Recent discussions
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Rob Martin
Interesting, will look into this more
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Richard Reynolds
Unlocked cabinets could very result in an AED not be available at all if it’s been stolen or vandalised. lock cabinets already get vandalised and if they can get free access to the AED it’s going to be take.
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Dr. Russell MacDonald
I agree with the proposed treatment recommendations. I reviewed the literature on this topic earlier this year and found no credible evidence of efficacy, effectiveness, or safety. What is published is retrospective, with limitations and biases. What was disturbing is that the National Association of Fire Chiefs were proposing advocating for this maneuver, and there was significant resistance from the EMS community because of scant evidence. To have ILCOR now make a clear, evidence-based statement that there is no role for this (apart from a study protocol) is exactly what is needed to resolve the issue.
Dr. Russell D. MacDonald
Medical Director, Toronto Paramedic Services
Medical Director, Toronto Central Ambulance Communication Centre
Professor, Faculty of Medicine, University of Toronto
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Dr Sreenivasarao Surisetty
The purpose of doing CPR is to maintain cerebral perfusion along with other vital organs. I don't think the technique varies with obesity. Yes, I too agree it's a little bit difficult to do effective chest compressions, but the rescuer has to do that to save a life. Along with chest compressions maintaining the airway also be difficult, but no other way for us, we have to follow the routine guidelines.
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Markus Skrifvars
Markus Skrifvars for the ALS Task Force
In the conducted randomized controlled trials on out-of-hospital cardiac arrest (OHCA) patients where different mean arterial pressures have been targeted, the majority of patients have required a vasopressor to achieve the required pressure (1-4). Therefore, it is unlikely that spontaneous hypertension would have been common during the first 72 hours. However, it needs to be noted that most trials thus far have focused on patients with a cardiac cause of the arrest and the patient have received targeted temperature management and sedation (which may decrease blood pressure). There are some observational studies examining the association between a high blood pressure (spontaneous or induced) and outcome (5,6). In these studies, it appears that hypertension is more common than in the aforementioned randomized trials. In observational trials the blood pressure is commonly collected as a part of a severity of illness score i.e. APACHE/SAPS and is thus the most abnormal (lowest and highest) value over the first 24 hours in the intensive care unit (ICU) (5,6). In general, a high blood pressure (MAP > 104 mmHg, SAP > 156 mmHg) appears associated with worse outcome but the opposite has also been shown (7). There are no RCT examining treatment of hypertension after OHCA. In patients with other types of brain injury the threshold for treating hypertension varies based on the etiology (8). In patients with a haemorrhagic stroke a systolic blood pressure of 140 mmHg is targeted. In patients with ischaemic stroke treatment is not recommended unless the blood pressure is extremely high (>220/120 mmHg) with the exception of those patients who undergo thrombolytic where the target is a blood pressure less than 185/110 mmHg (8). In general ICU patients the general threshold for treatment has been proposed to be 180 mmHg (9). In conclusion, there is insufficient evidence to recommend a specific upper threshold for blood pressure treatment in OHCA patients. Based on indirect evidence one proposed threshold where treatment is considered could be 180 mmHg.
- Niemelä et al. Resuscitation 189: 109862
- Kjaergaard et al. N Engl J Med 387: 1456-1466
- Ameloot et. Eur Heart J 40: 1804-1814
- Jakkula et al. Intensive Care Med 44: 2091-2101
- Huang et al. Resuscitation. 120:146–52.
- McGuigan et al. Crit Care. 27(1):4.
- Bro-Jeppesen et al. Crit Care Med. 43(2):318–27.
- Guo et al. Am J Hypertens. 35(6):483-499.
- Salgado et al. Ann Intensive Care 3(1): 17.
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Jacob Jentzer
While I would expect that there is limited evidence to support such a recommendation, it would be important to establish whether a blood pressure “ceiling” exists, i.e. a MAP above which worse outcomes occur that could justify blood pressure lowering therapy.
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Joyce Yeung
Thank you for your comment.
There was insufficient evidence from the studies included in our review for our taskforce to make a recommendation on triage policies or transfer protocols.
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Joyce Yeung
Thank you for your comment. We look forward to your publication and including evidence from your work in future evidence synthesis. There was insufficient evidence for our taskforce to make specific recommendations about different geographical areas.
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Krisa Van Meurs
We recommend that cooling should be considered, initiated, and conducted under clearly defined protocols similar to the randomized controlled trials (RCTs) previously conducted in high-income countries. Furthermore, we believe a cord or baby blood gas and a neurologic exam demonstrating moderate to severe encephalopathy are essential entry criteria for cooling. Careful consideration of the differential diagnoses of neonatal encephalopathy is important.
In addition to the treatment recommendations listed we suggest the use of amplitude integrated EEG (aEEG) or continuous video EEG (vEEG) throughout the cooling and rewarming periods in order to improve the accuracy of seizure diagnosis. Misdiagnosis of seizures can lead either to overtreatment or inadequate treatment of seizures. With overtreatment, potential brain injury secondary to the use of antiepileptic drugs may occur, and with inadequate treatment, brain injury can be associated with increased seizure burden.
We emphasize the use of brain monitoring may be particularly crucial in LMICs, where there is a heightened incidence of seizures. A recent study published by Variane et. al. (1), describes a cohort of 872 infants with HIE monitored with video aEEG/EEG, demonstrating the feasibility of applying such monitoring in a LMIC.
- Variane, G. F. T., Dahlen, A., Pietrobom, R. F., et al. Remote monitoring for seizures during therapeutic hypothermia in neonates with hypoxic-ischemic encephalopathy. JAMA Network Open, 6(11), e2343429-e2343429.
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Jeremias Bordon
Excellent topic!... continuous monitoring of the temperature of the newborn in the delivery room is essential... I think it is a huge gap even today to give the importance it deserves to thermoregulation and its impact on neonatal outcomes. One of the main difficulties, especially in low-resource centers, is precisely the lack of equipment that allows continuous temperature monitoring, which could increase the cases of admissions of newborns with hyperthermia in those where rapid rewarming is performed. It is very important to cover thermoregulation and hypothermia prevention measures in order to improve neonatal outcomes.