods of airway management and ventilation in the context of cardiac arrest. We conclude that, especially in the prehospital environment and in the context of limited PPE, the immediate insertion of a laryngeal tube with an airway filter may reduce aerosol spread during chest compressions. -
Paul Snobelen
Such an important and relevant review considering the times we are in. Thank you to all involved on the timeliness of this work. A couple of comments: 1) I would also note that dispatcher provided CPR should remove instruction to “ventilate” or provide “rescue breaths” if that is part of their current instruction. Also advise that dispatch directed CPR modifing breathing assessment from “place your ear close to the patient’s mouth” to “Can you see the chest moving up and down” 2) In the absence of having a cloth or towel to place over the mouth and nose of someone suffering an OHCA for lay rescuers, could it also be recommended that the lay rescuer turn the patients head to the side to allow any froth, blood or fluids to drain. Our work with lay rescuers has shown that fluids can cause a distraction for lay rescuers as they will physically roll a person to clear the mouth. Turning the head will help minimize the potential movement and promote uninterrupted compressions. However, I support the notion of a cloth being placed over the mouth and nose as this will hide some of the visuals associated with agonal breathing. A potential problem is if they hear audible noises as a result of agonal breathing and experience has shown a lay rescuer will most likely remove the cloth and discontinue compressions. We will watch for this our OHCA’s. Our work has shown that the distraction of agonal breathing interrupting compressions was only present in a quarter of the cases we followed-up with. So in addition to the cloth as a barrier, an alternative I would suggest would be to turn the patients head to the side. I do not foresee a cognitive barrier or concern from a lay rescuer’s perspective discontinuing ventilations and switching to compression only CPR. Compression only CPR is very common now. -
James Fenwick
Could we not just ask resuscitation professionals who has, during resuscitation experienced splashing from the patients mouth / airway while performing chest compressions, especially with so much emphasis on compressions we are often starting when the patient is not breathing normally, so encounter agonal breaths against our compressions. I know several people I have spoken with have experienced it. Is that an aerosol? For me, it is.