Recent discussions
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Виктория Антонова
I completely agree with the above statement from Christian Vaillancourt- at our organisation most staff (outside of high risk areas ED,ICU, theatre or recovery) for covid positive patients for routine care- not aerosol generating will be wearing droplet precautions so we have put in place that the first responder can start compressions only CPR once Hudson mask applied to patient's face but this responder needs to replaced as soon as possible and if the second responder who would be wearing airborne precautions enters the room and defib can be attempted but with the first responder in droplet precautions is to stand at the foot of the bed- at least two meters away from the patient. Then they get swapped out at the earliest possible time with a responder in airborne precautions- once all staff in the room are in airborne precautions then we can attempt airway-ventilation with intubation/LMA bag vent with viral filter and lots of muscle relaxant etc. as per the ideal process- then recommence CPR once airway secured. If staff are caring for a patient in a non-covid area and non-covid positive patient then they leave the room as soon as cardiac arrest is confirmed and don aerosol precautions PPE. It does increase delay to compressions but staff safety is imminent. Happy for your thoughts on this. -
Виктория Антонова
Ken, I completely concur with your statement that there is no evidence that defibrillation is NOT an AGP, and agree with your opinion. I think it is imperative that HCW's safety is prioritised over defibrillation, failure to recommend PPE for HCWs in the setting of defibrillation of COVID-19 positive patients (or presumed positive) unnecessarily puts them at risk, and may have future legal repercussions. -
Виктория Антонова
Experience in China, Italy and elsewhere demonstrates that the most critical shortfall in the healthcare system is not a shortage of ventilators, nor of PPE, but of trained personnel to use them, especially as the pandemic drags on for weeks or months. Preservation of skilled staff is essential for the long-term sustainability of the healthcare system. Acknowledging the dearth of high-level evidence at this time, I believe that a stronger stance on the use of personal protective equipment in the face of the unknown would be appropriate. ILCOR should take this opportunity to provide leadership in a time of crisis and not be hamstrung by academic conventions that were never meant for this type of situation. If little level 1 evidence exists then an opinion based on first-principles may reasonably be offered to minimise harm. -
Виктория Антонова
Timely and important review. Many thanks to all the authors. I have some concerns with regard to the treatment recommendation on potential for production of aerosol particles during chest compressions. The treatment recommendation currently reads as follow: We suggest that chest compressions and cardiopulmonary resuscitation have the potential to generate aerosols (weak recommendation, very low certainty evidence). Reading the review content, it appears there was no direct evidence evaluating this question specifically. On the other hand, some suggestions have been made that the tidal volume generated during chest compressions is barely above the patient's respiratory dead space. Would be far less significant than a patient's own cough, which is considered a "droplet" producing event. I have no doubt that chest compressions DO generate some levels of particle production. A key element to determine is if these are "droplets" or "aerosolized" particles. Most health care workers are now wearing surgical masks on clinical units. We have recently completed a cardiac arrest simulation at our institution where we are asking these health care workers to doff their surgical masks and put on aerosol N95 masks BEFORE initiation of chest compressions. At best, this resulted in a 2-3 min no flow delay before compressions were initiated. I am completely in support of staff wearing PPE during chest compressions. I can't help but wonder if aerosol N95 masks are necessary during chest compressions. This, before we start manipulating the airway for LMA/ETT intubation during which N95s SHOULD be worn. We should of course always be on the side of safety...but in the absence of any direct evidence, how many cardiac arrest victims may be harmed using this abundance of caution? Person discovering the cardiac arrest victim could possibly initiate CPR (and apply AED/defib) while wearing their "droplet" surgical mask, and leave the room as soon as someone else enters wearing "aerosol" protection with N95 and BEFORE airway manipulation occur. -
Виктория Антонова
Interesting and useful review. Can this be made clear that this it only refers to adult victims of cardiac arrest. Emergency Service response times can be in excess of 20-30 minutes, even for a cardiac arrest, especially in isolated rural settings such as the southwest of the UK where I live. Chest compressions only CPR is unlikely to be effective. Furthermore not all cardiac arrests in these circumstances will be due to COVID-19. Where there is good evidence that it is in someone with known cardiac disease, and no evidence of infection with COVID-19, CPR should be performed with use of an AED at the earliest opportunity. Finally, the reference to work by Deakin is incorrect. The correct reference is Deakin CD, O'Neill JF, Tabor T. Resuscitation 2007;75:53-59. This was a study in intubated patients, receiving chest compression only CPR, where the mean tidal volume was only 41.4 ml (range 33-62ml). No investigation was carried out into aerosol generation. -
Виктория Антонова
This is an excellent and timely review. It is helpful to all who are trying to deal with COVID-19 and should inform regional and national guidelines. There is a lack of evidence identified which hopefully this pandemic will rectify if countries keep appropriate data. For the present if Health Care Professional Health is prioritised the recommendations aren’t entirely appropriate in the balance of probabilities and risks. Thank you for this work at this time. -
Виктория Антонова
This statement needs to be qualified for ADULTS: "We suggest that in the current COVID-19 pandemic lay rescuers consider compression-only resuscitation and public-access defibrillation (good practice statement)." also the review did not seem to pick up the manuscript showing that CPR can be done effectively in full PPE for children: Pediatr Emerg Care. 2020 Feb 24. doi: 10.1097/PEC.0000000000002028. [Epub ahead of print] Impact of Personal Protective Equipment on the Performance of Emergency Pediatric Tasks. Adler MD1,2, Krug S1, Eiger C3, Good GL4, Kou M5, Nash M6, Henretig FM7, Hornik CP8, Gosnell L8, Chen JY9, Debski J9, Sharma G9, Siegel D10, Donoghue AJ7,11; Best Pharmaceuticals for Children Act–Pediatric Trials Network¶¶. Author information Abstract OBJECTIVES: Personal protective equipment (PPE) is worn by health care providers (HCPs) to protect against hazardous exposures. Studies of HCPs performing critical resuscitation tasks in PPE have yielded mixed results and have not evaluated performance in care of children. We evaluated the impacts of PPE on timeliness or success of emergency procedures performed by pediatric HCPs. METHODS: This prospective study was conducted at 2 tertiary children's hospitals. For session 1, HCPs (medical doctors and registered nurses) wore normal attire; for session 2, they wore full-shroud PPE garb with 2 glove types: Ebola level or chemical. During each session, they performed clinical tasks on a patient simulator: intubation, bag-valve mask ventilation, venous catheter (IV) placement, push-pull fluid bolus, and defibrillation. Differences in completion time per task were compared. RESULTS: There were no significant differences in medical doctor completion time across sessions. For registered nurses, there was a significant difference between baseline and PPE sessions for both defibrillation and IV placement tasks. Registered nurses were faster to defibrillate in Ebola PPE and slower when wearing chemical PPE (median difference, -3.5 vs 2 seconds, respectively; P < 0.01). Registered nurse IV placement took longer in Ebola and chemical PPE (5.5 vs 42 seconds, respectively; P < 0.01). After the PPE session, participants were significantly less likely to indicate that full-body PPE interfered with procedures, was claustrophobic, or slowed them down. CONCLUSIONS: Personal protective equipment did not affect procedure timeliness or success on a simulated child, with the exception of IV placement. Further study is needed to investigate PPE's impact on procedures performed in a clinical care context. -
Виктория Антонова
We need evidence from the current pandemic. This literature looks at historic smaller outbreaks and not specifically at the important areas of compression only or ventilation or defibrillation. Please, please start gathering data from the regions of the international community who have experienced this first and let us do some learning. -
Виктория Антонова
Thank you for the rapid publication of this review. I have conducted an extensive search of the literature independent of this important work. I could only one paper that mentions defibrillation in the context of being a potential AGP, and it indicated as you have done that there is no reliable evidence that defibrillation is an AGP’s, but it is important to safety to note that there is no evidence that defibrillation is NOT an AGP. In the absence of evidence we have to rely on professional opinion. When we defibrillate people, arms can flail and air is usually expelled very rapidly from the patient’s mouth and nose as a result of the widespread muscular contraction that occurs in the chest, lungs and heart as a result of electrical energy passing through the person’s chest wall. It isn’t difficult to work out, that if a person infected with the Covid-19 virus, receives an electric shock from a defibrillator, at that moment, millions of viral particles will be forcefully expelled into the air from the mouth and the nose. There is very strong evidence specific to corona virus particles, that theses particles may remain present in the air for up to three hours. (https://www.nejm.org/doi/10.1056/NEJMc2004973) This places any HCP without adequate mask protection (not wearing a respirator type mask) in the vicinity of the patient in a position of risk. I would not put myself in that position, nor would I expect any other HCP to do so. I would be grateful if you would consider this as a significant safety risk to hospital-based healthcare workers -
Виктория Антонова
Dr Tinnion makes very good points and I am not going to repeat all of them in my own comments but I would like to reiterate one point he makes and to do this as one of the authors of Sproat et al. The ILCOR team need to make a very clear distinction between term and preterm infants. Our data showed a universally poor outcome (death) in prolonged resuscitation of preterm infants. With regards to term infants there are survivors between 10 and 20 minutes but with a high risk of significant impairment and little in the way of concrete markers as to what might be antecedent factors that will allow accurate prediction of outcome. I suspect, as Dr Tinnion writes, the better than previously published outcomes do relate to better antenatal care and particularly better ability to predict the moment where deliver must happen. There is reasonable evidence that resuscitation beyond 20 minutes has an incredibly poor outcome and therefore I do not think it is unreasonable to attach an upper time limit to term infants with a lack or response to 20 minutes with consideration of appropriateness of continuation from 10 minutes of age