Recent discussions
-
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
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. -
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
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.