Consensus on Science with Treatment Recommendations (CoSTR)
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.
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.
Ken, I completely agree. The evidence is poor in relation to defibrillation being an AGP. Rapid muscular contraction from the immediate delivery of energy from defibrillation may produce little expiratory aerosol, however the ROSC will. The benefit of rapid and early defibrillation is to the patient with the risks the HCP's not fully accounted for. What are the benefits and risks associated with delayed defibrillation and appropriate PPE.
Defibrillation of shockable rhythm may produce ROSC in a timeframe not permitting the donning of PPE even if it is available. Defibrillation prior to donning of PPE would risk HCP's to an unnecessary risk.
Timely and important review. Many thanks to all the authors
In most developing countries we use manual hand held paddles instead of self adhesive pads .
Is this considered a AGP ? When we talk about defibrillation it is better to reflect on above as well.
Bringing both paddles to the chest and switching off oxygen before the shock needs 2 persons unless single rescuer switch off oxygen , select energy charge the paddles on the machine and then bring the paddles to the chest .
Thank you for this extensive review as well as for the responses. I am in agreement with some of the comments already made. I will mainly comment on BLS in the health care setting as that is where my area of expertise is.
As mentioned by some already, the evidence for the risk for AGP of defibrillation is unclear and the risk for transmission during CPR is not deemed high, I do agree with comments made by others that health care staff safety is most important. I think providing defibrillation prior to donning PPE should NOT be recommended. I think all health care staff should done PPE prior to attempt any part of the BLS (and ALS) algorithm for COVID positive/suspected patients. I am in strong favour of compression-only CPR until a definitive airway (LMA) has been established. ANd airway management should only be attempted by experienced operators. We all know that maintaining a good seal with bag mask ventilation can be very challenging during a cardiac arrest and the airway operator is the person closest to the 'fire line' of COVID droplets so we should not put more people at risk than required.
I would like ILCOR (and the national resuscitation councils following ILCOR guidelines) to be strong in their advice for recommendations for BLS/ALS during the COVID-pandemic. Recommendations that state that "providers can consider" might not provide enough guidance and can create more confusion. I would prefer strong recommendations. Individual health care organisations and first aid provides can still decide what they do with these recommendations. People are looking at experts to get advice - I think in times like these the panels of experts need to step up and provide strong guidance.
I completely agree with the above statement from Christian Vaillancourt- at our organisation most staff (outside of high risk areas ED,ICU, theatre or recovery) for covid positive patients for routine care- not aerosol generating will be wearing droplet precautions so we have put in place that the first responder can start compressions only CPR once Hudson mask applied to patient's face but this responder needs to replaced as soon as possible and if the second responder who would be wearing airborne precautions enters the room and defib can be attempted but with the first responder in droplet precautions is to stand at the foot of the bed- at least two meters away from the patient. Then they get swapped out at the earliest possible time with a responder in airborne precautions- once all staff in the room are in airborne precautions then we can attempt airway-ventilation with intubation/LMA bag vent with viral filter and lots of muscle relaxant etc. as per the ideal process- then recommence CPR once airway secured.
If staff are caring for a patient in a non-covid area and non-covid positive patient then they leave the room as soon as cardiac arrest is confirmed and don aerosol precautions PPE. It does increase delay to compressions but staff safety is imminent.
Happy for your thoughts on this.
Unfortunately, experience from Italy, NY, New Orleans, Copenhagen reveals that Covid-19 was found often in unsuspected cases. On CT-abd for patients admitted for appendicitis (lower lung cuts), on shoulder Xray of dislocated shoulder, and on autopsy...all unsuspected Covid+ cases. Once reaching a pandemic and significant community transmission, especially given the possible contagiousness starting 24-48hrs prior to any symptom, it is probably dangerous to play a guessing game when it come to who has and who doesn't have Covid. Agree many will fall victim of these precautions...but we cannot afford to lose any more healthcare workers.