Recent discussions
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Dorothy (Doreen) Igharo
Base on this research review outcome, the recommended treatment remains unchanged since 2021. It proposes against the use of head-up CPR r/t very-low-certainty evidence. It also suggests that the usefulness of head-up CPR during be assessed in clinical research or trial initiatives-very-low-certainty evidence and weak recommendation. As per this review research outcome, there is no substantial evidence that the head-up CPR bundle is connected with better neurological and survival outcomes. This research review outcome did point out that the “significant outcome of ROSC, the observational study by pepe et al. an augmented rate of resuscitation success as seen in hospital arrival with continued spontaneous circulation whereby the Moore and the Bachista studies both indicated that ROSC were not statistically significant difference between the head-UP CPR group and the conventional CPR groups”
Therefore, I think that further research is required to determine the effects of head-Up CPR on Neurological and survival outcomes
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Peter Mertins
I agree with the findings of the task force regarding Head Up CPR.
I agree that more research on this area is warranted before it becomes a treatment recommendation in BLS and ACLS. After having reviewed some of the references, I have a better understanding of how CPR compressions increases ICP and how Head Up CPR along with ACD along with ITD may benefit reduced ICP pressures from brain to heart and increase cerebral perfusion as well. I can understand how Head up CPR would have to be implemented along with ITD and ACDs and with that further training and cost of these tools and training would be rather extensive and perhaps not possible for some regions of care Further research and study into this area may indeed prove effective for its use, but I would argue to continue with traditional CPR compressions maintaining adequate rate, depth, and recoil while using a compression feedback device if available Also the use of a CPR coach is ideal to monitor the compressions and give feedback as needed, or even to recommend that compressor roles be switched(team CPR).
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Joe Holley
I have read with interest the CoSTR statement on Effects of Head-Up CPR on Survival and Neurological outcomes (BLS_2020): TFSR. I appreciate the opportunity to provide some feedback.
There was a recent article by Dr. Debaty in Resuscitation (2024) that needs to be reviewed and considered in the treatment recommendations.
Secondly, there is extensive animal data showing a striking benefit of head-up CPR, when performed correctly, is not discussed at all, especially when one considers that >95% of all of the AHA and ILCOR CPR recommendation lack level 1 RTCs. Head-up CPR is a major breakthrough in the field. It helps protect the brain from the build up of venous blood, which is an inherent limitation of conventional flat CPR. The lack of mention of the mechanisms of action of head-up CPR is a major deficiency in this review. Full chest wall recoil is essential to driving blood flow back to the heart after each chest compression. Nearly every 2b recommendation for CPR by ILCOR suffers form a similar lack of randomized trials. Consider conventional CPR. Despite it being the standard of care for >60 years, neurologically intact survival remain <9% in nearly every country in the world.
Most recently Debaty el al tested 3 CPR adjuncts, an automated active compression decompression device, a patient position system, and an impedance threshold device, in witnessed out-of-hospital cardiac arrest patients. (https://doi.org/10.1016/j.resuscitation.2024.110406) These devices were shown in pigs by Moore et al to lower intracranial pressure, increase brain blood circulation, and increase neurologically-intact survival compared with conventional CPR. In his recent paper Debaty et al found that ETCO2 values were strikingly higher in patients treated with head-up CPR. In fact, the ETCO2 values were within normal limits in his study, regardless of the presenting rhythm. It would be most unfortunate for the field if this article was not included in your review.
Finally, I am the medical director for two EMS agencies in Tennessee. We were among the first in the US to implement head-up CPR and I am a co-author on some of the clinical papers you reference. For over 4 years we have continued to have saves, with our overall percent survival rates for all patients in out-of-hospital cardiac consistently in the high teens to low twenties.
It will be a loss for the field if Debaty’s article and the science underlying head up CPR is not part of this year’s CoSTR review.
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Cees van Romburgh
At the Dutch North Sea coast, we have quite some experiences with swimmers who have come into contact with jellyfish. For the first International First Aid and Resuscitation Guidelines of the IFRC, I once researched this item back in 2015/2016.
The therapy after jellyfish / envenomation is primarily aimed at inhibiting the nematocysts, followed by pain relief. I agree that seawater is the first recommended method for pain management.
Using vinegar prevents any remaining nematocysts from "firing," but it does not neutralize the toxin and can even cause some irritation to the wound. It is unclear whether rinsing with vinegar (5%) for 30 to 60 seconds is applicable for jellyfish other than the Australian box jellyfish. Therefore, I am pleased with the confirmation of the advice that lay first aid providers should know the type of jellyfish responsible for the envenomation before beginning treatment.
It is unclear whether rinsing with vinegar (5%) for 30 to 60 seconds is applicable for jellyfish other than the Australian box jellyfish. [Prestwich H., Jenner R. Treatment of jellyfish stings in UK coastal waters: vinegar or sodium bicarbonate? Emergency Medicine Journal. 2007; 24, 664] Consider intoxications by Portuguese Man-of-Wars (Physalia species) and Lion’s Mane Jellyfish (Cyaneidae sp.), where rinsing with household vinegar or acetic acid (5%) is also effective. Vinegar could also be used after stings from the Sea Wasp (Carybdea marsupialis) and the Compass Jellyfish (Chrysaora hysoscella). [Montgomery L, Seys J, Mees J. To Pee, or Not to Pee: A Review on Envenomation and Treatment in European Jellyfish Species. Mar Drugs 2016;14(7):127.]
Therefore, I am pleased with the confirmation of the advice that lay first aid providers should know the type of jellyfish responsible for the envenomation before beginning treatment.
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Prof. Oxford York
As Master Instructor good neurological outcome and survival to hospital discharge are critical measures often assessed in cases of cardiac arrest or severe neurological injury. In this context, high-quality Cardiopulmonary Resuscitation (CPR) can significantly influence patient outcomes.The Heads Up CPR and heads up CPR Bundle shows considerable potential for improving neurological outcomes and survival to hospital discharge, but its successful implementation and efficacy will depend on further research and training. Prioritizing effective team dynamics, minimizing interruptions, and adapting to the challenges of various environments will be key to its success. Definitely content with the innovation but more clinical research is needed.
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Caitlyn Pavey-Smith
Thank you for the opportunity to comment on this draft CoSTR.
We are concerned about the wording of the Good Practice Statement that “We advise against using locked cabinets”. While it is immediately followed by a statement around unlocking instructions, this may lead to design of a system requiring unlocked cabinets that may be suboptimal for the setting.
In Western Australia, our locked cabinet system, which uses a keypad combination provided during emergency calls, has benefits like confirming an emergency call has been made and tracking defibrillator deployment for quick consumable replacement. While we agree that unlocked cabinets are generally better for patients, we believe that not all scenarios are equal.
As we discuss in our (accepted but not yet published) correspondence in reply to the recently published scoping review, our experience is that locked cabinets are far more acceptable to organisations considering making their AED publicly accessible based on a perception of risk of theft or vandalism.In regions where Public Access Defibrillators (PADs) are funded by governments or health services, unlocked cabinets may be ideal. However, in places like WA, many PADs come from organisations that may lack the resources to replace stolen devices. In these cases, a locked cabinet can encourage more PADs to be available, despite the minor delay in unlocking.
Acceptability and feasibility will vary by EMS systems based on resource availability, risk perceptions, and system capability. In our region, we provide unlocking codes during emergency calls, minimising delays. We are aware that this capability does not exist in all EMS systems for many reasons including that an EMS system may not operate their own emergency call-taking and dispatch service so cannot provide information on nearby PADs and unlocking codes on the emergency call. In such cases it may be that regardless of acceptability, unlocked cabinets are the practical solution.
Given these variations and the limited evidence available, we recommend that the good practice statement be rephrased more cautiously. EMS systems should evaluate their specific circumstances to decide which model strikes the best balance between the accessibility of unlocked cabinets and the security of locked systems.
Lastly, we support careful design considerations for cabinets to prevent rescuer injury, such as avoiding break-glass designs.
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Cees van Romburgh
At the Dutch North Sea coast, we have quite some experiences with swimmers who have come into contact with jellyfish. For the first International First Aid and Resuscitation Guidelines of the IFRC, I once researched first aid for encounters with marine animals (especially jellyfish) back in 2015.
The therapy after jellyfish / envenomation is primarily aimed at inhibiting the nematocysts, followed by pain relief. I completely agree that seawater is the first recommended method for pain management. After washing away, the tentacle remnants and remaining nematocysts with seawater or a 0.9% NaCl saline solution, the pain can possibly be treated by rinsing with warm water (if available, as mentioned in the first aid stations at or near the beach).
Using vinegar prevents any remaining nematocysts from "firing," but it does not neutralize the toxin and can even cause some irritation to the wound. For a whole range of jellyfish, it is unwise to use vinegar, such as with Sea Nettles (Chrysaora sp.), Clinging Jellyfish (Gonionemus sp.), Mauve Stingers (Pelagia noctiluca), and Sea Anemones (Actiniaria sp.). Vinegar can stimulate the remaining unfired nematocysts to fire. [Handbook of Clinical Toxicology of Animal Venoms and Poisons. Editors: Meier J, White J. New York, USA; CRC Press Inc. 1995: 89-116]
It is unclear whether rinsing with vinegar (5%) for 30 to 60 seconds is applicable for jellyfish other than the Australian box jellyfish. [Prestwich H., Jenner R. Treatment of jellyfish stings in UK coastal waters: vinegar or sodium bicarbonate? Emergency Medicine Journal. 2007; 24, 664] Consider intoxications by Portuguese Man-of-Wars (Physalia species) and Lion’s Mane Jellyfish (Cyaneidae sp.), where rinsing with household vinegar or acetic acid (5%) is also effective. Vinegar could also be used after stings from the Sea Wasp (Carybdea marsupialis) and the Compass Jellyfish (Chrysaora hysoscella). [Montgomery L, Seys J, Mees J. To Pee, or Not to Pee: A Review on Envenomation and Treatment in European Jellyfish Species. Mar Drugs 2016;14(7):127.]
Therefore, I am pleased with the confirmation of the advice that lay first aid providers should know the type of jellyfish responsible for the envenomation before beginning treatment.
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Dr Sreenivasarao Surisetty
External uterine massage for PPH as a part of first aid, whenever there are no alternative treatment methods available, we can try it, but we should be aware of the Dangers of PPH complications, if you are not treated properly PPH can lead to maternal death also, a lot of mechanisms are included to cause PPH. Yes, external massage may stimulate the uterus to contract, but it depends upon the awareness of external massage by laypeople like where to give a massage, etc. So proper training is also required for laypeople, & they need training on how to identify the complications of PPH, then we can try it as first aid for PPH
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Cees Van Romburgh
At the Dutch North Sea coast, we have quite some experiences with swimmers who have come into contact with jellyfish. For the first International First Aid and Resuscitation Guidelines of the IFRC, I once researched first aid for encounters with marine animals (especially jellyfish) back in 2015.
The therapy after jellyfish / envenomation is primarily aimed at inhibiting the nematocysts, followed by pain relief. I completely agree that seawater is the first recommended method for pain management. After washing away, the tentacle remnants and remaining nematocysts with seawater or a 0.9% NaCl saline solution, the pain can possibly be treated by rinsing with warm water (if available, as mentioned in the first aid stations at or near the beach).
Using vinegar prevents any remaining nematocysts from "firing," but it does not neutralize the toxin and can even cause some irritation to the wound. For a whole range of jellyfish, it is unwise to use vinegar, such as with Sea Nettles (Chrysaora sp.), Clinging Jellyfish (Gonionemus sp.), Mauve Stingers (Pelagia noctiluca), and Sea Anemones (Actiniaria sp.). Vinegar can stimulate the remaining unfired nematocysts to fire. [Handbook of Clinical Toxicology of Animal Venoms and Poisons. Editors: Meier J, White J. New York, USA; CRC Press Inc. 1995: 89-116]
It is unclear whether rinsing with vinegar (5%) for 30 to 60 seconds is applicable for jellyfish other than the Australian box jellyfish. [Prestwich H., Jenner R. Treatment of jellyfish stings in UK coastal waters: vinegar or sodium bicarbonate? Emergency Medicine Journal. 2007; 24, 664] Consider intoxications by Portuguese Man-of-Wars (Physalia species) or Lion’s Mane Jellyfish (Cyaneidae sp.), where rinsing with household vinegar or acetic acid (5%) is also effective. Vinegar could also be used after stings from the Sea Wasp (Carybdea marsupialis) and the Compass Jellyfish (Chrysaora hysoscella). [Montgomery L, Seys J, Mees J. To Pee, or Not to Pee: A Review on Envenomation and Treatment in European Jellyfish Species. Mar Drugs 2016;14(7):127.]
Therefore, I am pleased with the confirmation of the advice that lay first aid providers should know the type of jellyfish responsible for the envenomation before beginning treatment.
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Dr Sreenivasarao Surisetty
After thoroughly reading all the studies, I concluded that washing the sting areas with sea water followed by applying heat using hot water or hot water bags to treat sting pain is the best treatment. However, take precautions to ensure that the hotness of the water doesn't cause burns. In any study, they didn't mention at what temperature the water should be, so be cautious about the temperature of hot water.