Recent discussions
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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.
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Bryan Fischberg
Is there anything in the evidence for this CoSTR to support the current good practice recommendation to avoid placing defibrillation pads over or close to implanted devices? Or, should this be included as a good practice statement? Thank you. Bryan
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ILCOR Staff
Thank you for this comment. The ILCOR task force considers first aid for life threatening and resuscitative conditions as a part of a continuum of care, initiated by anyone to save lives and reduce suffering, and involving engagement with more advanced healthcare providers whenever necessary. We also take into account the wide range of resources and emergency care systems around the globe. For people experiencing postpartum hemorrhage, this ranges from individuals in higher-resource settings and immediate access to advanced professional care, as well as people in settings with no access to formal or highly trained obstetrical and birthing providers. Our recommendation to provide external uterine massage as a first aid intervention accounts for these diverse contexts. It does not in any way suggest that this first aid intervention alone should be considered sufficient or definitive management of postpartum hemorrhage. The scope of our review concerned the effects of external uterine massage on morbidity and mortality. However, we also agree and recognize that implementation of that intervention would require education and knowledge translation efforts beyond the scope of this review.
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Ansari Shabnam Ateeq
Many women who identify as practising Muslims would choose DNR or resuscitation without bra removal. That's because the person is clinically dead and required to be buried as soon as possible, rather than be subjected to a violation of modesty. A few women may want to have a second chance at life because of vulnerable dependants. However, as per faith, the responsibility of a person towards living individuals ceases upon death. Persons with out-of-body experiences report being sent back to life due to pending responsibilities. But that is a matter between them and the Almighty. Healthcare professionals do not have the ability to know who wants to be resuscitated or not. Hence, it may be relevant to empower women with DNR and DNUDR (do not uncover during resuscitation) tags to wear around the neck. As a Muslim woman of 55 years, I want to do this but not sure if caregivers will look for it and comply.
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Denise Welsby
I read with concern the potential recommendation to move away from ABC to CAB for both children and Adults. I believe that further clarification, is required as to when it is acceptable to applying the CAB over ABC and would suggest that in the monitored or cardiac paediatric patients where the evidence of cardiac arrest is undoubted this will be a good first step, to manage the low flow no flow states and buy time.
However, in the vast majority of paediatric patients, cardiac disease is not the primary cause, respiratory support remains the primary focus to prevention hypoxia and a resulting cardiac arrest, so by maintaining respiratory support, chest compressions will be avoided. It appears that low evidence manikin/simulation studies appear to be driving this change and not paediatric studies
Removal of the pulses check in adults was great step in 2021 but to recommend this for the paediatric patients, I believe a negative step given the primary cause is usually hypoxia in children and the heart is still beating i many cases.
The effect of the 2021 the recommendation to commence chest compressions if no signs of life, has resulted in our UK organisation paediatric patients receiving unnecessary CPR for 10+5 and staff de skilling .
In addition, this suggestion to apply CAB over ABC will cause further false cardiac arrest declarations in the UK (NCAA guidance of 1 chest compression = cardiac arrest) in paediatrics, and further de-skill staff by encouraging them to pounce first and check later.
I would recommend teach staff CAB for all cardiac monitored patients' adult and paed.
ABC remains in Europe at least so staff remain focused on hypoxia as the main cause of collapse and to be prepared. BMV's are as cheap as chips and can be kept at the bed side.
Don't underestimate the power of ABC and don't compromise quality prevent of cardiac arrest over speed to preform compressions.