Lorem ipsum dolor sit amet, consectetur adipisicing elit?
Lorem ipsum dolor sit amet, consectetur adipisicing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum.
Resubmission
Lorem ipsum dolor sit amet, consectetur adipisicing elit?
Lorem ipsum dolor sit amet, consectetur adipisicing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum.
Joris R(Jul 19 2023 3:48AM):
I like the 'natural' flow of steps in the 1.0 version, e.g. the BLS box and prolonged CPR box with the dotted lines are distracting in that sences.
[Edited]
Joris R(Jul 19 2023 4:04AM):
I miss a complete descriptioni of CPA assessement, e.g. non-breaching. It gives the impresson 'assessment' is not a first step in the CPR process. I suggest to add it.
[Edited]
You’re thinking that adding a box to the top that says something like “unresponsive, apneic patient”? We decided to take that out because the algorithm is meant to be applied to patients believed to be in CPA as a reminder of the training the rescuers have already received. We thought that very basic aspect would be ok to leave off for simplicity’s sake. As a reminder, the intention of these cognitive aids is not to teach the algorithm exhuastively, but to serve as a cognitive aid for folks who have been trained. What do others think about the need for that box at the top? Great to get so many thoughtful suggestions!
Joris R(Jul 19 2023 4:06AM):
The algorithm assumes the patient is already intubated as an instruction for non-intubated patients is missing? This skips the BLS of a non-intubated patient: is that wise?
Joris R(Jul 19 2023 4:11AM):
Several separate boxes on the same step 'shockable rhythm'. I find it a bit confusing to be honest.
[Edited]more
I guess it goes back to what this flow chart is intended for. For me it gives an overview of the most important steps in the CPR process (as 1.0 version did well I think), not necessarily a more detailed broken down description of every step as it becomes less clear?
Good thoughts here. We were trying to address some of the issues that folks see to struggle with during in-person training, specifically the idea that compressions should be done while the defibrillator is charged and then AFTER the shock, a full 2 minute cycle of chest compressions should be done. Would love some more input on whether that’s clear on the left side of the algorithm and if there are suggestions for ways to make that clearer.
Valerie G(Aug 13 2023 5:04PM):
In the section for pulse, I think it should say rhythm check-- PQ can be unpredictable and we need to ensure that a visual check is done not just a PQ
Katie N(Jul 16 2023 11:12PM):
I would suggest grouping 'Start BLS (1), 2 full minutes, no pauses' and an abbreviated 'Start ALS (2,3,4)' together in the same text box (can split in half by colours), then have a dotted line to the current 'start ALS box' and expand on 2,3 and 4 here.
more
The new algorithm looks incredible! I can see how much thought has gone into making it very streamlined and clear while still fitting on a page for printing purposes.
Rebecca W(Jul 18 2023 2:37PM):
I agree - I think this is a great suggestion - Start ALS can be in box 1 (top) and keep the ALS information on the right side (mirroring the BLS information) with monitoring/IV access and reversals
The only issue is that the “Start BLS” is repeated every 2 minute cycle but “Start ALS” is only done once. This is why we pulled it off to the side in it’s own box that just terminates (i.e., doesn’t loop back to the main algorithm). We were concerned that having Start ALS in that same box and then looping the algorithm back to it would be confusing. Would love some more input on this.
Valerie G(Aug 13 2023 4:59PM):
I think that we could have a "trainer" version and an on- floor version of this. I miss the original (2nd version) visuals for those who are just learning.
[Edited]more
I also see that CO2 is now >18 not 15. has that been validated already?
Susanna T(Jul 19 2023 4:29AM):
I like the second half a lot, but I think this first half is over complicated and could put people off.
more
BLS info should all be in 1 box so you don’t have to look elsewhere for the info. Pause and check should come after ALS, not along side. I think you have tried to indicate this by matching the red colour to ALS steps, but it needs to be clearer.
I suggest reformat this area to 3 wider boxes stacked vertically.
Dan F(Jul 20 2023 10:09AM):
Thanks for the comments! A few things to consider
more
For small teams, there are times when all of the ALS initiation steps don’t get done before the end of the first 2 minute cycle, so we thought pulling that out to the side made sense so it didn’t get confusing (they should stop at 2 minutes). It’s also important that the CPR training will focus on teaching the algorithm, so although it is a bit complicated (as is CPR!), this is meant just as a reminder, not as something that would be used by folks who have not been trained in CPR. As for the BLS details, the issue is space on the algorithm and fitting everything in, but we could definitely look at widening that BLS box to pull the details in. We’ll send that suggestion to the graphic designer and see what she can come up with.
Kathy G(Jul 19 2023 3:40PM):
The recommendations state less than <5-10 seconds between cycles but this states <10-15 seconds which is a really long time.
Aurora Z(Jul 27 2023 8:08AM):
Hi, I wonder if there is a chance to add more clarification here, as in the esmolol domain I noticed refractory defined as 3 + shocks and esmolol recommended after 1. Thanks.
Dan F(Jul 27 2023 9:16AM):
Hi Aurora! This says 2 or more shocks, so it is consistent with the esmolol recommendation.
more
The only way to know if the first shock was unsuccessful would be to get to the end of the second cycle of BLS (after shocking at the end of the first) and then recheck the rhythm. The recommendation would be to shock a second time and then we suggest giving a dose of esmolol. It’s a little confusing, but is consistent with the esmolol recommendation. Let me know if that answers your question!
Kenneth J(Jul 24 2023 7:57AM):
Having a pulse and adequate circulation is an important question. CPR assists cardiac output when poor circulation is present. Should this be asked now or is t part of the PCA algorythm?
Chantal F(Jul 20 2023 8:13PM):
Awesome work! Initial
more
I really like the suggested updates and appreciate the immense amount of work that goes into a project like this! At first glance here are my initial thoughts on the new algorithm.
1. I personally find the arrows difficult to follow sometimes. I do appreciate the difficulty of looping things back to an event so it something that will take getting used to.
2. The start BLS box 2 full minutes doesn’t lead my eye to the second BLS box but rather to the pause and check box which is telling me to make a rhythm diagnosis and palpate pulse but I haven’t started ALS which would have me putting on the ECG, ETCO2, IV, Reversal. I really like the 1.0 color coding of the algorithm and found that people found it to lock into as they progressed from BLS to ALS.
3. Is the question about diluting amiodorone being addressed? Is it to be given undiluted as a bolus or diluted per drug instructions and given as a bolus or given over 15 minutes? All questions that continue to be asked.
4.I am assuming there will be a major drug chart update as well with doses for Esmlol.
5. And finally,I am curious about the bicarb since the patient is already very acidotic and bicarb breaks down into CO2 and water, is this considered a Hail Mary because of the potential that the acidosis may worsen?
Again, incredible work and I am sure the final product will be outstanding. The quote I leave my students with “It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.” Change is good! Keep up the good work!
Desktop/Laptop: double-click any text, highlight a section of an image, or add a comment while a video is playing to start a new conversation. Tablet/Phone: single click then click on the "Start One" link (look right or below).
Click "Reply" on a comment to join the conversation.
icons on the left to see existing comments.
0 General Document comments
0 Sentence and Paragraph comments
0 Image and Video comments
New Conversation
New Conversation
Hide Thread Detail
You’re thinking that adding a box to the top that says something like “unresponsive, apneic patient”? We decided to take that out because the algorithm is meant to be applied to patients believed to be in CPA as a reminder of the training the rescuers have already received. We thought that very basic aspect would be ok to leave off for simplicity’s sake. As a reminder, the intention of these cognitive aids is not to teach the algorithm exhuastively, but to serve as a cognitive aid for folks who have been trained. What do others think about the need for that box at the top? Great to get so many thoughtful suggestions!
New Conversation
Hide Full Comment
New Conversation
I guess it goes back to what this flow chart is intended for. For me it gives an overview of the most important steps in the CPR process (as 1.0 version did well I think), not necessarily a more detailed broken down description of every step as it becomes less clear?
New Conversation
Hide Full Comment Hide Thread Detail
Good thoughts here. We were trying to address some of the issues that folks see to struggle with during in-person training, specifically the idea that compressions should be done while the defibrillator is charged and then AFTER the shock, a full 2 minute cycle of chest compressions should be done. Would love some more input on whether that’s clear on the left side of the algorithm and if there are suggestions for ways to make that clearer.
New Conversation
Hide Full Comment
New Conversation
The new algorithm looks incredible! I can see how much thought has gone into making it very streamlined and clear while still fitting on a page for printing purposes.
New Conversation
Hide Full Comment Hide Thread Detail
New Conversation
Hide Thread Detail
The only issue is that the “Start BLS” is repeated every 2 minute cycle but “Start ALS” is only done once. This is why we pulled it off to the side in it’s own box that just terminates (i.e., doesn’t loop back to the main algorithm). We were concerned that having Start ALS in that same box and then looping the algorithm back to it would be confusing. Would love some more input on this.
New Conversation
Hide Full Comment
I also see that CO2 is now >18 not 15. has that been validated already?
New Conversation
Hide Full Comment
BLS info should all be in 1 box so you don’t have to look elsewhere for the info. Pause and check should come after ALS, not along side. I think you have tried to indicate this by matching the red colour to ALS steps, but it needs to be clearer.
I suggest reformat this area to 3 wider boxes stacked vertically.
New Conversation
Hide Full Comment Hide Thread Detail
For small teams, there are times when all of the ALS initiation steps don’t get done before the end of the first 2 minute cycle, so we thought pulling that out to the side made sense so it didn’t get confusing (they should stop at 2 minutes). It’s also important that the CPR training will focus on teaching the algorithm, so although it is a bit complicated (as is CPR!), this is meant just as a reminder, not as something that would be used by folks who have not been trained in CPR. As for the BLS details, the issue is space on the algorithm and fitting everything in, but we could definitely look at widening that BLS box to pull the details in. We’ll send that suggestion to the graphic designer and see what she can come up with.
New Conversation
Hide Full Comment
New Conversation
New Conversation
Hide Thread Detail
New Conversation
New Conversation
New Conversation
Hide Thread Detail
The only way to know if the first shock was unsuccessful would be to get to the end of the second cycle of BLS (after shocking at the end of the first) and then recheck the rhythm. The recommendation would be to shock a second time and then we suggest giving a dose of esmolol. It’s a little confusing, but is consistent with the esmolol recommendation. Let me know if that answers your question!
New Conversation
Hide Full Comment
New Conversation
New Conversation
General Document Comments 0
I really like the suggested updates and appreciate the immense amount of work that goes into a project like this! At first glance here are my initial thoughts on the new algorithm.
1. I personally find the arrows difficult to follow sometimes. I do appreciate the difficulty of looping things back to an event so it something that will take getting used to.
2. The start BLS box 2 full minutes doesn’t lead my eye to the second BLS box but rather to the pause and check box which is telling me to make a rhythm diagnosis and palpate pulse but I haven’t started ALS which would have me putting on the ECG, ETCO2, IV, Reversal. I really like the 1.0 color coding of the algorithm and found that people found it to lock into as they progressed from BLS to ALS.
3. Is the question about diluting amiodorone being addressed? Is it to be given undiluted as a bolus or diluted per drug instructions and given as a bolus or given over 15 minutes? All questions that continue to be asked.
4.I am assuming there will be a major drug chart update as well with doses for Esmlol.
5. And finally,I am curious about the bicarb since the patient is already very acidotic and bicarb breaks down into CO2 and water, is this considered a Hail Mary because of the potential that the acidosis may worsen?
Again, incredible work and I am sure the final product will be outstanding. The quote I leave my students with “It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.” Change is good! Keep up the good work!
New Conversation
Hide Full Comment