Recent discussions
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Виктория Антонова
Dear Sir´s As a complement to your outstanding guidelines work I have a short comment: In the Swedish study (Ring et al NEJM 2015) primary endpoint was bystander CPR. Not survival. In summary, The mobile-phone positioning system was activated in 667 out-of-hospital cardiac arrests: 46% (306 patients) in the intervention group and 54% (361 patients) in the control group. The rate of bystander-initiated CPR (primary endpoint) was 62% (188 of 305 patients) in the intervention group and 48% (172 of 360 patients) in the control group (absolute difference for intervention vs. control, 14 percentage points; 95% confidence interval, 6 to 21; P<0.001). To my opinion you should therefore not report this study as a non-concluded or negative in regards to survival at 30 days. The study did not have power nor were design to study survival. Keep up the good work! Leif Svensson Professor cardiology, senior and principal investigator in the Ringh study -
Виктория Антонова
Sad to say, 30 years after Utstein and just look at the bias, heterogeneity, and overall certainty of evidence presented here. Why is there not better overall coordination of the studies being done? I don’t fault ilcor. I know large multicenter trials are difficult to put together. But as someone who was practicing EM before and after Utstein I find the lack of progress a bit depressing. -
Виктория Антонова
I wish debriefing was automatically part of every cardiac arrest for quality improvement, educational purposes and staff moral support. I have been going to cardiac arrests for 32 years and as an ACLS, PALS and NRP, I see this as often an "untapped gem!" Hopefully it will become part of the algorithm. -
Виктория Антонова
The Aquatics sub-council of the American Red Cross Scientific Advisory Council supports the recommendations of the recent ILCOR CoSTR to take in to account submersion duration, if known, when determining the utility and feasibility of an aquatic search and rescue operation. We recommend that agencies charged with aquatic search, rescue, and/or recovery operations include known submersion in decision pathways when developing operational procedures, with the aim of optimizing rescuer safety and resource allocation. -
Jeffrey Pellegrino
Can the potential harm (e.g., tourniquet effect) of improperly placing a compression wrap over an injury be addressed, especially if asking a minimally trained first aider. Would it be better served to say this is outside of the FA skill set but may be left to other professionals with training, ability to monitor, and with responsibility (athletic trainer, ED, physical therapist). Also, it would be beneficial to place this in context to the recovery domain of the Chain of Survival Behaviors. Compression wraps might be confused with immobilizing an acute injury with a splint to protect it from further injury. -
Виктория Антонова
I realize all the recommendations are weak with low to very-low certainty, which raises the questions whether it would be better to say that there isn't enough adequate quality evidence to guide treatment/make recommendations and rather focus on the justification of said statement and knowledge gaps that need to be addressed so adequate recommendations can be made. It can not be stressed enough what the impact of the self fulfilling prophecy of early WLST has on whether many of these findings predict a good or bad outcome, which is a major limitation in most, if not all, studies to date. Comments on the recommendations: Agree with Dr. Hirsch that the use of epileptiform is problematic and not c/w the CCEEG nomenclature. Re: the recommendation on EEG reactivity should probably read as "suggest against absence of EEG background reactivity alone to predict" or "suggest against EEG background unreactivity" rather than "suggest against EEG background reactivity alone to predict poor outcome" as what was described above was related specifically to absence of EEG reactivity. Very few studies have looked the potential of the presence of EEG reactivity to predict good outcome, though there is some early signal that it's presence may be assist with good outcome prediction (Sivaraju 2015, Admiraal 2019). Note the following recommendation does not have a recommendation or level or evidence: •We suggest using the presence of epileptiform activity on EEG to predict poor outcome in adult patients who are comatose after cardiac arrest. There is such a wide range or "epileptiform" activity on EEG - without further guidance seems like a very slippery slope such that any duration, frequency or presence or sporadic discharges should be used to predict poor outcome. Re: the recommendation that seizures should be used to predict a poor outcome - seizures (and are we talking about recurrent seizures, a handful of seizures, 1 seizure etc...) in isolation, should not be used to predict poor outcome. In it of itself, if the EEG background were continuous and reactive and the patient had seizures (albeit likely a much less common scenario) the EEG would not be used in isolation to predict poor outcome. With regards to prognostication off sedation for a couple of the recommendations: For how long off sedation? Does it depend on the cumulative dose, whether someone who was cooled to 33 vs 36 or whether this is renal or hepatic impairment, all of which impact metabolism and drug clearance, which could then impact the ability to prognosticate? Seems too general a statement. Given the various definitions used in some studies, highly malignant EEG patterns may in fact qualify as nonconvulsive status epilepticus. So in one recommendation to suggest against using SE to predict poor outcome coupled with another recommendation to suggest using highly malignant EEG patterns to predict poor outcome seems contradictory. -
Виктория Антонова
Thank you for this interesting and important review. Please take this response on behalf of the British Red Cross. With increasing pressure on emergency services, changes to how people learn, and the emerging models for community resilience which include preparedness and skills to respond, exploration of this topic indicates significant gaps in research and insight. The outcomes you were looking for were inevitably limited. By not including social/ethical/environmental outcomes either because the studies did not report them, or because they could not be directly linked to patient outcomes seems a significant limitation. Outcomes not included here such as community resilience, learner confidence/intention/likelihood/willingness to act, empowerment of lay responders, interdependence between lay and professional responders created as a result of community education would be interesting and important to explore in this context. It appears that ‘bystander CPR rate’ has possibly been used as a proxy for all these more nuanced outcomes, and in doing so the review misses an opportunity to recognise the wider benefits of community education. ‘Bundled initiatives’ is not a term we were familiar with, although having read the review we understand it to be a set of clinically focused education interventions grouped together. From an educational perspective this also seems limiting. Blended learning is not mentioned in this review, although it could have similar benefits for the learner. Perhaps an additional gap to note might be to find the optimal mix of both topics and educational approaches to achieve identified outcomes. -
Lloyd Jensen
Great discussion of a very important point. Agree that for those in the Delivery Room with experience and equipment, the UVC is a simple , fast and reliable method. As long as it is only placed in 2 to 4 cm, there is no need for radio-graphic confirmation during an emergency. Agree completely with Scott De Boer regarding situations outside of the DR.- ie the responder/provider in the ED, in the field, in facilities without experience in UVC placement, or where you did not get the emergent UVC, or the neonate with a dried cord. The skill to place a IO can be life saving. This skill has to be practiced. The task training to place an IO is a critical skill for those responding to emergencies. If one does not have a "drill" or a "manual" IO devise a larger spinal needle could be used- 13, 18. (or 20 gauge) .The problem is the length of those needles. My opinion is that it is a skill that should be included in neonatal resuscitation training-especially for non NICU/DR providers. -
Виктория Антонова
Agree. UVC is the preferred route but if it can't be placed (i.e. week old infant) and peripheral access is not easily obtained an IO is the only other option. -
Виктория Антонова
I am conducting an intervention study related to neonatal resuscitation in one of the poorest regions of Brazil. In this region, there are no doctors specializing in neonatology, the structure is very precarious and about 7000 newborns are born per year. I believe that IO training for this population would be more feasible given the difficulty of a practitioner with poor CUV practice succeeding in advanced resuscitation.