Recent discussions
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Chris Lindsell
As a person who, in their profession attends many arrests. I see the use of mechanical devices particularly the Lucus as very problematic due to poor placement and time off the chest. There needs to be more emphasis that these should not be used routinely when not necessary. I also see trauma to the skin often and am aware of the the psychological impact from family members, especially with the Lucus when hands are attached to the machine.
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Mohamud Daya
Without high-quality data supporting AL vs AP pad placement in cardiac arrest, both should be allowed as options, as they are in the current ERC guidelines, without recommending AL as a preferred approach. Many factors influence impedance, including pad size, pad position, intervening tissue (an issue with obese patients), timing (lungs expanded vs not), pressure on the pads, etc. AL pads may also be easier to misplace than AP, though we need more data to understand this.
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Kerry Bachista
Third, I encourage your group to consider the potentially stifling effect statements like this can have on innovation. Every incremental improvement in survival rates translates into lives saved. The national survival rate for cardiac arrest has stagnated for decades, making it essential to explore new paradigms. Dr. Peter Safar, the father of CPR and rescue breathing and a three-time Nobel Prize nominee, warned of the limitations of randomized controlled trials (RCTs) in resuscitation research prior to implementation. In his autobiography Careers in Anesthesia (2000, Wood Library-Museum of Anesthesiology), he discusses how “The enormous number of unknown or uncontrollable clinical variables makes it impossible to control RCTs and to prove no effect.” He emphasized that: “Convincing positive results from outcome studies in reproducible large-animal outcome models should replace clinical randomized outcome studies in CPCR research, while clinical feasibility and side-effect studies should precede any treatment becoming part of guidelines for routine use. “
The current consensus statement: “We suggest against the use of head-up CPR or head-up CPR bundle during CPR except in the setting of clinical trials or research initiatives (weak recommendation, very-low-certainty evidence)"—is too cautious. This approach is why we have had stagnation in survival rates over the past 50 years. Although I don’t claim that the head-up CPR bundle is the ultimate solution or that there aren’t other advancements on the horizon, the outcomes we've seen in my EMS system have been better than those we’ve achieved with standard CPR. While there is demand by some for a large RCT. Who will do that and spend the money with position statements angling on discouraging? All innovation has costs at first, but then becomes more available at scale. If we poison the well of development, then we will continue to stifle our work and humanity pays the price.
Therefore, I encourage you to revise your recommendation to something more constructive, such as: "Head-Up CPR, when implemented with a head and thorax patient positioning system device, suction cup-based active compression-decompression CPR, and an impedance threshold device, could be considered a complementary option for cardiac arrest patients, with low certainty of evidence. This approach is supported by animal studies and observational human studies and warrants further investigation."
Thank you for again for allowing. comments.
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Elibene Junqueira
I agree with Ilcor's guidance
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Kerry Bachista
Thank you for including my paper in your review and allowing the opportunity to provide comments.
First, I would like to highlight a significant omission in the review—the absence of a recent study by Dr. Debaty published in Resuscitation (2024) (https://doi.org/10.1016/j.resuscitation.2024.110406). This prospective before-and-after study is the first to evaluate circulation during head-up CPR in humans. The study found End-tidal CO2 (ETCO2), a well-established marker of circulation, was notably higher in patients treated with head-up CPR, reaching values within a normal range, regardless of the presenting rhythm. The inclusion of this study is important as it demonstrates enhanced circulation. Non-invasive markers like ETCO2 have long been accepted as proxies for good perfusion. These markers are integrated into numerous CPR algorithms, making this study essential to your review.
Second, it’s important to clarify that head-up CPR, as described by Dr. Moore and Dr. Debaty, involves a specific bundle of three devices working synergistically to enhance cerebral blood flow during CPR. These devices include an impedance threshold device (ITD), a suction cup-based active compression-decompression CPR device (ACD), and a patient positioning system designed to elevate the head and thorax in a controlled manner. I have implemented this technique in one of my EMS systems since January 2021, with data being submitted to a registry. We have published promising results, and we continue to observe positive outcomes when this approach is executed by trained personnel as part of a basic life support (BLS) intervention. From both animal studies and early clinical experiences, we have gained valuable insights into the deployment of this technology. I urge you to emphasize that head-up CPR is not a single device but a comprehensive approach, and to avoid including reviews of methods that do not adhere to this specific bundle. Including studies that utilize a wedge or other alternative methods only serves to cloud the data, as these techniques can be harmful in laboratory settings. The currently trialed head-up CPR bundle builds on decades of conventional CPR experience and should not be combined with other techniques.
Continued…
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Natalie Camillo oliveira
I agree with the above and maintain the same opinion as evidence in my work.
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Paulo Nader
The use of videolaringoscopy is very useful in a premature less than 1000g. can be recommended.
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Andrea Lube
In our State, there is no availability of videolaryngoscopy for neonatal use in delivery rooms and neonatal units. For anesthesia, some services have video laryngoscopes available for older patients. Equipment not appropriately sized for newborns. In my clinical practice I had the opportunity to use neonatal equipment for a period of 1 week. Colleagues who used it did not like it, as it took longer for the procedure. Possibly because they are not familiar with it. In my practice of teaching intubation on mannequins, the use of the video laryngo is very useful as it allows us to visualize what the student is seeing, favoring the correction of the technique. But the equipment was purchased by a colleague especially for use in teaching. The equipment is very expensive and managers are still not convinced of its benefits within the hospital unit. The convincing work started about a year ago in the units where I work, but we have not yet been successful.
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Giselda Silva
I Inform you That I Do not workshop in places with vídeo laryngoscopy and I have no problems regarding intubation in newborn
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Dominic Larose
Consider changing “anterolateral” to “anteroaxillary”. This is to make it even more clear that the lateral pad is often too anteriorly, and too caudal. Consider publishing an image that shows the ideal position, since most 2D drawings are inaccurate and misleading. See this reference, and many others.
Foster AG, Deakin CD. Accuracy of instructional diagrams for automated external defibrillator pad positioning. Resuscitation. 2019 Jun;139:282-288. doi: 10.1016/j.resuscitation.2019.04.034. Epub 2019 May 5. PMID: 31063839.
Larose D. Teaching optimal paddle position for defibrillation. Ann Emerg Med. 1993 Dec;22(12):1925. doi: 10.1016/s0196-0644(05)80429-9. PMID: 8239119.