Recent discussions
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Виктория Антонова
Thank you for your comments. As mentioned in the response to Comment #1 above, this specific PICOST questions pertains to using POCUS for prognostication of clinical outcome during cardiac arrest. It is agnostic to POCUS as a diagnostic test for specific etiologies of cardiac arrest or POCUS as a means to assess hemodynamic response to therapy. Additionally, we are adding additional clarifying language to the final print version of this CoSTR (pending publication in October, 2020). “Finally, in 2015 the question of whether the use of cardiac ultrasound during CPR changed outcomes was reviewed {Soar 2015 e71, Callaway 2015 s84}. This topic was not prioritized for an evidence update in 2020. The 2015 treatment recommendation currently remains pending further review: We suggest that if cardiac ultrasound can be performed without interfering with standard ACLS protocols, it may be considered as an additional diagnostic tool to identify potentially reversible causes (weak recommendation, very-low-quality evidence).” -
Виктория Антонова
Thank you for your comment. We agree completely! We will be communicating this suggestion to the respective regional resuscitation councils in charge of developing algorithms. -
Виктория Антонова
Dear colleagues, I wonder why the study of Grunau et al. Resuscitation 2019 vol. 135 51 - 56 validating the Bokutoh criteria in North-America is not included in the analysis, this study was published within your time frame. My general comment is that there will always be unmeasured variability, 100% prediction is impossible and we need to accept the fact that uncertainty is inherent to medicine. As such we have to look at the number needed to treat (which is huge for some subpopulations, when for instance looking at the Bokutoh criteria (284 in their validation cohort) ) and allow and validate the clinical insight of the team to decide on an individual patient whether to proceed with resuscitation or whether to start at all. Especially since an estimated 13 - 20% of the cardiac arrests occur in dismal conditions (non-witnessed, non-shockable, old) the collateral damage we are causing needs to be stressed more, the extremely bad outcomes in non-shockable non-witnessed arrests in older people should not be treated by default but only in exceptional circumstances based on the clinical insight of the team or within a randomized controlled trial. I have a problem with the sentence: 'inclusion of a TOR within a termination guideline has the potential to reduce variation in practice associated with clinician judgment and improve termination decisions more generally." This variability can be justified and needs to be accepted due to the differences between patients. -
Виктория Антонова
I believe it is important to keep in mind the history of this topic. The 2-min post-shock CC protocol was instituted in 2005 not primarily to provide circulation for pulselessness after successful shocks; rather, it was clearly adopted to mitigate the harm of the lengthy “hands-off” periods for repeated rhythm analysis required by automated external defibrillators (AEDs). There is evidence that this strategy does improve survival when AEDs are used. However, its appropriateness for resuscitative attempts using manual defibrillators is highly questionable. If defibrillation results in the quick return of a perfusing rhythm, 2 additional min of CCs poses a risk of harm to the victim. Based on prior evidence for the efficacy of "stacked" shocks, a 2-min delay in giving a second shock for continuing VF could significantly decrease the likelihood of success. Claims of long intervals of pulselessness after successful shocks are dubious: one study found that delays of 2 min for return of a palpable pulse were common--if the first pulse check did not occur until the two-minute mark! The blanket recommendation for 2 min (or indeed any interval) of CCs before rhythm analysis and pulse check obscures a relative disadvantage of AEDs; it stands as a case of undue influence of the medical device industry over guidelines development. -
Виктория Антонова
EIT would like to thank for the comment. EIT is aware that that all the regional resuscitation councils have a teaching program exactly addressing that and offer a variety of teaching courses from BLS over neonatal, pediatric and adult courses. -
Виктория Антонова
Thanks for their insight and we consider including these limitations of the scoping review in future reviews and we will define better what is meant by “bundles of care”. Furthermore, this review was not intended to assess teaching methods, therefore no statement about blended learning was made - ILCOR EIT assessed that in other PICOSTs. -
Виктория Антонова
Thanks for the comments, which are in line with the knowledge gaps EIT delineated in this review. We will communicate our suggestions to the educational responsible persons of the local resuscitation councils. -
Виктория Антонова
In the 'narrative summary of evidence identified', the second paragraph reads '(...) where bedside echocardiography was performed during CPR in patients at high risk for pulmonary embolism. RV dilatation and systolic dysfunction were associated with low ETCO2. Emboli were not directly seen on echocardiographic images (...)' I believe this section might have been displaced as it appears to discuss Morgans study from 2018, as the 2017 Steffen's study only focused on cardiac standstill and does not mention pulmonary emboli. -
Виктория Антонова
From an EMS perspective I can't disagree with the quality and lack of evidence but what I don't see is any modification for the risk of not terminating resuscitation on scene. This would result in a lights & sirens journey to hospital which places both the practitioners and public at a greater risk. I suggest too is a knowledge gap that needs addressing and adding to the wider picture of care -
Виктория Антонова
Thank you for your insightful and energising review of this contemporary topic. I am responding on behalf of the British Red Cross where we have conducted our own exploration through testing first aid education approaches with opioid user groups. We have a number of observations and questions evolving from your review: - In relation to the knowledge gaps, would it be possible to sequence these in order to prioritise and clarify aspects of research needed to take this forward? For example, your last bullet point is about lay responder recognition. Given the lifestyle and behavioural challenges associated with this, do we have enough social commentary, or is more required before we can effectively customise traditional education approaches to recognition? And if recognition is a precursor to administration, then this piece perhaps should take priority. We accept that this is interdependent on other gaps you have identified, such as points within the Chain of Survival Behaviours which could be a focus for public eduction, but recognition does seem to be a natural starting point. - Naloxone education as an embedded part of BLS is an admirable target. We would suggest that an incremental approach, following the creation of effective practice (across healthcare professionals and lay public) which begins with those with a duty to respond - including an unofficial duty, such as being the first person on the scene - be a good place to start. - Availability and accessibility to Naloxone does not appear to be flagged as a significant issue, but this is likely to limit the implementation of recommendations on this topic in different countries and perhaps could be flagged. -Finally, you have identified self-recovery as one of the domains that this topic should consider. Does this include self-administration during the acute phase, indeed is this even possible, or is it more about longer term addiction recovery programmes? Thank you again, this is very progressive and interesting with many opportunities for research which I hope will be prompted by your review.