Recent discussions

  • Racire Silva

    I believe that the self-inflating balloon, despite being inferior to the use of the manual T-shaped fan, still remains an alternative in places where it is impossible to use it. With a low cost, we can provide quality care to newborns in the delivery room.
    In following article:
    Devices for administering Positive Pressure Ventilation (PPV) at birth: (NLS#870) Systematic Review
  • Karl Kern

    The PEARL study (Kern 2020) was not stopped for futility by the DSMB nor the PI, but was simply under-enrolled and seriously under-powered. I believe this is quite different than a formal DSMB decision to halt the trial for futility.
    In following article:
    Early Coronary Angiography Post-ROSC: ALS CoSTR Systematic Review
  • Eveline Castro

    The T-piece resuscitator improve the quality of care of premature newborn with more advantages than the self-inflating bag use. The use de CPAP in delivery room in distress syndrome leads to decrease in neonatal intubation.
    In following article:
    Devices for administering Positive Pressure Ventilation (PPV) at birth: (NLS#870) Systematic Review
  • Leila Cuttle

    • Absolutely agree that more burn first aid treatment research is required. There are some barriers related to future research which perhaps this consensus statement could provide comment on: 1) It is difficult to assess the patient outcomes related to first aid treatment, if first aid use and duration is not recorded in the patient’s pre-hospital or hospital notes. Australia has been the first region to adopt the mandatory collection of this data, but other regions could also add this variable to their datasets for future research 2) the retrospective collection of first aid duration information from a typically traumatic situation lends itself to inaccuracies. With animal studies, the duration is accurate, but animal studies are low quality evidence. Human RCTs have been difficult to perform in this area. 3) temperature monitoring of the thermo-compromised burn patient is still very low (<25%) in the pre-hospital and hospital setting. As core body temperature is related to mortality and poor outcomes, this variable could also be added to future datasets for all burn patients. This was the main conclusion from the Fein et al 2014 paper where there was no relationship found between hypothermia (<36C) and first aid duration. • There are other studies which could be included in this systematic review: Harish 2019, Harish 2019, Riedlinger 2015, Nguyen 2002, Skinner and Peat 2002, Tung 2006. The earlier papers/datasets are unlikely to have durations recorded, but the datasets might still contain value. • Rather than TBSA and depth (characteristics of the initial burn) being designated as primary outcome measures, patient outcomes such as length of stay, grafting requirements, or days to re-epithelialisation might be more appropriate. These patient outcomes would need to be adjusted for TBSA, depth and potentially mechanism of burn, to discern the impact of first aid treatment, as depth/TBSA/mechanism are known contributors. • Inconsistencies in the first aid recommendations by various bodies internationally are probably contributing to the public’s poor knowledge or uptake of bystander first aid. Uncertainty regarding the duration of first aid may also make it difficult for paramedics to justify staying on the scene to deliver first aid before transport. Currently, Australia & New Zealand, UK, and European guidelines all recommend 20 minutes duration, whereas other organisations state 5 or 10 minutes is sufficient. Harmonisation of these guidelines would assist with ensuring first aid is delivered every time and every burn patient can benefit from first aid treatment.
    In following article:
    Duration of cooling with water for thermal burns as a first aid intervention: FA 770 Systematic Review
  • Keith Lurie

    The current proposed head-up CPR recommendations are: Treatment Recommendations We suggest against the routine use of head-up CPR during CPR (weak recommendation, very-low-certainty evidence). We suggest that the usefulness of head-up CPR during CPR be assessed in clinical trials or research initiatives (weak recommendation, very-low-certainty evidence). As one of the individuals involved with the discovery of head-up CPR, I am writing to respectively request that the ILCOR substantially modify the discussion and conclusions on this topic. A little history and commentary will hopefully provide some context for this request. When we first described the physiological benefits of head-up CPR in pig studies in 2015 we knew that elevation of the head and thorax would only be helpful if used in conjunction with CPR adjuncts, already shown and known to increase blood flow compared with conventional closed chest CPR. As such, a ‘bundle of care’ is needed for head-up CPR since blood needs to be pumped ‘up hill’. Conventional CPR just does not provide enough flow for this and, as a consequence, head-up CPR using conventional CPR is not of benefit and can be harmful. We described this imperative for the bundle more fully in an important letter to the editor in Resuscitation by Moore et al that should be referenced. (Moore J, Segal N, Debaty G, Lurie K. “The Do’s and Don’ts” of Head Up CPR: Lessons learned from the Animal Laboratory [Letter to the editor]. Resuscitation. 2018; 2018(129):e6-e7. doi.org/10.1016/j.resuscitation.2018.05.023.) The pig studies on head-up CPR are compelling and all are positive as long as certain now-known methods are followed. (Please note a complete reference list can be found at the end of this commentary – the references listed in the current proposed systematic review are incomplete). More specifically we have learn from pigs studies that one cannot elevate the head too fast or too high, one needs to use an impedance threshold device (ITD) for circulatory augmentation, and priming is needed to circulate blood before elevating the head and the heart. In more recent years we learned that a slow elevation sequence, elevating the head from about 10 cm in height to 24 cm in height and the heart from about 7 cm to 9 cm over 2 minutes, provides a significant increase in brain blood flow versus the flat position, when using either a LUCAS device or an automated active compression decompression (ACD) CPR. We also know the feet should not be lower than the abdomen or blood will eventually run downhill and that can be dangerous. These findings have been well-documented in pig studies from two different groups of investigators. The increase in blood flow to the heart and brain, the reduction in ICP, and the increase in neurologically-intact survival rates are striking when head-up CPR is performed correctly. For the first time this new approach helps drain venous blood from the brain, an inherent limitation of conventional flat CPR. The back up of venous blood in the brain during conventional CPR in the flat position and the constant bombarding of the brain with high venous pressures with each compression, reported in humans by Paridis et al in 1990 in humans, (JAMA 1990 Feb 23;263(8):1106-13) is a likely contributory factor to poor outcomes with conventional CPR. Head-up CPR attenuates these untoward effects of any method of CPR in the flat position. There are very limited published human data with this new approach. This fact is key to my request. Without peer-review human data it is premature to weigh in positively or negatively about head-up CPR. The proposed recommendations are negative in tone and will dissuade the use of head-up CPR for a long time. It would be far better for patients and progress in this CPR space for ILCOR to say something like: 'At the present time there are multiple positive animal studies but limited clinical data on a new approach to CPR called 'head up CPR'. Given the lack of clinical data, we cannot make any recommendations at this time regarding use of head-up CPR in patients in cardiac arrest. Further clinical data are needed." Importantly, the only published clinical article by Pepe et al used a jerry-rigged system to tilt the whole body upwards using a pelican case to prop up the head of the stretcher. While conceptually of value, it was not a study of head-up CPR by itself at all. The method was not standardized, there are no long-term endpoints, and multiple new interventions were introduced and performed simultaneously, including whole body head up tilt, preventing us from knowing which intervention resulted in more patients alive to hospital admission. Dr. Joanna Moore and others, including me, have started a Head-Up CPR Registry. She presented our first data at the AHA late-breaking session this past November and at NAEMSP this January. Time to start of a head-up CPR bundle of care is a critical determinant of outcome. We are learning how to best perform head-up CPR in patients. Similar to time to defibrillation, without rapid implementation of a head-up bundle, survival rates are similar to historical controls. A peer-reviewed manuscript is under preparation and should be submitted in 4-6 weeks. That will be the first published data on head-up CPR in patients where the only new intervention is device-assisted controlled sequential elevation of the head and thorax. The results are positive but still we still have a lot to learn. Rather than a treatment recommendation against the use of head-up CPR, based on little to no clinical data, it would be fairer and better for potential progress in this field to state what we know from pigs, which is very positive, emphasis the do’s and don’ts based upon lessons learned, and highlight the lack of published clinical studies and the need for such human data before ILCOR weighs in with a recommendation. That would be in-keeping with the manner in which ILCOR has traditionally assessed new approaches and it would not tilt the scales in the negative direction from the start with this new and promising approach. Thank you for your consideration of this request. Keith Lurie MD Head-Up CPR References Duhem H, Moore J, Rojas-Salvador C, Salverda B, Lick M, Pepe P, et al. Improving post-cardiac arrest cerebral perfusion pressure by elevating the head and thorax [Experimental Paper]. Resuscitation. 2021 February 2021;159:45-53. Moore JC, Salverda B, Rojas-Salvador C, Lick M, Debaty G, Lurie K. Controlled sequential elevation of the head and thorax combined with active compression decompression cardiopumonary resuscitation and an impedance threshold device improves neurological survival in a porcine model of cardiac arrest. Resuscitation. 2021 January 2021; 158:220-27. DOI:https://doi.org/10.1016/j.resuscitation.2020.09.030 Moore J, Salverda B, Lick M, Rojas-Salvador C, Segal N, Debaty G, Lurie K. Controlled progressive elevation rather than an optimal angle maximizes cerebral perfusion pressure during head up CPR in a swine model of cardiac arrest [Experimental Paper]. Resuscitation. 2020b; 150:23-28. Pepe P, Aufderheide T, Lamhaut L, Davis D, Lick C, Polderman K, et al. Rationale and Strategies for Development of an Optimal Bundle of Management for Cardiac Arrest. Critical Care Explorations. 2020. 2:e0214. Holley J, Moore J, Jacobs M, Rojas-Salvador C, Lick C, Salverda B, Lick M, Frascone RJ, Youngquist S, Lurie K. (2020). Supraglottic airway devices variably develop negative intrathoracic pressures: A prospective cross-over study of cardiopulmonary resuscitation in human cadavers. Resuscitation(2020), 32-38. https://doi.org/https://doi.org/10.1016/j.resuscitation.2019.12.022 Rojas-Salvador C, Moore J, Salverda B, Lick M, Debaty G, Lurie K. (2020). Effect of controlled sequential elevation timing of the head and thorax during cardiopulmonary resuscitation on cerebral perfusion pressures in a porcine model of cardiac arrest. Resuscitation, 2020, EPub ahead of print. doi:10.1016/j.resuscitation.2019.12.011 Park Y, Hong K, Shin S, Kim T, Ro Y, Song K, Ryu H. (2019). Worsened survival in the head-up tilt position cardiopulmonary resuscitation in a porcine cardiac arrest model. Clnical and Experimental Emergency Medicine, 6(3), 250-256. https://doi.org/https://doi.org/10.15441/ceem.18.060 Pepe P, Scheppke K, Antevy P, Crowe R, Millstone D, C Moore J, Holley J, Segal N, Lick M. et al. Consistent head up cardiopulmonary resuscitation haemodynamics are observed across porcine and human cadaver translational models. Resuscitation. 2018; 132: 133-139. https://doi.org/10.1016/j.resuscitation.2018.04.009 Moore J, Segal N, Lick M, Dodd K, et al. Head and thorax elevation during active compression decompression cardiopulmonary resuscitation with an impedance threshold device improves cerebral perfusion in a swine model of prolonged cardiac arrest. Resuscitation. 2017;2017(121):195-200. doi: http://dx.doi.org/10.1016/j.resuscitation.2017.07.033. Kim T, Shin SD, Song KJ, Park YJ, Ryu HH, Debaty G, et al. The effect of resuscitation position on cerebral and coronary perfusion pressure during mechanical cardiopulmonary resuscitation in porcine cardiac arrest model. Resuscitation. 2017; 113:101-107. doi: https://doi.org/10.1016/j.resuscitation.2017.02.008. Ryu H, Moore J, Yannopoulos D, Lick M, McKnite S, Shin SD, et al. The Effect of Head Up Cardiopulmonary Resuscitation on Cerebral and Systemic Hemodynamics. Resuscitation. 2016;102:29-34. Debaty G, Shin S, Metzger A, Kim T, Ryu HH, Rees J, et al. Tilting for perfusion: head-up position during cardiopulmonary resuscitation improves brain flow in a porcine model of cardiac arrest. Resuscitation. 2015;87(2015):38-43. Letters to the Editor Moore J, Segal N, Debaty G, Lurie K. “The Do’s and Don’ts” of Head Up CPR: Lessons learned from the Animal Laboratory [Letter to the editor]. Resuscitation. 2018; 2018(129):e6-e7. doi.org/10.1016/j.resuscitation.2018.05.023 Putzer G, Martini J, Helbok R, Mair P. Reply to “The Do’s and Don’ts” of Head Up CPR: Lessons learned from the Animal Laboratory [Letter to the Editor]. Resuscitation. 2018; 2018(129):e8. doi:10.1016/j.resuscitation.2018.06.006. Editorials Paxton J, O'Neil B. Is ‘heads up’ the way forward [Editorial]. Resuscitation. 2020;158:270-272. Gazmuri R and Dhliwayo N. From a toilet plunger to head-up CPR: Bundling systemic and regional venous return augmentation to improve the hemodynamic efficacy of chest compression [Editorial]. Resuscitation. 2020;2:Online Strobos, NC. Debunking another CPR myth: Lay the patient flat, or head up CPR? [Editorial]. Resuscitation. 2018;132:A1-A2. https://doi.org/10.1016/j.resuscitation.2018.07.010 Review Articles Elphinstone A, and Laws S. Does ‘heads-up’ cardiopulmonary resuscitation improve outcomes for patients in out-of-hospital cardiac arrest? A systematic review [Literature Review]. British Paramedic Journal. 2020;4(4):16-24 Lurie K, Nemergut E, Yannopoulos D, Sweeney M. The Physiology of Cardiopulmonary Resuscitation [Review Article]. Anesthesia & Analgesia. 2016;122(3):767-783.
    In following article:
    Head-up CPR: BLS Systematic Review
  • Silvio Quirino

    I am privileged to work in a hospital that has “T” manual ventilators in all delivery rooms. The response of the "NB", with regard to the reabsorption of the pulmonary fluid, in the first minutes of life, avoiding the separation of the binomial, among others and promoting a quick return of the "NB" to skin-to-skin contact and the maternal breast it is only one of several reasons for defending the use of a manual “T” ventilator in all delivery rooms. I think we still have a lot to research, since the manual “T” ventilator is very recent, when compared to the time of use of the BALLOON & MASK in neonates.
    In following article:
    Devices for administering Positive Pressure Ventilation (PPV) at birth: (NLS#870) Systematic Review
  • Gerard Meijer

    From a first aider view, the technique of neonatal, newborn ventilation in the field is a art. The technique would be best a 'specialised learnt skill'. In first aid groups there are then some members who would take on regular simulation training as a CPD of infant, neonatal ventilation till help arrives..
    In following article:
    Devices for administering Positive Pressure Ventilation (PPV) at birth: (NLS#870) Systematic Review
  • Philip Sorkin

    I have worked as a Respiratory Therapist in Neonatal since 1977. It has been my experience that a self inflating bag with a peep valve allows me to determine the lung compliance and pressure needed to inflate the lungs. With a T Piece I must pre set a pressure and work from there, giving me no idea what actual pressure is needed. I can see the benefHospitals with a large it of the T Piece in Community Hospitals without experienced people in resuscitation. But in a high volume delivery room with a NICU the bag is the best and most used tool for delivering PPV and CPAP.
    In following article:
    Devices for administering Positive Pressure Ventilation (PPV) at birth: (NLS#870) Systematic Review
  • David Zideman

    The Task Force thanks you submitting your comment.
    In following article:
    Pediatric Tourniquet Types: First Aid New TF SR
  • David Zideman

    Thank you for the comment. Based on primarily military data, the Task Force believes that tourniquets will save lives when used for life-threatening extremity bleeding in the pediatric population. However, the Task Force did not feel that it was necessary to include statements from either the Pediatric Trauma Society or the Committee for Tactical Emergency Casualty Care Pediatric Working Group in this consensus on science, although they may be considered in the introduction or discussion of an accompanying systematic review manuscript. While commentary on the application or availability of tourniquet devices is not specifically made within the Consensus on Science, it was discussed by the Task Force as part of the evidence to decision process and included in the Evidence to Decision table under resources required, cost effectiveness, equity, acceptability and feasibility.
    In following article:
    Pediatric Tourniquet Types: First Aid New TF SR
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