Recent discussions
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Jana Djakow
The CoSTR report raises critical concerns about the shift from the ABC sequence to CAB in pediatric resuscitation. While it questions the significance of delays in ventilations, it does not apply the same scrutiny to delays in chest compressions. This inconsistency is particularly concerning given the lack of pediatric-specific data to justify prioritizing compressions over ventilations.
Goh et al., suggested that delayed chest compressions can have serious consequences. However, this study excluded children and relied on "time of arrest," a variable prone to errors. Additionally, their data showed no significant difference in survival outcomes within one minute of delay, raising doubts about the robustness of their conclusions.
CO-CPR vs. RB-CPR: Risks for Pediatric Patients
A major concern is the potential rise in compression-only CPR (CO-CPR) rates at the expense of rescue breaths (RB-CPR). Naim et al. (2021) reported an increase in CO-CPR rates in the U.S. following the adoption of CAB, without a corresponding rise in bystander CPR rates. This trend is troubling for infants, the largest group of pediatric cardiac arrests, where CO-CPR offers no significant advantage over no CPR. This raises doubts about whether CAB truly benefits pediatric patients or risks reducing survival rates.
Importance of Initial VentilationsHolgersen et al. (2022) analyzed outcomes in Denmark, where ABC remains the standard. They reported a 30-day survival rate of 40% for pediatric out-of-hospital cardiac arrests (OHCA). While neurological outcomes were not detailed, Denmark’s consistent use of the ABC sequence, supported by comprehensive training, suggests that ABC is not inferior to CAB and highlights the importance of system-level education rather than sequence change.
The shift to CAB in peds BLS lacks evidence showing differences in critical or important outcomes in real patients as defined in P-COSCA. The potential risks, including increased CO-CPR rates and reduced survival in infants, argue for caution. Studies like those by Skrisovska et al. and Holgersen et al. emphasize the value of initial ventilations and the benefits of system-wide training.
The ILCOR should focus on evidence-based, patient-centered outcomes when revising guidelines. In the absence of pediatric-specific data demonstrating CAB's superiority, overhauling an entire function system of education, clinical practices, and lay rescuer protocols—may compromise safety and effectiveness in achieving good outcomes. -
Diminique Biarent
The CoSTR report raises critical concerns about the shift from the ABC sequence to CAB in pediatric resuscitation. While it questions the significance of delays in ventilations, it does not apply the same scrutiny to delays in chest compressions. This inconsistency is particularly concerning given the lack of pediatric-specific data to justify prioritizing compressions over ventilations.
Goh suggested that delayed CC can have serious consequences. However, this study excluded children and relied on "time of arrest," a variable prone to estimation errors. Additionally, their data show no significant difference in survival outcomes within one minute of delay, raising doubts about the robustness of their conclusions.
A major concern is the potential rise in compression only (CO) CPR rates at the expense of rescue breaths (RB)CPR. Naim (2021) reported an increase in CO-CPR rates following the adoption of CAB, without a rise in bystander CPR rates. This trend is troubling for infants, the largest group of pediatric CA where CO-CPR offers no significant advantage over no CPR. This raises doubts about whether CAB truly benefits pediatric patients or risks reducing survival rates
Holgersen et al. (2022) analyzed outcomes in Denmark, where ABC remains the standard. They reported a 30-day survival rate of 40% for pediatric out-of-hospital cardiac arrests (OHCA). While neurological outcomes were not detailed, Denmark’s consistent use of the ABC sequence, supported by comprehensive training, suggests that ABC is not inferior to CAB and highlights the importance of system-level education rather than sequence changes.
The shift to CAB in pediatric resuscitation lacks robust evidence, particularly in children. The potential risks, including increased CO-CPR rates and reduced survival in infants, argue for caution. Studies like those by Skrisovska et al. and Holgersen et al. emphasize the value of initial ventilations and the benefits of system-wide training.
The ERC should focus on evidence-based, patient-centered outcomes when revising guidelines. In the absence of pediatric-specific data demonstrating CAB's superiority, overhauling an entire system—including education, clinical practices, and lay rescuer protocols—may compromise safety and effectiveness in achieving favorable outcomes in pediatric resuscitation.
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Cibele Lebrao
The use of the video laryngoscopy device will be useful in assisting premature babies and difficult airways. However, this is not the current practice in most services.
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Silvia Heloisa Moscatel Loffredo
I agree with the proposed recommendation and consider it a promising practice for reducing the neonate’s exposure to adverse events associated with traditional laryngoscopy intubation. It will also be beneficial for training in endotracheal intubation.
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Jesus López-Herce
The initiation sequence of basic CPR is a controversial topic with important implications for CPR training. There is no solid scientific evidence but making a recommendation can have a great relevance for CPR training.
As the authors of this systematic review acknowledge, no studies in humans have been identified, and no new study has been found that provides significant evidence to make a recommendation on what is the best sequence for starting CPR. Only 5 studies with simulation with mannequins have been found in which, the overall certainty of evidence was rated as very low for all outcomes, downgraded for a very serious risk of bias and indirectness.
The results indicate, as is logical, that with the CAB sequence that begins with chest compressions, the start of chest compressions is done earlier than with the ABC sequence. On the contrary, with the ABC sequence ventilation starts earlier than with the CAB sequence. These results are common sense and no scientific studies are needed to deduce them. Regarding the other results there were differences between the studies.
These results do not at all support the recommendation made “In adults and children in cardiac arrest, we suggest commencing CPR with compressions rather than ventilations. This is a personal opinion of the researchers, very respectable, but not based of the results.
In our opinion, starting CPR with the CAB or ABC sequence probably does not make any relevant clinical difference because both sequences only differ in starting one manoeuvre or the other a few seconds earlier, the rest of the resuscitation being the same.
The 2020 pediatric recommendations concluded that there was insufficient evidence to make a recommendation. Resuscitation. 2020 Nov;156:A120-A155.
Furthermore, and most importantly, although the current recommendation is only a suggestion with a very low level of evidence, it can have an important impact on teaching since it can be interpreted by teaching groups as an obligation to change their recommendations, which involves an enormous teaching effort without any clinical benefit.
For these reasons, we consider that the recommendation on this subject should be “There is currently insufficient scientific evidence to recommend an initial sequence of CAB or ABC CPR in adults or children”.
Ignacio Manrique and Jesús López-Herce
Representing the Spanish Group of Pediatric and Neonatal CPR
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David Dillon
Fantastic summary of the current data and well supported recommendations for ongoing clinical practice. My only minor comment is that the name author name for the reference Dillon 2024 is misspelled as Dhillon 2024 throughout the document.
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Jesus Lopez-Herce
The initiation sequence of basic CPR is a controversial topic with important implications for CPR training. There is no solid scientific evidence but making a recommendation can have a great relevance for CPR training.
As the authors of this systematic review acknowledge, no studies in humans have been identified, and no new study has been found that provides significant evidence to make a recommendation on what is the best sequence for starting CPR. Only 5 studies with simulation with mannequins have been found in which, the overall certainty of evidence was rated as very low for all outcomes, downgraded for a very serious risk of bias and indirectness.
The results indicate, as is logical, that with the CAB sequence that begins with chest compressions, the start of chest compressions is done earlier than with the ABC sequence. On the contrary, with the ABC sequence ventilation starts earlier than with the CAB sequence. These results are common sense and no scientific studies are needed to deduce them. Regarding the other results there were differences between the studies.
These results do not at all support the recommendation made “In adults and children in cardiac arrest, we suggest commencing CPR with compressions rather than ventilations. This is a personal opinion of the researchers, very respectable, but not based of the results.
In our opinion, starting CPR with the CAB or ABC sequence probably does not make any relevant clinical difference because both sequences only differ in starting one manoeuvre or the other a few seconds earlier, the rest of the resuscitation being the same.
The 2020 pediatric recommendations concluded that there was insufficient evidence to make a recommendation. Resuscitation. 2020 Nov;156:A120-A155.
Furthermore, and most importantly, although the current recommendation is only a suggestion with a very low level of evidence, it can have an important impact on teaching since it can be interpreted by teaching groups as an obligation to change their recommendations, which involves an enormous teaching effort without any clinical benefit.
For these reasons, we consider that the recommendation on this subject should be “There is currently insufficient scientific evidence to recommend an initial sequence of CAB or ABC CPR in adults or children”.
Ignacio Manrique and Jesús López-Herce
Representing the Spanish Group of Pediatric and Neonatal CPR
-
Jesus Lopez-Herce
The initiation sequence of basic CPR is a highly controversial topic with important implications for CPR training. As the authors acknowledge, there is no solid scientific evidence on which to base one or another recommendation. However, making a recommendation can have a greatrelevance for CPR training.
In the current systematic review, no new work has been found that really provides significant evidence to make a recommendation on what is the best sequence for starting CPR. No studies in humans have been identified. Only 5 studies with simulation with mannequins have been found in which, authors point out, the overall certainty of evidence was rated as very low for all outcomes, downgraded for a very serious risk of bias and indirectness.
The results indicate, as is logical, that with the CAB sequence that begins with chest compressions, the start of chest compressions is done earlier than with the ABC sequence. On the contrary, with the ABC sequence ventilation starts earlier than with the CAB sequence. These results are common sense and no scientific studies are needed to deduce them. Regarding the other results there were diffferences between the studies.
These results do not at all support the recommendation made “In adults and children in cardiac arrest, we suggest commencing CPR with compressions rather than ventilations”. This is a personal opinion of the researchers, very respectable, but not based of the results.
In our opinion, starting CPR with the CAB or ABC sequence probably does not make any relevant clinical difference because both sequences only differ in starting one manoeuvre or the other a few seconds earlier, the rest of the resuscitation being the same. The 2020 pediatric recommendations concluded that there was insufficient evidence to make a recommendation. Resuscitation. 2020 ;156:A120-A155. doi: 10.1016/j.resuscitation.2020.09.013.
Furthermore, and most importantly, although the current recommendation is only a suggestion, it can have an important impact on teaching since it can be interpreted by teaching groups as an obligation to change their recommendations, which involves an enormous teaching effort without any clinical benefit.
For these reasons, we consider that the recommendation should be “There is currently insufficient scientific evidence to recommend an initial sequence of CAB or ABC CPR in adults or children.
Ignacio Manrique and Jesús López-Herce
Representing the Spanish Group of Pediatric and Neonatal CPR
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Nádia Sandra Orozco Vargas
I agree that the use of vídeo laringoscopy Will be useful and brings a Lot of benefits in the medical assistance to the prematures and microprimes. With less cerebral damage.
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adriano peris
Should the duration of CPR cycles be different in the presence of in-hospital cardiac arrest distinguishing between monitored patients (ECG, Pulse O2......) and non-monitored patients?
After the onset of ROSC in a controlled environment (ED, ICU, OR..) knowing the vital parameters that precede cardiac arrest, the duration of the cycles must take into account the state of perfusion that precedes cardiac arrest? For example, if the average pressure was 80 mmHg, even if adrenaline-dependent, is it convenient to re-establish a perfusion attempt without interrupting the CPR cycles?