Recent discussions
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Виктория Антонова
Could we not just ask resuscitation professionals who has, during resuscitation experienced splashing from the patients mouth / airway while performing chest compressions, especially with so much emphasis on compressions we are often starting when the patient is not breathing normally, so encounter agonal breaths against our compressions. I know several people I have spoken with have experienced it. Is that an aerosol? For me, it is. -
Виктория Антонова
Such an important and relevant review considering the times we are in. Thank you to all involved on the timeliness of this work. A couple of comments: 1) I would also note that dispatcher provided CPR should remove instruction to “ventilate” or provide “rescue breaths” if that is part of their current instruction. Also advise that dispatch directed CPR modifing breathing assessment from “place your ear close to the patient’s mouth” to “Can you see the chest moving up and down” 2) In the absence of having a cloth or towel to place over the mouth and nose of someone suffering an OHCA for lay rescuers, could it also be recommended that the lay rescuer turn the patients head to the side to allow any froth, blood or fluids to drain. Our work with lay rescuers has shown that fluids can cause a distraction for lay rescuers as they will physically roll a person to clear the mouth. Turning the head will help minimize the potential movement and promote uninterrupted compressions. However, I support the notion of a cloth being placed over the mouth and nose as this will hide some of the visuals associated with agonal breathing. A potential problem is if they hear audible noises as a result of agonal breathing and experience has shown a lay rescuer will most likely remove the cloth and discontinue compressions. We will watch for this our OHCA’s. Our work has shown that the distraction of agonal breathing interrupting compressions was only present in a quarter of the cases we followed-up with. So in addition to the cloth as a barrier, an alternative I would suggest would be to turn the patients head to the side. I do not foresee a cognitive barrier or concern from a lay rescuer’s perspective discontinuing ventilations and switching to compression only CPR. Compression only CPR is very common now. -
Виктория Антонова
We conducted a study on aerosol spread during cpr. A preprint short report can be found here: https://zenodo.org/record/3739498 Recent research revealed, that a supraglottic airway is at least non inferior to other methods of airway management and ventilation in the context of cardiac arrest. We conclude that, especially in the prehospital environment and in the context of limited PPE, the immediate insertion of a laryngeal tube with an airway filter may reduce aerosol spread during chest compressions. -
Виктория Антонова
There are countries like ours which still use paddles in some centres, for defibrillation, instead of adhesive pads and would be interesting to know what recommendations can be given. Thanks. -
Виктория Антонова
Ken, I completely agree. The evidence is poor in relation to defibrillation being an AGP. Rapid muscular contraction from the immediate delivery of energy from defibrillation may produce little expiratory aerosol, however the ROSC will. The benefit of rapid and early defibrillation is to the patient with the risks the HCP's not fully accounted for. What are the benefits and risks associated with delayed defibrillation and appropriate PPE. Defibrillation of shockable rhythm may produce ROSC in a timeframe not permitting the donning of PPE even if it is available. Defibrillation prior to donning of PPE would risk HCP's to an unnecessary risk. -
Виктория Антонова
We still have a very limited access to defib pads. As the rescuer has to get quite close to deliver shocks with paddles ,isn’t it better to approach only with proper PPE? -
Виктория Антонова
Timely and important review. Many thanks to all the authors In most developing countries we use manual hand held paddles instead of self adhesive pads . Is this considered a AGP ? When we talk about defibrillation it is better to reflect on above as well. Bringing both paddles to the chest and switching off oxygen before the shock needs 2 persons unless single rescuer switch off oxygen , select energy charge the paddles on the machine and then bring the paddles to the chest . -
Виктория Антонова
Thank you for this extensive review as well as for the responses. I am in agreement with some of the comments already made. I will mainly comment on BLS in the health care setting as that is where my area of expertise is. As mentioned by some already, the evidence for the risk for AGP of defibrillation is unclear and the risk for transmission during CPR is not deemed high, I do agree with comments made by others that health care staff safety is most important. I think providing defibrillation prior to donning PPE should NOT be recommended. I think all health care staff should done PPE prior to attempt any part of the BLS (and ALS) algorithm for COVID positive/suspected patients. I am in strong favour of compression-only CPR until a definitive airway (LMA) has been established. ANd airway management should only be attempted by experienced operators. We all know that maintaining a good seal with bag mask ventilation can be very challenging during a cardiac arrest and the airway operator is the person closest to the 'fire line' of COVID droplets so we should not put more people at risk than required. I would like ILCOR (and the national resuscitation councils following ILCOR guidelines) to be strong in their advice for recommendations for BLS/ALS during the COVID-pandemic. Recommendations that state that "providers can consider" might not provide enough guidance and can create more confusion. I would prefer strong recommendations. Individual health care organisations and first aid provides can still decide what they do with these recommendations. People are looking at experts to get advice - I think in times like these the panels of experts need to step up and provide strong guidance. -
Виктория Антонова
Thanks for your quick response to the situation of COVID19. It very extensive review and up to the points needed by most of the councils particularly in our area. -
Виктория Антонова
Unfortunately, experience from Italy, NY, New Orleans, Copenhagen reveals that Covid-19 was found often in unsuspected cases. On CT-abd for patients admitted for appendicitis (lower lung cuts), on shoulder Xray of dislocated shoulder, and on autopsy...all unsuspected Covid+ cases. Once reaching a pandemic and significant community transmission, especially given the possible contagiousness starting 24-48hrs prior to any symptom, it is probably dangerous to play a guessing game when it come to who has and who doesn't have Covid. Agree many will fall victim of these precautions...but we cannot afford to lose any more healthcare workers.