Recent discussions
-
Виктория Антонова
• 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. -
David Zideman
The Task Force thanks you submitting your comment. -
David Zideman
Thank you for submitting your comment. The Task Force agrees that while most of the data, as you cite, is from military evidence (Sokol 2015, Kragh 2012), the use of tourniquets for life threatening extremity hemorrhage will improve survival in the pediatric population (Callaway 2017). This review was performed using GRADE methodology, with inclusion of studies performed on humans. Modeling studies (El-Sherif 2019, Kragh 2019 and Vretis 2018) performed on plastic manakins, ballistics gel with rubber tubing, or stair rails were not included in this systematic review but were described in the Evidence to Decision Table. The Task Force expressed concern as to how the rigidity of the plastic or metal equates to human tissue or how the outcomes of “tightness” or compressing rubber tubing equate to stopping human blood flow from potentially large, difficult to compress, arteries. In addition, in the most robust of these studies (El-Sherif 2019), the task force was unable to interpret the clinical utility of certain definitions, such as “windlass enabled pass”. While the Harke and Kelly studies also used an indirect outcome, abolishing distal pulses in uninjured extremities, these studies were performed on children instead of models, allowing their inclusion in the review and subsequent treatment recommendation. -
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. -
David Zideman
Thank you for the comment. The Task Force acknowledge that there are a wide range of different studies that could be undertaken but that it would be difficult to list all of these in this systematic review. -
David Zideman
Thank you for your comment. The Task Force has considered your comment and agree that there is less data in the pediatric population on the scope of life threatening extremity bleeding in the pre-hospital population and we would agree that further research is needed on this topic. However, it cannot be assumed that all tourniquets, even those “designed” for the pediatric population work in the pediatric population. Some modelling studies (El-Sheif 2019, Vretis 2018) suggest otherwise and it is important that published scientific evidential research supports the use of these life-saving interventions. -
Виктория Антонова
I have worked in neonatal care for >30 years and watched developments in treatment. I think experience and consistency is very important for device use and resuscitation. The T Piece is set to ensure consistent pressure administration and this in itself is probably beneficial. Interesting to read the information re results. Experientially I think we are seeing less air leaks, interesting that there is no significant difference. -
Виктория Антонова
The use of T-piece resuscitator has the advantaged if necessary, make cpap in delivery room in respiratory distress syndrome. Sometimes they don't need the surfactant therapy because the cpap in delivery room. -
Виктория Антонова
Although there are limited studies, there is information about how small both the CAT (windlass) and the RMT (ratcheting) tourniquets can go, and therefore be used in small children. The CAT-6 and CAT-7 can be use on an extremity as small as 5.2 in (13.1 cm) in circumference _approx. forearm of a 4-6month old child. The ratcheting Medical Tourniquet (RMT) has a pediatric size for those less than 120 lbs 955 kg) that can be used in an extremity as small as 4.4in (11 cm)- forearm of a 0-3 month old. References Engel WT, Otting M: procedure 25: Tourniquet application in : Fuchs S, McEvoy M, eds. pediatric Education for Prehospital Professionals, 4th ed, Burlington, MA: Jones & Bartlett learning 2021:441-444. Ross EM, Bolleter S, Simon E, et al. Pediatric extremity hemorrhage and tourniquet use. J Emerg Med Services 2018: 1. Kelly JR, Levy MJ, Reyes J, et al. (your ref 4) Effectiveness of the combat application tourniquets for arterial occlusion in young adults. J trauma Acute Care Surg 2020;88:644-647. A study done on pediatric war casualties ( Kragh JF Jr, Cooper A, Aden JK et al, Survey of trauma registry data on tourniquet use in pediatric war casualties. Pediatr Emerg Care 2012:28:1361-1365) demonstrated improved survival -
Виктория Антонова
In order to accumulate meaningful data suggest ILCOR Strongly Recommend reporting of all cardiopulmonary arrests in prone position. Reports to include timing of interventions and follow up for at least 30 days post discharge from hospital. All patients should be referred for functional testing post discharge.