Professional Documents
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Cardiovascular Disease
In Europe cardiovascular disease accounts for 40% of all deaths < 75 yrs One third of all people developing an MI die before reaching hospital Presenting rhythm in most of these cases is VF/VT In-hospital cardiac arrest more likely non-VF/VT
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Chain of Survival
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Cardiac Arrest
Precordial Thump if appropriate
Assess Rhythm
VF/VT
Defibrillate X 3 as necessary CPR 1 min
Non-VF/VT
During CPR
Correct reversible causes If not already: check electrodes, paddle position and contact attempt / verify airway & O2 i.v. access give epinephrine every 3 min Consider: amiodarone, atropine / pacing buffers
CPR 3 min*
* 1 min if immediately after defibrillation
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RC (UK)
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Objectives
To understand: The causes of cardiorespiratory arrest in adults How to identify patients at risk The role of a Medical Emergency Team The initial management of patients at risk of a cardiorespiratory arrest
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Pulmonary disorders
pneumothorax, lung pathology
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Primary Secondary Ischaemia Asphyxia Myocardial infarction Hypoxaemia Hypertensive heart disease Blood loss Valve disease Septic shock Drugs Electrolyte abnormalities
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Airway obstruction
Symptoms and signs Difficulty breathing, distressed, choking Shortness of breath Stridor, wheeze, gurgling See-saw respiratory pattern Actions Suction, positioning BLS manoeuvres Advanced airway intervention
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Breathing inadequacy
Symptoms and signs Short of breath, anxious, irritable Decrease in conscious level Tachypnoea Cyanosis
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Stable angina
Pain from myocardial ischaemia tightness/ache across chest radiating to throat/arms/back/epigastrium provoked by exercise settles when exercise ceases NOT an acute coronary syndrome
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Unstable angina
Angina of effort with increasing frequency and provoked by less exertion Angina occurring recurrently and unpredictably - not specific to exercise Unprovoked and prolonged episode of chest pain - no ECG or laboratory evidence of MI
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Percutaneous transluminal coronary angioplasty (PTCA) Coronary artery bypass surgery (CABG)
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MONA Heparin continuous infusion unfractionated, or subcutaneous low molecular weight Intravenous nitrate If high risk: glycoprotein IIb/IIIa inhibitor Consider beta-blockers
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Any Questions?
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Summary
Airway, breathing or cardiac problems can cause cardiorespiratory arrest Patients often have warning symptoms and signs Early recognition may allow arrest prevention In acute coronary syndromes consider MONA and start reperfusion therapy early, if indicated
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Objectives
To understand: The risks to the rescuer during resuscitation How to perform BLS The differences between layperson and in-hospital BLS
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Assessment
Ensure safety of rescuer and victim
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Assess Breathing
Look for chest movement Listen for breath sounds Feel for expired air Assess for 10 seconds before deciding breathing is absent
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Finger sweep
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Assess Circulation
Look, listen and feel for normal breathing, coughing, or movement by the victim Check the carotid pulse (if trained) Take no more than 10 seconds
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Is a circulation present? NO
Start chest compressions Continue with rescue breathing
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Identify xiphisternum
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Chest compressions:
Depress sternum 4-5 cm Rate: 100 per minute
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Chest compressions
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Mouth-to-nose ventilation
If mouth-to-mouth technically difficult If mouth seriously injured Rescue from water Resuscitation carried out by a child Aesthetic reasons
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Compression-only CPR
Reluctance to perform mouth-tomouth ventilation Chest compression alone better than no CPR If possible combine with head tilt Appropriate for telephone-CPR
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Abdominal Thrusts
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Patient Collapsed
Definite Pulse and Breathing Present? No Call cardiac arrest team / Get defibrillator Start BLS if defibrillator not immediately available Apply pads / monitor Defibrillate if appropriate Ventilate with oxygen Chest compressions ALS on arrival of Cardiac Arrest Team Yes Call for medical assistance
Any Questions?
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Summary
ABC of basic life support rescue breathing chest compressions modifications
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Upper Airway
Larynx
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FEEL
But, death from hypoxia is more common than from injury to the cervical spinal cord RC (UK)
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Jaw Thrust
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Suction
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Advantages Limitations Avoids direct person When used with a to person contact facemask: Allows oxygen Risk of inadequate supplementation up ventilation to 85% Risk of gastric Can be used with inflation facemask, LMA, Need two persons Combitube, tracheal for optimal use tube
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Limitations Rapidly and easily No absolute inserted guarantee against Variety of sizes aspiration More efficient Not suitable if very ventilation than high inflation facemask pressures needed Avoids the need Unable to aspirate for laryngoscopy airway
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LMA Insertion
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The Combitube
Advantages Rapidly and easily inserted Avoids need for laryngoscopy Protects against aspiration Can be used if inflation pressures high Limitations Available in 2 sizes only Potential for ventilation via wrong lumen Damage to cuffs on insertion Trauma on insertion Single use RC (UK)
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Tracheal Intubation
Advantages Limitations Allows ventilation Training and with up to 100% O2 experience essential Isolates airway, Failed insertion, preventing aspiration oesophageal placement Allows aspiration of the airway Potential to worsen cervical cord or head Alternative route for injury drug administration
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Tracheal Intubation
Attempting intubation: Pre-oxygenate the patient Allow 30 seconds only for attempt Insert tube through larynx under direct vision If in doubt or difficulty, re-oxygenate before further attempts Patients are harmed by failure of oxygenation, not failure of intubation!
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Cricoid Pressure
Anteroposterior pressure on cricoid cartilage by an assistant to occlude the oesophagus against cervical vertebra
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Cricoid Pressure
Advantages Limitations Reduces risk of May make regurgitation and intubation more aspiration difficult Useful during May impair intubation, ventilation via ventilation with facemask , LMA facemask or LMA Avoid if active vomiting
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Needle Cricothyroidotomy
Indication Failure to provide an airway by any other means Complications Malposition of cannula
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Any Questions?
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Summary
Recognise and relieve airway obstruction using basic techniques Oxygen The role of the LMA, Combitube and tracheal intubation in managing the airway during CPR Ventilation techniques during CPR
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Objectives
To understand: Indications & techniques for ECG monitoring Basic electrocardiography How to read a rhythm strip cardiac arrest rhythms peri-arrest arrhythmias
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Which patients?
Cardiac arrest or other important arrhythmias Chest pain Heart failure Collapse / syncope Shock / hypotension Palpitations
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12-lead ECG
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12-lead ECG
3D electrical activity from heart More sophisticated ECG interpretation ST segment analysis
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Ventricular fibrillation
Bizarre irregular waveform No recognisable QRS complexes Random frequency and amplitude Unco-ordinated electrical activity Coarse / fine Exclude artifact
movement electrical interference
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Asystole
Absent ventricular (QRS) activity Atrial activity (P waves) may persist Rarely a straight line trace Consider fine VF
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A broad complex tachycardia should be assumed to be ventricular in origin unless there is a very good reason to suspect otherwise.
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Site of pacemaker:
AV node 40 - 50 min-1 Ventricular myocardium 30 - 40 min-1
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Any Questions?
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Summary
Monitoring which patients techniques Recognition cardiac arrest rhythms other rhythms
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DEFIBRILLATION
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Objectives
To understand: What is meant by defibrillation The indications for defibrillation How to deliver a shock safely using: a manual defibrillator an automated external defibrillator (AED)
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Mechanism of defibrillation
Definition The termination of fibrillation or absence of VF/VT at 5 seconds after shock delivery Critical mass of myocardium depolarised Natural pacemaker tissue resumes control
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Defibrillation
Success depends on delivery of current to the myocardium Current flow depends upon: Electrode position Transthoracic impedance Energy delivered Body size
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Transthoracic Impedance
Dependent upon: Electrode size Electrode/skin interface Contact pressure Phase of respiration Sequential shocks
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Defibrillators
Design Power source Capacitor Electrodes Types Manual Automated Monophasic or Biphasic waveform
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Defibrillator waveforms
Damped Monophasic
Truncated Biphasic
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Biphasic Defibrillators
Require less energy for defibrillation smaller capacitors and batteries lighter and more transportable Repeated < 200 J biphasic shocks have higher success rate for terminating VF/VT than escalating monophasic shocks
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BLS
If AED not immediately available Switch defibrillator ON Attach electrodes Follow spoken/visual directions
AED Algorithm
ANALYSE
Shock Indicated
After every 3 shocks CPR 1 minute
No shock Indicated
If no circulation CPR 1 minute
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Manual Defibrillation
Relies upon: Operator recognition of ECG rhythm Operator charging machine and delivering shock Can be used for synchronised cardioversion
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Defibrillator Safety
Never hold both paddles in one hand Charge only with paddles on casualtys chest Avoid direct or indirect contact Wipe any water from the patients chest Remove high-flow oxygen from zone of defibrillation
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Shock Energy
Initial shock energy 200 J*, repeat once if unsuccessful Subsequent shocks at 360 J* Shocks delivered in groups of three If defibrillation restores the patients circulation and VF/VT recurs, start again at 200J*
*or biphasic equivalent
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Defibrillation
A series of 3 shocks should be delivered rapidly, do not interrupt the sequence for CPR or a pulse check unless:
Possible restoration of cardiac output Uncertain ECG rhythm
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Synchronised cardioversion
Convert atrial or ventricular tachyarrhythmias Shock synchronised to occur with the R wave Short delay after pressing discharge buttons keep defibrillator electrodes in place Conscious patients: sedation or anaesthesia Check mode if further shock/s required
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Any Questions?
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Summary
Defibrillation is the only effective means of restoring cardiac output for the patient in VF or pulseless VT Defibrillation must be performed promptly, efficiently and safely New technology has improved machine performance and simplified use
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Objectives
Understand the reasons for venous access Review the equipment used Outline the routes used for venous access Understand the associated complications
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Any Questions?
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Summary
If a peripheral cannula is in place and working, use it initially Central veins are the route of choice if expertise is available, but beware of complications The tracheal route can be used with appropriate adjustment of dose
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DRUGS
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Objectives
To understand the indications, doses and actions of drugs used in resuscitation To understand the indications, doses and actions of some of the common drugs used to treat peri-arrest arrhythmias
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Epinephrine
Indications: All cardiac arrest rhythms Bradycardia Special circumstances: anaphylaxis
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Epinephrine
Dose: 1 mg intravenous 10 ml 1:10,000 (1 ml 1:1,000) every 2-3 mins during resuscitation 2-3 mg via tracheal tube 210 mcg min-1 for atropine resistant bradycardia 0.5ml 1:1,000 i.m., 3-5 ml 1:10,000 i.v. in anaphylaxis, depending on severity
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Epinephrine
Actions: agonist vasoconstriction resistance arterial
systemic vascular
Atropine
Indications: Asystole Symptomatic bradycardias PEA (rate < 60 beats min-1)
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Atropine
Dose: Asystole / PEA (rate < 60 beats min-1) 3 mg i.v., once only 6 mg via tracheal tube Bradycardia 0.5 mg i.v., repeated as necessary, maximum 3 mg
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Atropine
Actions: Blocks effects of vagus nerve
Amiodarone
Indications:
Refractory VF / Pulseless VT Haemodynamically stable VT Other resistant tachyarrhythmias
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Amiodarone
Dose:
Amiodarone
Actions: Lengthens duration of action potential Prolongs Q-T interval Mild negative inotrope - may cause hypotension
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Magnesium
Indications:
Shock refractory VF
(with possible hypomagnesaemia) Ventricular tachyarrhythmias (with possible hypomagnesaemia) Torsades de pointes
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Magnesium
Dose: Shock Refractory VF 24 ml 50% (48 mmol) i.v. over 1-2 mins Can be repeated after 10-15 minutes Other circumstances 5 ml of 50% (10 mmol) i.v. over 30 mins
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Magnesium
Actions:
Depresses neurological and myocardial function Acts as a physiological calcium blocker
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Lidocaine
Indications:
Refractory VF / Pulseless VT when amiodarone is unavailable Haemodynamically stable VT as an alternative to amiodarone
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Lidocaine
Dose: Refractory VF / Pulseless VT 100 mg i.v. further boluses of 50 mg, max 200 mg Haemodynamically stable VT 50 mg i.v. further boluses of 50 mg, max 200 mg Reduce dose in elderly or hepatic failure
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Sodium Bicarbonate
Indications:
Severe metabolic acidosis (pH < 7.1) Hyperkalaemia Special circumstance Tricyclic antidepressant poisoning
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Sodium Bicarbonate
Dose: 50 mmol (50 ml of 8.4% solution) i.v.
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Sodium Bicarbonate
Actions: Alkalinizing agent (increases pH) But may: increase carbon dioxide load inhibit release of oxygen to tissues impair myocardial contractility cause hypernatraemia interact with adrenaline
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Calcium
Actions: Essential for normal cardiac contraction Excess may lead to arrhythmias The trigger for cell death in the ischaemic myocardium Excess may impair cerebral recovery
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Calcium
Indications: Pulseless electrical activity caused by: severe hyperkalaemia severe hypocalcaemia overdose of calcium channel blocking drugs Dose 10 ml 10% calcium chloride (6.8 mmol) Do not give immediately before or after sodium bicarbonate
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Adenosine
Indications: Broad complex tachycardia, uncertain aetiology Paroxysmal supraventricular tachycardia
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Adenosine
Dose:
6 mg intravenously, by rapid injection If necessary, three further doses each of 12 mg can be given every 12 mins
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Adenosine
Actions: Slows conduction across the AV node
Must only be used in a monitored environment
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Naloxone
Dose: 0.2 - 2.0 mg i.v. May need to be repeated up to a maximum of 10 mg May need an infusion
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Naloxone
Indications:
Opioid overdose Respiratory depression secondary to opioid administration
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Naloxone
Actions: Opioid receptor antagonist Reverses all opioid effects, particularly respiratory and cerebral May cause severe agitation in opioid dependence
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Any Questions?
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Summary
Indications, dose and actions of drugs used during cardiac arrest
Indications, dose and actions of drugs used in the management of peri-arrest arrhythmias
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Objectives
To understand: Treatment of patients in: ventricular fibrillation and pulseless ventricular tachycardia asystole or pulseless electrical activity (non-VF/VT rhythms)
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Cardiac Arrest
Precordial Thump if appropriate
Assess Rhythm
VF/VT
Defibrillate X 3 as necessary CPR 1 min
Non-VF/VT
During CPR
Correct reversible causes If not already: check electrodes, paddle position and contact attempt / verify airway & O2 i.v. access give epinephrine every 3 min Consider: amiodarone, atropine / pacing buffers
CPR 3 min*
* 1 min if immediately after defibrillation
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Precordial thump
Indication: witnessed or monitored cardiac arrest
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Cardiac Arrest
Precordial Thump if appropriate BLS Algorithm if appropriate
Attach Defib-Monitor
VF/VT
Non-VF/VT
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VF/VT
Defibrillate X 3 as necessary
CPR 1 min
VF/VT
Shock 200 J* Shock 200 J* Shock 360 J*
Deliver 3 shocks, if required, in < 1 minute Do not interrupt shock sequence for BLS After shock/s, palpate carotid pulse only if waveform compatible with a cardiac output
During CPR
Correct reversible causes If not already: check electrodes, paddle position and contact attempt / verify: airway & O2 i.v. access give epinephrine every 3 min Consider: amiodarone, atropine / pacing, buffers
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VF/VT (continued)
Shock 360 J* Shock 360 J* Shock 360 J* Epinephrine every 3 minutes Consider bicarbonate 50 mmol if pH < 7.1 Consider paddle positions
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Non-VF/VT
Asystole Pulseless Electrical Activity
CPR 3 min*
* 1 min if immediately after defibrillation
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Asystole
Confirm: check leads - view via leads I and II check gain Epinephrine 1 mg every 3 minutes Atropine 3 mg i.v. or 6 mg via tracheal tube
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Spurious asystole
When monitoring with paddle-gel pads More likely with increasing number of shocks and high chest impedance Displays apparent asystole Confirm rhythm with monitoring leads
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Any Questions?
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Summary
In patients in VF/pulseless VT attempt defibrillation without delay In patients in refractory VF or with a non-VF/VT rhythm identify and treat any reversible cause
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CARDIAC PACING
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Objectives
To understand: The peri-arrest indications for cardiac pacing How to perform percussion pacing How to apply safely transcutaneous electrical pacing The problems with temporary transvenous pacing
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Atrioventricular junctional region Intrinsic rate 40-50 per min - Narrow QRS complex Distal His-Purkinje fibres Intrinsic rate 0 - 30 per min - Broad QRS complex
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Artificial Pacemakers
Indicated when natural pacemaker too slow or unreliable Rarely successful in straight-line asystole Mechanical pacing Electrical pacing
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Artificial Pacemakers
Classification
Non-invasive Percussion pacing Transcutaneous pacing Invasive Temporary transvenous pacing Permanent implanted pacing Implantable cardioverter defibrillators (ICDs)
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Transcutaneous Pacing
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Artificial Pacemakers
Classification
Non-invasive Percussion pacing Transcutaneous pacing Invasive Temporary transvenous pacing Permanent implanted pacing Implantable cardioverter - defibrillators (ICDs)
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Any Questions?
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Summary
Non-invasive pacing is easily performed Therapy of choice for immediate management of drug resistant bradyarrhythmias Non-invasive pacing is a temporising manoeuvre Seek expert help
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PERI-ARREST ARRHYTHMIAS
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Peri-arrest arrhythmias
To understand: The importance of arrhythmias that occur in the peri-arrest period The principles of management of these arrhythmias
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Peri-arrest arrhythmias
Principles of treatment
How is the patient? What is the arrhythmia?
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Treatment options
Bradycardias Cardiac pacing Tachycardias Cardioversion All Arrhythmias Antiarrhythmic and other drugs
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Cardiac pacing
Reliable method of treating bradycardias Requires expert help to insert transvenous pacing system Used in presence of adverse signs or when drugs have failed
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Cardioversion
Effective at converting tachyarrhythmias
to sinus rhythm
Used when adverse signs Drugs are relatively ineffective May cause VF ! Must use a synchronised shock Need for sedation / anaesthesia
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All drugs that are used to treat arrhythmias can cause arrhythmias !
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Bradycardia
Are there any adverse signs? Systolic blood pressure < 90 mmHg Heart rate < 40 beats min-1 Ventricular arrhythmias requiring suppression Heart failure If YES give atropine 500 g i.v. and assess response
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Bradycardia
If there is a satisfactory response to atropine, and There are NO adverse signs Determine the risk of asystole: Recent episode of asystole? Mobitz type II heart block? Complete heart block with wide QRS? Ventricular pause > 3 seconds?
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Bradycardia
1. 2. 3. 4. There is a risk of asystole If there is NO response to atropine Further doses of atropine, 3 mg maximum External pacing Epinephrine infusion, 2-10 g min-1 Arrange transvenous pacing SEEK EXPERT HELP !
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Bradycardia
If there is a response to atropine, and: There is NO risk of asystole
Observe the patient
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BRADYCARDIA
(Rate <40 beat min-1 or inappropriately slow for haemodynamic state)
Adverse signs? Systolic BP <90 mm Hg Rate < 40 beat min-1 Ventricular arrhythmias requiring suppression Heart failure
NO
YES
NO YES Interim measures: Atropine 500 g i.v. repeat to maximum of 3 mg External pacing Epinephrine 2-10 g min-1 Seek expert help Arrange transvenous pacing
Risk of asystole? Recent asystole Mobitz II AV block Complete heart block with broad QRS Ventricular pause >3 s
NO Observe
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YES
Seek expert help
Cardioversion
Antiarrhythmics
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Pulse?
NO
Use VF protocol
YES Adverse signs? Systolic BP <90 mm Hg Chest pain Heart failure Rate >150 beat min-1
NO
YES
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NO
Adverse signs? Systolic BP <90 mm Hg Chest pain Heart failure Rate >150 beat min-1
Amiodarone 150 mg i.v. over 10 mins or Lidocaine i.v. 50 mg over 2 mins repeated every 5 mins to maximum dose of 200mg; Seek expert help Synchronised DC shock 100 J: 200 J: 360 J or equivalent biphasic energy
Give potassium chloride up to 60 mmol, max rate 30mmol h-1 Give magnesium sulphate i.v. 5ml 50% in 30min
If necessary, further amiodarone 150 mg i.v. over 10 mins, then 300 mg over I hour
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Adverse signs? Systolic BP <90 mm Hg Chest pain Heart failure Rate >150 beat min-1
YES Seek expert help Synchronised DC shock 100 J:200J: 360 J or equivalent biphasic energy If potassium known to be low, see panel Amiodarone 150 mg i.v. over 10 mins Further cardioversion as necessary For refractory cases consider additional pharmacological agents: amiodarone, lidocaine, procainamide or sotalol or overdrive pacing Caution drug-induced myocardial depression
Give potassium chloride up to 60 mmol, max rate 30mmol h-1 Give magnesium sulphate i.v. 5ml 50% in 30min
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NO
YES
Seek expert help If potassium known to be low see panel Synchronised DC shock 100 J:200J: 360 J or equivalent biphasic energy
Amiodarone 150 mg i.v. over 10 mins or Lidocaine i.v. 50 mg over 2 mins repeated every 5 mins to maximum dose of 200mg;
Give potassium chloride up to 60 mmol, max rate 30mmol h-1 Give magnesium sulphate i.v. 5ml 50% in 30min
Amiodarone 150 mg i.v. over 10 mins Seek expert help Further cardioversion as necessary
For refractory cases consider additional pharmacological agents: amiodarone, lidocaine, procainamide or sotalol or overdrive pacing Caution drug-induced myocardial depression
If necessary, further amiodarone 150 mg i.v. over 10 mins, then 300 mg over I hour
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Atrial fibrillation
Treatment based on risk to patient from the arrhythmia
High risk
Rate > 150 beats min-1 Chest pain Critical perfusion
Low risk
Rate < 100 beats min-1 Mild or no symptoms Good perfusion
Intermediate risk
Rate 100-150 beats min-1 Breathlessness
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Atrial fibrillation
High risk
Rate > 150 bpm Chest pain Critical perfusion
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Atrial fibrillation
Intermediate risk Rate 100-150 beats min-1 Breathlessness SEEK EXPERT HELP !
1. Poor perfusion or structural heart disease? 2. Onset within 24 hours?
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Atrial fibrillation
Intermediate risk
NO structural heart disease/poor perfusion
Onset > 24 hours ago: Control rate with drugs Onset < 24 hours ago: Heparinisation
OR
Anticoagulation Later synchronised DC shock
Antiarrhythmics
Synchronised DC shock if indicated
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Atrial fibrillation
Intermediate risk
structural heart disease / poor perfusion
Onset > 24 hours ago: Control rate with amiodarone (with anticoagulation) Later synchronised DC shock if indicated Onset < 24 hours ago: Heparinisation
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Atrial fibrillation
Low risk Rate < 100 beats min-1 Mild or no symptoms Good perfusion
Onset > 24 hours ago: Consider anticoagulation Onset < 24 hours ago: Heparinisation
Antiarrhythmics
DC shock if indicated
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Atrial Fibrillation
High risk? Rate > 150 beats min-1 Chest pain Critical perfusion Intermediate risk? Rate 100-150 beats min-1 Breathlessness Low risk? Rate < 100 beats min-1 Mild or no symptoms Good perfusion
YES
YES
YES
Seek expert help Seek expert help Immediate heparin and synchronised DC shock 100J, 200J:360J or equivalent biphasic energy
NO
YES
Heparin Amiodarone: 300mg over 1 hr repeated once if necessary OR Flecainide 100-150 mg i.v. over 30 mins and/or DC shock if indicated
NO
YES
NO Rate control with: Beta blockers, or Verapamil, or Diltiazem, or Digoxin, or Anticoagulate with: Heparin Warfarin, then Later DC shock if indicated
YES
YES Attempt cardioversion Heparin Flecainide 100-150 mg i.v., or Amiodarone 300 mg i.v. over 1 h Synchronised DC shock if indicated
NO
Initial rate control: Amiodarone 300mg over 1hour, may be repeated once if necessary AND Anticoagulation: Heparin Warfarin Later synchronised DC shock if indicated
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1. Vagal manoeuvres
Valsalva Carotid sinus massage
2. Adenosine i.v.
6mg, rapid bolus 12mg, every 1-2 minutes, (max 3 doses)
Follow AF algorithm
If not already done, give oxygen and establish i.v. access Vagal manoeuvres (caution if possible digitalis toxicity, acute ischaemia, or presence of carotid bruit for carotid sinus massage) Adenosine 6 mg by rapid bolus injection; if unsuccessful, follow, if necessary, with up to 3 doses each of 12mg every 1-2 mins* Caution adenosine with known Wolf-Parkinson-White syndrome
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NO
YES
Choose from: Esmolol: 40 mg over 1 min + infusion 4 mg min-1 (i.v. injection can be repeated with increments of infusion to 12 mg min-1 OR Verapamil 5-10 mg i.v. OR Amiodarone: 300 mg over 1 hour, may be repeated once if necessary OR Digoxin: maximum dose 500 g over 30 mins x2
If necessary, amiodarone 150 mg over 10 mins then 300 mg over 1 hour, and repeat shock
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NO
Adverse signs? Systolic BP< 90 mm Hg Chest pain Heart failure Rate >200 beats min-1
YES
Choose from: Esmolol: 40 mg over 1 min + infusion 4 mg min-1 (i.v. injection can be repeated with increments of infusion to 12 mg min-1 OR Verapamil 5-10 mg i.v. OR Amiodarone: 300 mg over 1 hour, may be repeated once if necessary OR Digoxin: maximum dose 500 g over 30 mins x2
If necessary, amiodarone 150 mg over 10 mins then 300 mg over 1 hour, and repeat shock
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Any Questions?
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Summary
Peri-arrest arrhythmias may need treatment to prevent cardiac arrest or to restore haemodynamic stability Treatment depends upon both the patients condition and the arrhythmia SEEK EXPERT HELP early
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Objectives
To understand how resuscitation techniques should be modified in the special circumstances of:
Special Circumstances
Common cause of cardiopulmonary arrest in younger age group Cardiac arrest often preventable Suitable patients may require a prolonged period of resuscitation
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Hypothermia
Definition: Core temp < 35 C (low reading thermometer) Mild Moderate Severe 32 - 35 C 30 - 32 C < 30 C
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Hypothermia
Special problems of: Immersion Elderly Very young Injury/illness Drugs/alcohol
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Caution
The clinical features of hypothermia can mimic death Cerebral protective effect Not Dead until Warm and Dead, except: obvious lethal injuries body so frozen - resuscitation impossible in-hospital - clinical judgement
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Circulation
Beware extreme bradycardia Consider use of Doppler probe Oesophageal temperature Chest wall stiffness Central or large proximal veins
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Temp
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Circulation
Defibrillation may not be successful until core temp > 30C Other arrhythmias spontaneously improve with warming alone Reduced efficacy of drugs < 30 C Bradycardia may be physiological in severe hypothermia
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Rewarming
Remove from cold environment Movement may precipitate arrhythmias Prevent further heat loss Rapid transfer to hospital Remove cold/wet clothing
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Active Rewarming
External
Forced air warming blankets
Internal (core)
Cardiopulmonary bypass Ventilation with warm humidified 02 Warm i.v. fluids (40 C) Gastric, peritoneal, pleural, bladder lavage Continuous veno-venous haemofiltration
RC (UK)
RC (UK)
Decision to resuscitate
Full recovery possible even after prolonged immersion High risk of hypothermia if water temperature < 25C Submersion related to epilepsy or alcohol?
RC (UK)
RC (UK)
Circulation
Beware extreme bradycardia Hypovolaemia from squeeze effect Intravenous fluids Nasogastric tube Salt/fresh water unimportant
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Investigations
Arterial blood gas analysis Electrolytes Glucose ECG CXR
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Further management
If not had cardiac arrest consider discharge after 6 hours observation in hospital ONLY if: No clinical symptoms or abnormal clinical signs Normal Pa02 breathing room air Normal CXR No other worrying symptoms There is a small risk of late pulmonary oedema
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Resuscitation: Airway
Decreased conscious level common: airway obstruction respiratory arrest Avoid mouth-to-mouth ventilation if:
cyanide hydrogen sulphide corrosives organophosphates
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Breathing
High concentration of 02 (except paraquat) Intubate unconscious patients Arterial blood gas analysis Rapid sequence induction with cricoid pressure (expert help required)
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Circulation
Drug-induced hypotension is common Fluid therapy +/- inotropes Correct acid-base status Cardioversion for life-threatening arrhythmias
RC (UK)
RC (UK)
Poisons Information
National Poisons Information Service TOXBASE Edinburgh NPIS
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Specific antidotes
Paracetamol Organophosphates Cyanides - N-acetylcysteine - Atropine - Sodium nitrite - Sodium thiosulphate - Dicobalt edetate - Fab antibodies - Naloxone
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Digoxin Opioids
Further Management
Prolonged coma - rhabdomyolysis Electrolytes (K+) and glucose Arterial blood gases Temperature
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Any Questions?
RC (UK)
Summary
Prompt and correct treatment may prevent cardiac arrest Modify advanced life support techniques for special circumstances of arrest
RC (UK)
RC (UK)
Objectives
To understand how resuscitation techniques should be modified in the special circumstances of: Hypothermia Immersion and submersion Poisoning
Resuscitation in pregnancy
Two people to resuscitate Early involvement of obstetrician and neonatologist
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Airway
risk of regurgitation Cricoid pressure Tracheal intubation (difficult): obesity of neck breast enlargement glottic oedema
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Breathing
Difficult because of: Diaphragmatic splinting High inflation pressures may be required
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Circulation
Supine position causes caval compression Displace uterus using: sandbags or (Cardiff) wedge manual displacement left lateral tilt Volume replacement Early surgical intervention if bleeding
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RC (UK)
Electrocution
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Electrocution
Electricity (AC): domestic industrial Lightning strike (DC)
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Electrical injury
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Lightning
Depolarisation of myocardium asystole or VF Respiratory muscle paralysis may cause respiratory arrest Widespread neurological damage
RC (UK)
RC (UK)
Resuscitation
Early BLS and ALS Early intubation if burns to face/neck Muscular paralysis may persist for 30 minutes after high voltage shocks
RC (UK)
RC (UK)
Anaphylaxis
Anaphylaxis - hypersensitivity reaction mediated by IgE Anaphylactoid - similar reaction but not dependent on hypersensitivity Manifestations and management similar
RC (UK)
RC (UK)
Resuscitation
Remove likely allergen High flow oxygen Epinephrine shock, stridor, etc - 0.5 ml 1:1000 i.m. profound shock - titration of 1:10,000 i.v. Fluids Antihistamine - H1, consider H2 Hydrocortisone and inhaled 2 agonist
RC (UK)
Consider when compatible history of severe allergic-type reaction with respiratory difficulty and/or hypotension especially if skin changes present Oxygen Stridor, wheeze, respiratory distress or clinical signs of shock
RC (UK)
RC (UK)
Risk of tension pneumothorax Effective chest compression difficult Allow prolonged respiratory time Consider open chest cardiac massage
RC (UK)
RC (UK)
Any Questions?
RC (UK)
Summary
Prompt and correct treatment may prevent cardiac arrest Modify advanced life support techniques for special circumstances of arrest
RC (UK)
RC (UK)
Objectives
To understand: The need for continued resuscitation after return of spontaneous circulation The need for monitoring and investigations How to facilitate safe transfer How to optimise organ function Prognostication after cardiac arrest
RC (UK)
The return of spontaneous circulation is the first step in the continuum of resuscitation
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RC (UK)
Consider continued intubation, sedation and controlled ventilation in patients with obtunded cerebral function Avoid excessive hyperventilation
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RC (UK)
RC (UK)
Circulation
Pulse and blood pressure Peripheral perfusion Right ventricular failure distended neck veins Left ventricular failure pulmonary oedema Measurement of CVP +/- PAP
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RC (UK)
RC (UK)
RC (UK)
RC (UK)
RC (UK)
RC (UK)
Prognostication
No neurological signs that can predict outcome in the first hours after ROSC Serum S-100 protein Somatosensory evoked potentials Poor outcome predicted at 3 days by: absent pupillary light reflexes absent motor response to pain
RC (UK)
Any Questions?
RC (UK)
Summary
The return of a spontaneous circulation does not mark the end of resuscitation Post-resuscitation care influences outcome Appropriate monitoring, safe transfer and continued organ support Prognostication difficult
RC (UK)
RC (UK)
Objectives
To understand: The ethical and legal implications of the duty of care in regard to resuscitation The implications of Do Not Attempt Resuscitation orders and Advanced Directives The involvement of relatives in witnessing resuscitation attempts The considerations involved in the decision to stop a resuscitation attempt
RC (UK)
RC (UK)
The overall responsibility for the decision to perform resuscitation rests with the senior clinician in charge of the patients care.
RC (UK)
RC (UK)
RC (UK)
RC (UK)
Prolonged resuscitation
Indicated in special circumstances: Hypothermia Near drowning Drug overdose Children
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Advance Directives
Refusing CPR can be legally binding if certain safeguards are met and doctor is satisfied that request is genuine May be difficult in emergencies If in any doubt - Resuscitate
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Advanced Directives
Safeguards: Adult Patient mentally competent when decision made Circumstances foreseen Not under duress Patient aware of the implications
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RC (UK)
Any Questions?
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Summary
It is important to commence resuscitation promptly and effectively To know when such measures are contraindicated To know when resuscitation attempts should cease
RC (UK)
A colleague states that she doesnt want to be resuscitated if she ever has a cardiac arrest. The next week she sustains a cardiac arrest in front of you. Do you start resuscitation? You find out that she was diagnosed last week with cancer and is taking anti-depressants. Do you continue resuscitation? Her partner arrives and asks you to reverse your decision What do you do?
RC (UK)
An 82 year old woman falls and sustains a fractured neck of femur. She lives in sheltered housing, is prone to forgetfulness, and has been unwell for the last 2 days. A resuscitation decision needs to be made. Who should be involved with this decision? What makes a DNAR order valid?
RC (UK)
It is 3 am and 54 year old Albert Jones is recovering from a routine hernia operation when he collapses, is unsuccessfully resuscitated, and dies. How do you contact the relatives who live an hour away? How do you receive them as they arrive on the ward? Who should discuss the collapse with them and how?
RC (UK)
In the A&E department, a 42 year old man is brought in by his wife suffering from a suspected MI. They are in the cubicle together when he collapses in VF
What do you do with his wife? She wants to stay what support do you offer her? Should relatives be present during resuscitation?
RC (UK)
A 48 year old man collapses in a public place as you are driving past. Would you stop to assist? Would you start resuscitation if needed? What is the legal and professional view in this situation? The Ambulance Service arrive and, on monitoring, he is found to be asystolic and remains in this rhythm. When do you decide to stop? RC (UK)
Your elderly next door neighbour has not been seen out today. You find him on the floor, collapsed, not breathing, but with a weak pulse. There are a number of empty drug and brandy bottles around him. Pinned to his chest is a note saying DO NOT RESUSCITATE What do you do?
RC (UK)
RC (UK)
Objectives
To understand: How to support relatives witnessing attempted resuscitation How to care for the recently bereaved Religious and ethnic requirements Legal and practical arrangements
RC (UK)
Supporting relatives
In groups of 4 - 6, brainstorm the considerations before inviting a relative/close friend to witness the resuscitation
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Supporting relatives
Clear explanation of what they will see Clear explanation of the events leading to the arrest Provide an opt-out clause Direct not to interfere Use simple language Ensure they are supported by a member of the team
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Any Questions?
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Summary
Many relatives want the opportunity to be present during the attempted resuscitation. This may help their grieving process Communication with bereaved relatives should be honest, simple and supportive
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