Concord Repatriation General Hospital Cardiopulmonary Resuscitation Manual 2011

Concord Repatriation General Hospital Cardiopulmonary Resuscitation Manual

2011

Edition

Compiled by the Concord Repatriation General Hospital Cardiopulmonary Resuscitation Committee

May 2011

Second Edition - May 2011 Edited by Winston Cheung and the Concord Repatriation General Hospital Cardiopulmonary Resuscitation Committee - Winnie Au, Toni Cavalletto, Chris Chew, Wai Kuen Chow, Liz Cloughessy, Bianca Grasso, Alison Green, Janice Gullick, Liz Jones, Cootje Kroon, Angie Ng, John Quoyle, Cathie Spiker, Carlie Tighe, Beth Vogelzang Original Version - January 2006 Developed by Winston Cheung and the Concord Repatriation General Hospital Cardiopulmonary Resuscitation Committee - Winnie Au, Chris Chew, Glenda Glynn, Janice Gullick, Harry Lowe, Angie Ng, John Quoyle, Brian Shimadry, Govindasamy Thanakrishnan, Graeme Thompson Concord Repatriation General Hospital, Concord, NSW 2139, Australia. Acknowledgements We would like to thank the fearless volunteers who kindly allowed us to photograph them to use in this manual Version Date 31st May 2011

Concord Repatriation General Hospital Cardiopulmonary Resuscitation Manual

Contents
Introduction Basic Life Support (BLS) Basic Life Support Algorithm Basic Life Support Steps Danger/Safety Responsiveness Sending/Calling for Help Airway Foreign Body Airway Obstruction Breathing Checking Recovery Position CPR Assessment Position Chest Compressions Reassessment Rescue Breathing Occupational Health and Safety Ventilation Techniques Mouth-to-Mask Bag and Mask Basic Artificial Airways Mouth-to-Mouth Mouth-to-Nose Mouth-to-Shield Ventilation in patients with a tracheostomy Compression only CPR Attaching Defibrillator Advanced Life Support (ALS) Advanced Life Support Algorithm Overview Defibrillation Zoll M-Series Defibrillator Automatic Defibrillation Mode Manual Defibrillation Mode Defibrillation for Children Zoll AEDPro Defibrillator Advanced Airway Medications for Cardiac Arrest Rhythm Interpretation and Management Paediatric Basic and Advance Life Support References

Page

2 4 5 6 6 6 7 8 10 11 11 12 13 13 14 14 16 17 17 18 18 20 24 25 25 26 26 27 27 28 28 29 31 32 33 37 41 41 45 46 48 50 52
Page 1

Introduction

Introduction
Cardiopulmonary resuscitation (CPR) is an evolving science, with theories, techniques and technology constantly being reviewed or updated. Due to this ongoing research and scientific evaluation the management of cardiopulmonary resuscitation has changed considerably over the years. Every 5 years, representatives from around the world review the science of resuscitation at an international consensus conference. The latest conference, called the International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendation (CoSTR), resulted in recommendations being published by the International Liaison Committee on Resuscitation (ILCOR) Ref 1 and the European Resuscitation Council (ERC) Ref 2, the two largest collaborative resuscitation groups in the world. Many of the recommendations remain unchanged from the last consensus conference in 2005 Ref 3. In December 2010, the Australian Resuscitation Council (ARC) updated its own guidelines Ref 4. This manual is based on the recommendations made from the ARC. In cardiopulmonary arrest the most significant improvements in outcome occur because of 4 components of resuscitation care, collectively known as the Chain of Survival. These components are: 1 Early recognition of cardiac arrest with subsequent early activation of an emergency system 2 Early cardiopulmonary resuscitation 3 Early defibrillation 4 Good post-resuscitation care

The Chain of Survival (Adapted from Ref 1) This manual is designed to complement the Cardiopulmonary Resuscitation courses held at Concord Repatriation General Hospital, and provides local guidelines on how to manage the first 3 components of the Chain of Survival. The manual has deliberately been kept as simple as possible, but in doing so not all aspects of cardiopulmonary resuscitation have been covered. The aim of the cardiopulmonary resuscitation courses at Concord Hospital is to teach and reinforce the interventions that make a significant impact on outcome in cardiopulmonary arrest, and to teach staff to perform these interventions well.

Page 2

Introduction

The guidelines that have been used in this manual are based on what is considered to be best practice, but have been adapted to accommodate equipment and policies unique to Concord Repatriation General Hospital. The same equipment or policies may not be present at other institutions. Also, as with many other areas of medicine, there are many areas of resuscitation care that remain controversial. The recommendations from this manual in favour of certain techniques or management strategies does not necessarily imply that other strategies are less effective. We hope you find this manual to be a useful resource. The Concord Repatriation General Hospital Cardiopulmonary Resuscitation Committee Winnie Au Toni Cavalletto Winston Cheung (Chair) Chris Chew Wai Kuen Chow Liz Cloughessy Bianca Grasso Alison Green Janice Gullick Liz Jones Cootje Kroon Angie Ng John Quoyle Cathie Spiker Carlie Tighe Beth Vogelzang

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Basic Life Support - Introduction

Basic Life Support

In 2010 the ARC guidelines made several significant changes to the way in which we perform Basic Life Support (BLS). Some of these changes included:

Greater emphasis on sending for help as early as possible. Focusing on unresponsiveness and not breathing normally as indicators for starting resuscitation, rather than using the pulse check or looking for signs of life , as these have been shown to be unreliable and time-consuming. Emphasis on chest compressions as soon as possible, as it was recognized that in adults most arrests were primarily cardiac in nature, rather than respiratory. Recognition that the use of Automatic External Defibrillators (AEDs) should be part of BLS.

The new BLS algorithm on the following page was therefore developed.

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Basic Life Support Algorithm

Basic Life Support (BLS) Algorithm

Use this algorithm for children and adults Acronym:

Danger/Safety
Check

DRS ABCD
Shake and Shout

Responsiveness

Send for Help Airway

Open Airway

Check for Normal Breathing

Breathing
Start

30 Compressions : 2 Breaths

CPR

Attach

As soon as available and follow the prompts

Defibrillator

Continue CPR until person is responsive or normal breathing returns

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Basic Life Support - Danger/Safety

Basic Life Support

Step 1

Danger / Safety

Some cardiopulmonary arrests may occur because of other events, such as electrocution injury, trauma, and gas intoxication. Rescuers cannot help patients if they themselves are injured, and this potentially can put others at risk.

Ensure the safety of yourself and others

Only enter an area when it is safe to do so. Follow Occupational Health and Safety guidelines.

Wear protective equipment if possible

If possible: Wear protective eyewear (goggles, faceshield) Wear gloves Wear a splash-proof gown

Step 2 - Assess

Responsiveness

Tap or shake the patient. Shout Are you alright?

If the patient is unresponsive continue with next step.

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Basic Life Support - Call for Help

Step 3 -

Send/Call for Help

Most adults with sudden, witnessed, non-traumatic cardiac arrest are found to be in Ventricular Fibrillation (VF). For these patients, the time from collapse to defibrillation is the greatest determinant of survival. Survival falls by 7-10% per minute without defibrillation. At 12 minutes, survival from VF is 2-5%. In this scenario, contacting an emergency response system with access to defibrillation equipment is the priority.

Time (minutes)

There are several cardiopulmonary arrest scenarios where VF is less likely to occur. In infants (age < 1 year) and children (age 1-8 years), most cardiopulmonary arrests are related to airway or ventilation problems. VF is also less likely in cardiopulmonary arrest involving submersion or near drowning, trauma, and drug overdose. In all scenarios, however, it is vital to get help early.

How to Call for Help

The Concord Hospital emergency number for cardiac arrest, fire or other emergencies is:

Some wards have a red emergency alert button which can be pressed. This will sound a local alarm which should also inform the switchboard. However, because of previous problems with alarm connection to the switchboard, the switchboard must be informed separately on the 222 number in addition to activating the emergency alarm.

222

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Basic Life Support - Airway

Step 4

Airway

The unconscious patient has decreased muscle tone, and the tongue and epiglottis can fall back to the posterior pharynx and obstruct the airway. An obstructed airway is an early cause of mortality in patients with trauma. If the patient is unresponsive, breathing adequacy needs to be determined. To assess breathing, the patient should be supine (lying on their back), with an open airway.

Position the Patient

Place the patient in the supine position (lying on their back), on a firm, flat surface.
Be aware of the possibility of a cervical spine injury (especially in trauma). The patient should be moved maintaining complete spinal precautions if there is a possibility of spinal injury.

Rescuer Position
Position yourself by the patients side, ready to perform chest compressions and rescue breathing.

If there is a pillow under the victims head, leave it there. This may help maintain the head in the optimal airway position (called the sniffing position).
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Basic Life Support - Airway

Open the Airway

Remove any obstructing foreign bodies Remove any visible foreign material from the mouth
Extract any visible material in the mouth with your fingers, if it is possible (patient may be biting down). Blind sweeping with the fingers is not recommended as this can push material further down the pharynx. Consider rolling patient onto their side to allow material to drain out of the mouth. Dentures can be removed if they cannot be kept in place. Keeping them in place, however, can sometimes be useful to allow a better seal with mask ventilation.

Techniques to open the airway Head Tilt-Chin Lift

Place one hand on the patients forehead and apply firm, backward pressure, tilting the head back.

Place the fingers of the other hand under the boney part of the chin, and lift the jaw upward. Open the patients mouth to help with spontaneous breathing.

Jaw-Thrust
Place one hand on each side of the patients head. Position the fingers under the angle of the jaw, and lift or thrust the jaw forward such that it protrudes forward further than its natural resting position. The lip can be moved away with the thumb.

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Basic Life Support - Airway

In Foreign Body Airway Obstruction there is no single technique which has been shown to be better than other techniques. Sometimes, more than 1 technique is required to relieve the obstruction. The 2 recommended techniques are back blows, or chest compressions if the patient becomes unresponsive.

Foreign Body Airway Obstruction

Effective Cough
If the upper airway is obstructed by foreign material, but the patient has an effective cough, encourage the patient to keep coughing to expel the foreign material.

Ineffective Cough
If the patient has an ineffective cough, the following techniques can be used:

1 Back Blows
Deliver up to 5 firm slaps between the shoulder blades with the heel of the hand.

2 Chest Thrusts/Compressions
If the patient is conscious, chest compressions can be performed in the sitting position. Deliver 5 chest thrusts. If the patient is unconscious, perform chest compressions with the patient in the supine Position as instructed in the Basic Life Support-CPR section.

Abdominal Thrusts (also called the Heimlich Manoeuver and Subdiaphragmatic Abdominal Thrusts) are no longer recommended
This technique has been shown to cause significant complications.

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Basic Life Support - Breathing

Step 5

Breathing

Breathing can be difficult to assess. Breathing attempts may be present, but the breathing pattern may be abnormal. Gasping type respiratory movements may be present (agonal breathing) and may be inadequate. Therefore if the person is not breathing, or the breathing does not appear normal , go to step 6 and commence CPR.

Check for breathing

Check if the person is breathing normally.
This can be done by the following methods:

Look at the chest for the normal rise and fall

Look closely at the chest, while maintaining the airway. You may need to remove the victims clothing.

Listen for air movement

Place your ear near the nose and mouth while maintaining the airway, and listen for air movement, especially during exhalation.

Feel for the flow of air

Place the hand close to, but not obstructing the mouth, and feel for air movement.

If the breathing is absent or abnormal proceed to Step 6 and start CPR.

If the person is breathing normally, and becomes responsive, continue to maintain the airway. Consider placing the person in the recovery position.

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Basic Life Support - Breathing

Recovery Position
Contraindications to placing the person in this position include an unstable patient requiring ongoing resuscitation, and potential injuries which may be aggravated by being placed in the lateral position, such as spinal injury.

Place the patient on their side (left side down is generally preferred), in a stable position, with the top-side arm flexed forward, and top-side knee flexed forward in support.

The patient should be as close to true lateral position as possible, allowing fluid to drain from the mouth The position should be stable Avoid any pressure on the chest that impairs breathing The position should be such that it is easy to shift the patient back into the supine position It should be easy to access and observe the airway The position should not cause injury to the patient Turn the patient to the opposite side every 30 minutes to prevent pressure areas.

No single position is perfect for all patients. Placing patients on their side may help prevent airway obstruction from the tongue, and aid in drainage of pharyngeal contents, such as vomitus. A near-prone position may hinder ventilation, by splinting the diaphragm, and reducing chest wall compliance. Placing the arm closest to the ground, in front of the patient instead of behind, may cause nerve compression, but we currently recommend this position as it makes the patient easier to turn. The position will have to be tailored to each individual patient.

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Basic Life Support - Start CPR

Step 6 Start

CPR

In 2010, the new international and ARC guidelines recommend that CPR start with chest compressions. Previous guidelines recommended starting rescue breathing before chest compressions. The new guidelines also deemphasize the pulse check, and checking for signs of circulation (signs of life). Lay rescuers and healthcare professionals not trained in advanced life support should use unresponsiveness and lack of breathing to identify the need for resuscitation. Previous resuscitation guidelines relied on checking the pulse, however, studies have shown many problems. In 1 in 10 patients (10%), rescuers will interpret that a pulse is present when it is not. These patients will not receive chest compressions, which will be fatal. Conversely, in 4 out of every 10 patients (40%), rescuers will not feel a pulse when a pulse is actually present. These patients potentially will receive unnecessary chest compressions. Personnel trained in advanced life support can still check for a pulse, but as this can take up to 30 seconds in simulated studies, the pulse check is now limited to 10 seconds. If no pulse is palpable within 10 seconds, it is assumed to be absent. Assessing for signs of circulation previously involved assessing breathing, coughing or movement. As assessing for coughing and movement has been thought to waste valuable time, current recommendations have been changed to assess breathing only. If breathing is absent or abnormal, start CPR.

Further Assessment
If breathing is absent or abnormal, and you are trained in advanced life support, do a pulse check, but assess for no more than 10 seconds. If you are not confident that circulation is present, begin chest compressions immediately. If breathing is absent or abnormal, and you are not trained in advanced life support, begin chest compressions immediately.
Page 13

Basic Life Support - CPR

Position
Cardiac arrest victims should be placed on a firm surface. If chest compressions cannot be performed optimally due to damping by the surface (eg. bed mattress), a back-board should be placed under the patient.
When victims of cardiac arrest receive less than 80 chest compressions per minute survival is decreased. Cardiac stroke volume is fixed during chest compressions in cardiac arrest, therefore cardiac output is primarily determined by heart rate, or the rate of chest compressions. The greater the heart rate, the greater the cardiac output. Coronary artery filling, during CPR, however, is dependent on the time spent in artificial diastole, or the time during which the chest wall recoils to its neutral position. Higher chest compression rates, unfortunately, mean less time in diastole, and therefore less coronary blood flow. The optimum chest compression rate is probably somewhere between 80 to 130 compressions per minute. For simplicity we round this to 100 compressions per minute.

Chest compressions
Start CPR with chest compressions Perform chest compressions at the rate of 100 compressions per minute After every 30 chest compressions deliver 2 rescue breaths
If performing 2 person CPR, pause chest compressions to deliver the 2 breaths if the airway is not secured with an advanced airway (eg endotracheal tube). If the airway is secured with an advanced airway, do not pause compressions to give ventilations.

The chest compression to ventilation ratio is 30 : 2

This ratio is the same for 1 person or 2 person CPR. The same ratio is used for infants, children or adults.

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Basic Life Support - CPR

Chest Compression Technique

Place the heel of your dominant hand on the centre of the sternum, and lock your other hand on top. The hands may be interchanged if necessary.

Lock your elbows straight, position your shoulders directly over your hands so that the thrust is in a downward direction.

Depress the sternum one third of the chest depth.

Page 15

Basic Life Support - CPR

Release the pressure and allow the chest wall to completely recoil back to the normal position after each compression. Dont lift your hands away from the chest in between compressions. Allow equal time for compression and recoil.

Optimal sternal compression can be determined by palpating a pulse, either carotid or femoral, though another rescuer will be required to perform the check. Pulse absence does not necessarily indicate that compressions are not adequate. The pulse may be difficult to detect.

Reassessment
Continue CPR until the following occurs: The person is responsive or normal breathing returns It is impossible to continue (eg. exhaustion) A healthcare professional arrives and takes over CPR A healthcare professional directs that CPR be ceased

Page 16

Basic Life Support - CPR

Rescue Breathing
After the 30 chest compressions, provide 2 breaths, using a 1 second inspiratory time. Aim to provide a tidal volume of 600mls. If chest compressions are not required, ventilate at the rate of 6-10 ventilations per minute (approximately 1 ventilation every 6-10 seconds).

Occupational Health and Safety Policy at Concord Hospital

There are various methods to provide rescue breathing. Due to Occupational Health and Safety concerns regarding the transmission of infectious disease, and in accordance with Department of Health, NSW, infection control policy [Ref 2],

Concord Hospital no longer recommends using any rescue breathing technique that involves direct contact with patient body fluids.
Mouth-to-mouth, mouth-to-nose, and mouth-to-stoma breathing are all included in this following section so that staff can learn these techniques, however, staff are encouraged to use barrier techniques, such as mouth-to-mask, or bag and mask.

Page 17

Basic Life Support - CPR

Ventilation Techniques Mouth-to-Mask

Mask Assembly
The Concord mask is a modified mask that contains a one-way valve. There is an inlet on the lower part of the mask to allow the insertion of oxygen tubing, if this is available. Add the oxygen tubing as soon as possible, if this is available. Assemble the mask as follows:

Mouth-to-mask Ventilation Techniques

Two different techniques can be used.

Cephalic Technique
Position yourself above the patients head. Apply the mask to the patients face
Use the bridge of the nose as the initial placement point

Place the index fingers of both hands under the patients mandible and lift the jaw into the mask, and with the remaining fingers support the jaw. Squeeze the mask to the face to get an airtight seal.
Page 18

Basic Life Support - CPR

Tilt the head back (if there is no concern about a neck injury). Give 2 breaths, each with a 1 second inspiratory time

Lateral Technique
Position yourself beside the patients head. Apply the mask to the patients face
Use the bridge of the nose as the initial placement point

With the hand closest to the top of the patients head place the index finger and thumb along the upper border of the mask. Place the thumb of the other hand on the lower border of the mask, and the remaining fingers under the jaw. Squeeze the mask to the face to get an airtight seal.

Page 19

Basic Life Support - CPR

Tilt the head back (if there is no concern about a neck injury)

Give 2 breaths, each with a 1 second inspiratory time

Bag and Mask

Bag and mask assembly
Attach the self-inflating bag to the patient valve if this is not already attached. At Concord Hospital, the self-inflating bag comes preassembled.

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Basic Life Support - CPR

Test the valve by occluding the outlet with your thumb and squeezing the bag. Air should only leave the circuit if you remove your thumb while squeezing the bag. The bag should return to its original inflated position after each compression.

If oxygen is available, attach the oxygen reservoir bag to the oxygen reservoir valve and attach this to the self-inflating bag (the valve will only fit on one way). Attach the oxygen tubing if this is available and turn the oxygen on to 15 litres per minute.

Attach the patient air cushion mask to the patient valve

The device can be used without oxygen, to ventilate using room air only, if oxygen is not available.

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Basic Life Support - CPR

Bag and mask ventilation can be difficult. It requires practice and experience. Different techniques are available.

Ventilation using two-person technique

The two-person technique is the recommended technique for staff, if they are using bag and mask ventilation. One person seals the mask to the face, while the other squeezes the bag. More experienced operators may decide to use a one-person technique.

Position yourself above the patients head. Apply the mask to the patients face
Use the bridge of the nose as the initial placement point

Place the index fingers of both hands under the patients mandible and lift the jaw into the mask, and with the remaining fingers support the jaw. Squeeze the mask to the face to get an airtight seal.

Tilt the head back (if there is no concern about a neck injury) The second rescuer can now give 2 breaths of 600ml volume with an inspiratory time of 1 second each, and watch the chest rise and fall.

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Basic Life Support - CPR

Ventilation using one-person technique

Position yourself above the patients head. Apply the mask to the patients face using one hand, holding it in position with the thumb and second finger.
Use the bridge of the nose as the initial placement point

Place the third, fourth and little fingers of the same hand under the jaw, and squeeze the mask to the face to form an airtight seal.

Perform head-tilt and jaw thrust to keep the airway patent. With the other hand, give 2 breaths of 600ml volume with an inspiratory time of 1 second each, and watch for the chest to rise and fall.

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Basic Life Support - CPR

Basic Artificial Airways

Guedels (Oropharyngeal) Airway
A Guedels Airway can be used to support the airway open during mask ventilation. Caution should be exercised in patients with airway or facial trauma, or airway abnormalities (eg. pharyngeal malignancy).

Sizing
Use the distance from the outer lips or nose to the ear lobe to determine the approximate size of the Guedels Airway.

Insertion
Insert the airway facing backwards until it contacts the hard palate.

Then turn the Guedels airway so that the curve follows the contour of the tongue, and insert up to the lips.

Nasopharyngeal Airway
A nasopharyngeal airway may be considered if an oropharyngeal airway is inappropriate. It should not be inserted in facial or head trauma. Caution needs to be exercised in patients with coagulopathy and nasal airway abnormalities.

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Basic Life Support - CPR

Concord Hospital no longer recommends using any rescue breathing technique that involves direct contact with patient body fluids.
Mouth-to-mouth, mouth-to-nose, and mouth-to-stoma breathing are all included in this following section so that staff can learn these techniques, however, staff are encouraged to use barrier techniques, such as mouth-to-mask, or bag and mask.

Mouth-to-Mouth
Hold the airway open, pinch the nose, take a deep breath, make an airtight seal over the patients mouth with your mouth, and exhale slowly.

Gastric inflation can occur with mouth-to-mouth rescue breathing, which can cause regurgitation, or impair ventilation. This can be minimized by limiting over-inflation of the lungs. Smaller patients may require smaller volumes.

Mouth-to-Nose
This method can be used if it is impossible to ventilate through the patients mouth or for babies.

Tilt the head back, lift the mandible and close the mouth. Take a deep breath, seal your mouth around the patients nose and exhale gently.
Tilt the head back with one hand on the forehead, and with the other hand lift the mandible and close the mouth. The mouth may need to be opened for exhalation if there is a partial obstruction.

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Basic Life Support - CPR

Mouth-to-Shield
The technique is the same as for mouth-to-mouth, except that a face shield is placed over the patients mouth. These shields are not routinely available at Concord Hospital.

Hold the airway open, pinch the nose, take a deep breath, make an airtight seal over the patients mouth with your mouth, over the shield, and exhale.

Be aware that the shield may prevent vomit from clearing the airway. If vomiting occurs, remove the shield, and clear the airway using the usual maneuvers.

Complete tracheostomy management is beyond the scope of this manual. Basic ventilation can be performed using the following techniques.

Ventilation in patients with a tracheostomy

If a tracheostomy tube is present, rescue breathing can be performed via this tube. If the tracheostomy tube is blocked, and unable to be cleared, the inner canula can be removed. A fenestrated tube may need to be replaced with a non-fenestrated one. If ventilation is still not possible the tracheostomy tube may need to be removed, or replaced. If there is no tracheostomy tube insitu the following techniques can be used:

Mask to Stoma
The lungs can be ventilated using a self-inflating bag connected to a paediatric (round) mask or a black mask in the reverse position to seal around the stoma. A Concord mask in the reverse position can also be used.

Mouth-to-Stoma
Take a deep breath, seal your mouth around the stoma and exhale gently. Remove your mouth from the patient to allow passive expiration.
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Basic Life Support - CPR

Compression-Only CPR
It is known that there is growing reluctance amongst health care professionals to perform rescue breathing due to the risk of infection transmission, but the risk is considered low. The current evidence shows that chest compression, without mouth-to-mouth rescue breathing, significantly improves outcome, when compared with no CPR at all. Animal and some human studies also suggest that rescue breathing may not be necessary in the first 6 to 12 minutes of a cardiac arrest. The potential benefit gained in receiving ventilation may be negated by the time taken to perform the actual breathing, time which detracts from actual chest compressions. One study showed that patients receiving both chest compressions and rescue breathing at a 15 to 2 ratio received less than half the number of chest compressions when compared to just performing chest compressions alone. If the rescuer is unwilling or unable to perform rescue breathing, then chest compressions alone are recommended.

If the rescuer is unwilling or unable to perform rescue breathing: Perform chest compressions at the rate of 100 per minute

Step 7 - Attach

Defibrillator (AED)

Automatic External Defibrillators (AEDs) may be life saving, even when used by individuals without previous formal training. AED training is therefore now recommended as part of BLS training.

Attach and turn on the defibrillator. Follow the prompts.

The use of defibrillators is explained in the next section.

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Advanced Life Support - Algorithm

Advanced Life Support (ALS) Algorithm

Start CPR 30 chest compressions : 2 breaths Minimize Interruptions

Shockable Rhythm

Assess Rhythm

Non Shockable Rhythm

Shock

CPR for 2 minutes

Return of Spontaneous Circulation?

CPR for 2 minutes

Post Resuscitation Care

During CPR
Airway adjuncts (LMA/ETT) Oxygen Waveform capnography IV/IO access Plan actions before interrupting compressions (eg. charge manual defibrillator) Drugs Shockable Rhythm Adrenaline 1mg after 2nd shock, then every 2nd cycle Amiodarone 300mg after 3rd shock Non Shockable Rhythm Adrenaline 1mg immediately, then every 2nd cycle

Consider and Correct

Hypoxia Hypovolaemia Hyper / hypokalaemia / metabolic disorders Hypothermia / hyperthermia Tension Pneumothorax Tamponade Toxins Thrombosis

Page 28

Advanced Life Support - Overview

Advanced Life Support Overview

Begin CPR if the victim is unresponsive or not breathing normally (occasional gasps are not considered normal breathing). Start with chest compressions, The chest compression-ventilation ratio is 30:2

Attach a defibrillator as soon as possible, and review the rhythm.

If the rhythm is shockable (ie. Pulseless Ventricular Tachycardia or Ventricular Fibrillation): Deliver a single shock: On a Biphasic Defibrillator use 150 Joules

(Note that other hospitals may have their defibrillators set between 150 to 200 Joules, depending on the manufacturers recommendations)
Continue chest compressions and ventilation immediately to minimize no flow time, unless cardiac output has returned. Perform CPR for 2 minutes, before reviewing rhythm again. This should equate to 5 cycles of 30:2 CPR While performing CPR: Maintain the airway open Continue to ventilate and oxygenate if possible Obtain vascular access Verify electrode/paddle position and contact Correct reversible causes of cardiac arrest
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Advanced Life Support - Overview

During CPR consider the following (if these adjuncts are available): Airway adjunct (eg. endotracheal tube (ETT), laryngeal mask (LMA)) Waveform capnography Planning actions before interrupting chest compressions (eg. charging defibrillator in manual mode) Drugs (Adrenaline and Amiodarone) If an advanced airway has been inserted (eg. endotracheal tube): Ventilate at 6-10 ventilations per minute Perform chest compressions at 100 per minute. Do not pause chest compressions for delivery of ventilation once an advanced airway has been inserted. Consider potentially reversible causes of Cardiac Arrest
Hypovolemia Hypoxia Hydrogen ion-acidosis Hyper/Hypokalemia Hypothermia Tablets (Drug overdose) Tamponade, Cardiac Tension Pneumothorax Thrombosis, Coronary Thrombosis, Pulmonary (PE)

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Advanced Life Support - Defibrillation

Defibrillation
The defibrillators used at Concord Repatriation General Hospital are the Zoll M-Series Biphasic Defibrillator and the Zoll AEDPro. They are preset to be used in semiautomatic mode, but both defibrillators can be changed to manual mode. The manual overrides should only be used by trained staff. Multifunction Electrode (MFE) gel pads are already attached. The main reasons for using MFE pads as the standard attachment, instead of manual paddles, are that they are easier and simpler to apply, and staff who are not confident or experienced in the use of manual paddles find MFE pads easier to use. Our overall aim is to minimize time to defibrillation. Automated defibrillation has been shown to significantly reduce time to defibrillation in cardiac arrest. Waiting for medical staff or the cardiac arrest team to arrive before defibrillating patients suffering cardiac arrest potentially can lead to longer times to defibrillation. At Concord, the defibrillators have been preset in semiautomatic (automatic) mode, with multifunction electrode (MFE) gel pads attached, to encourage all staff to defibrillate early, when required, even before the cardiac arrest team has arrived. The Zoll M Series Defibrillator can deliver up to 200 joules (biphasic mode) into a 50 ohm impedance. The default setting in automatic mode is 150 joules, in line with current international guidelines for rectilinear biphasic defibrillators.

Attach the Defibrillator Pads

Remove all clothing covering the patients chest. Impedance (resistance) needs to be minimized. Dry chest if necessary. Excessive hair may need to be clipped.

Attach Multifunction Electrode (MFE) Pads (called stat padz at Concord Hospital)

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Advanced Life Support - Defibrillation with Zoll M-Series Defibrillator

Attach pads in the positions as shown (one pad at the apex of the heart and one pad to the right of the sternum). Ensure all MFE pads have good contact with the skin, and are not covering any ECG electrodes, GTN patches, or pacemaker boxes.

GTN patches should be removed (potentially flammable). Pads should be placed at least 8cm away from pacemakers. Antero-Posterior (AP) pad positions may considered if the Apical-Sternal positioning is deemed unsuitable.

Defibrillators at Concord Hospital

At Concord Hospital, there are 2 types of defibrillators:

The Zoll M-Series Biphasic Defibrillator The Zoll AEDPro

The Zoll M-Series Biphasic Defibrillator

At Concord Hospital, the Zoll Biphasic defibrillators are preset to semiautomatic mode (AED). There are several situations where changes may need to be made to defibrillation procedures: Implantable Pacemaker The rhythm analysis may not identify Ventricular fibrillation in the presence of a pacemaker. Manual mode should be used instead. Patient on a moving stretcher or moving ambulance The patient must be motionless during rhythm analysis. Movement will create artifact. Analysis should only be performed when the patient has stopped moving. Patients under 8 years of age The shock energies in AED mode are designed for adults (patients 9 years old or older). Paediatric pads will automatically lower the preset joules. If paediatric pads are not available, manual mode with lower energies should be used in younger patients. If this is not possible it is reasonable to use adult preset energy settings in an arrest situation.
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Advanced Life Support - Defibrillation with Zoll M-Series Defibrillator

Using the Zoll M-Series in Automatic External Defibrillation (AED) Mode

Be aware that the following situations may require changes to defibrillation procedures and may require advanced training: Patient has an implanted pacemaker
Use Manual Mode instead

Patient is on a moving stretcher or ambulance

Perform analysis only when not moving

Patient under 8 years of age

Use manual mode and weight-adjusted (age-adjusted) defibrillation settings

Step 1 Turn defibrillator ON

Turn selector dial to ON

The unit will beep 4 times after passing the self-test.

Step 2 Attach MFE Pads

If the MFE gel pads are not already attached, place them on the patients as shown previously. The unit will prompt you if this has not occurred.

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Advanced Life Support - Defibrillation with Zoll M-Series Defibrillator

Step 3 Press the ANALYZE Button

If the defibrillator does not automatically start analyzing the rhythm press the analyze button, located at the top right of the panel. The unit will ask everyone to STAND CLEAR, and will display ANALYZING ECG. If the rhythm is a non-shockable rhythm the unit will display a NO SHOCK ADV (ADVISED) message. Check the patient and resume resuscitation as indicated.

If the rhythm is shockable the unit will display SHOCK ADVISED, and begin charging automatically. A CHARGING message will be displayed.

The Zoll defibrillators are preset to charge to 150 Joules (biphasic waveform).

When the charging is complete the unit will display 150J READY.

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Advanced Life Support - Defibrillation with Zoll M-Series Defibrillator

Step 4 Check safety

Tell all persons attending the patient to STAND CLEAR. Do not touch the patient, bed, or equipment attached to the patient (eg. ECG wires) while defibrillating, or any substances that may conduct electricity (eg. water on the floor) Do not allow patient to contact any conducting surfaces (eg. bed-rail) Remove free-flowing oxygen and GTN patches Perform a clock-wise scan around the periphery of the bed AND ensure that all persons are clear (just because you have told everyone to STAND CLEAR DO NOT ASSUME that this has actually happened) Do not shock until the area is safe.

Step 5 Deliver Shock

A continuous tone will sound for 10 seconds, followed by an intermittent beeping for 5 seconds. The shock must be delivered within this 15 second interval or the defibrillator will disarm itself.

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Advanced Life Support - Defibrillation with Zoll M-Series Defibrillator

Press and hold the SHOCK button until the energy is delivered to the patient.
The shock button is located below the analyze button at the top right of the panel. The display will state the energy given, and the number of shocks administered to the patient.

Step 6 Continue CPR immediately then Re-evaluate Rhythm

Continue CPR immediately after the shock has been delivered. Return to Step 3 to restart the ECG analysis after 2 minutes of CPR. The defibrillator should do this automatically.

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Advanced Life Support - Defibrillation with Zoll M-Series Defibrillator

Using the Zoll M-Series in Manual Override Mode

There may be conditions present where it may be preferable to use the defibrillator in manual mode. These include: Patient has an implanted pacemaker Patient under 8 years of age Patient does not require defibrillation, but cardiac monitoring is required

Step 1 Turn the defibrillator ON and activate Manual Mode

Turn selector dial to ON

Press the Manual Mode softkey on the front panel, on the left.

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Advanced Life Support - Defibrillation with Zoll M-Series Defibrillator

The unit will ask you to confirm Manual mode by pressing the Confirm softkey, in the middle of the panel.

Once in Manual mode the defibrillator will return to Automatic mode when the Analyse softkey is pressed.

Step 2 Obtain and review ECG rhythm

There are 2 methods for obtaining an ECG reading:

Method 1- Attach MFE Pads (Standard method in Cardiac Arrest)

If MFE pads are available, place them on the patients as shown previously.

Method 2 - Attach 3-Lead electrode wires (Standard method in Non-Cardiac Arrest MET call)
The MFE pads cost $60 per set. Therefore, in situations where monitoring is required, but defibrillation is not, 3-lead electrode monitoring is used. Attach the leads in the positions shown, depending on how many leads are available. Press the Lead softkey to select lead.

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Advanced Life Support - Defibrillation with Zoll M-Series Defibrillator

If the rhythm is a shockable one and you wish to defibrillate then proceed.

Step 3 Select energy

The Zoll will deliver from 1 Joule to a maximum of 200 Joules (Biphasic waveform). The default setting is 150 Joules.

To change the energy use the up-down arrow buttons.

Step 4 Check safety

Tell all persons attending the patient to STAND CLEAR. Do not touch the patient, bed, or equipment attached to the patient (eg. ECG wires) while defibrillating, or any substances that may conduct electricity (eg. water on the floor) Do not allow patient to contact any conducting surfaces (eg. bed-rail) Remove free-flowing oxygen and GTN patches Perform a clock-wise scan around the periphery of the bed AND ensure that all persons are clear (just because you have told everyone to STAND CLEAR DO NOT ASSUME that this has actually happened) Do not shock until the area is safe.
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Advanced Life Support - Defibrillation with Zoll M-Series Defibrillator

Step 5 - Charge defibrillator

Press the CHARGE button on the front panel.

Step 6 Deliver shock

Repeat the safety check. Press SHOCK button on the front panel.

Step 7 Continue CPR immediately then Re-evaluate Rhythm

Continue CPR immediately after the shock has been delivered. Return to Step 2 to review the ECG after 2 minutes of CPR.

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Advanced Life Support - Defibrillation for Children

Defibrillation for Children using the Zoll M-Series defibrillator

For Children older than 8 years (> 8 years): Use Adult Defibrillation Guidelines Can use Automatic Mode Defibrillation or Manual Mode Defibrillation For Children aged 8 years or younger (< 9 years): Estimate the childs weight
[Ref 6]

One formula that can be used is: Weight in kg= (Age in years x 2) +9 Defibrillation dose is 4 J/kg (Biphasic or Monophasic) If the weight is unknown a standard dose of 50 J can be used instead If Paediatric pads are used there will be no need to manually adjust the defibrillator as the dose will automatically be lowered
The guidelines for defibrillation in children has changed because the initial dose of 2 J/kg from the previous guidelines is now thought to be too low to be effective.

The Zoll AEDPro defibrillator

With the importance of defibrillation in cardiac arrest now well recognized, the advent of the Automatic External Defibrillator (AED) has allowed defibrillation to be incorporated into Basic Life Support teaching. AEDs can identify a cardiac rhythm as shockable or non-shockable. Though the AED is designed for use in adults, standard adult AEDs and pads are suitable for use in children older than 8 years of age. Ideally for children between 1 and 8 years old, paediatric pads should be used, but standard adult pads can be used if paediatric pads are not available.

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Advanced Life Support - Defibrillation with Zoll AEDPro

Using the Zoll AEDPro

During ECG analysis, do not touch or move the patient. If transporting the patient, stop all movement before using the defibrillator.

Step 1 Turn defibrillator ON

Press and release the ON/OFF button

The unit will issue the voice and text message UNIT OK after it completes the power-on self-test.

Step 2 Attach MFE Pads

If the MFE gel pads are not already attached, place them on the patient as shown previously on page 31 and 32. The unit will prompt you if this has not occurred with the voice and text prompt ATTACH DEFIB PADS TO PATIENTS BARE CHEST.

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Advanced Life Support - Defibrillation with Zoll AEDPro

Step 3 - Allow AEDPro to analyze patients ECG

The defibrillator will prompt you to stop CPR to analyze the rhythm, by displaying and voicing DONT TOUCH PATIENT, ANALYZING.

The AEDPro will determine whether or not the patient has a shockable rhythm and then displays and voices its recommendation SHOCK ADVISED or NO SHOCK ADVISED.

Step 4 - Wait for defibrillator to charge

If a shock is needed, the defibrillator automatically begins charging. If a shock is not needed, the defibrillator will prompt you to perform CPR. When fully charged, the unit emits a charge-ready tone, repeatedly flashes the SHOCK button, and issues the voice and text prompts DONT TOUCH PATIENT. PRESS FLASHING SHOCK BUTTON.

If the shock button is not pressed in 30 seconds the defibrillator will automatically disarm itself.

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Advanced Life Support - Defibrillation with Zoll AEDPro

Step 5 - Check Safety

Tell all persons attending the patient to STAND CLEAR. Do not touch the patient, bed, or equipment attached to the patient (eg. ECG wires) while defibrillating, or any substances that may conduct electricity (eg. water on the floor) Do not allow patient to contact any conducting surfaces (eg. bed-rail) Remove free-flowing oxygen and GTN patches Perform a clock-wise scan around the periphery of the bed AND ensure that all persons are clear (just because you have told everyone to STAND CLEAR DO NOT ASSUME that this has actually happened) Do not shock until the area is safe.

Step 6 - Deliver Shock

Repeat Safety Check. Press and hold the SHOCK button until the shock is delivered.

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Advanced Life Support - Defibrillation and Advanced Airway

Step 7 Continue CPR immediately then Re-evaluate Rhythm

Continue CPR immediately after the shock has been delivered. The defibrillator will automatically reanalyze the rhythm again after 2 minutes. Go back to Step 3.

Advanced Airway
Use of an advanced airway will not be taught in the Concord Cardiopulmonary Resuscitation courses. Endotracheal tubes are generally used to secure the airway in cardiac arrests, but there is little data to show that using this technique changes overall outcome. There is evidence that without adequate training and experience, the complications resulting from attempted endotracheal intubation, such as oesophageal intubation, is high. Unfortunately, this course is not able to provide the necessary experience required to perform endotracheal intubation safely and proficiently. In patients where an endotracheal tube has been placed, unrecognized oesophageal intubation is a serious complication, and routine confirmation of endotracheal tube position by non-clinical means is recommended.

Confirming Advanced Airway Placement

Endotracheal position should be confirmed using capnography, if this is available, as soon as possible following endotracheal intubation. A chest x-ray should also be performed to check the endotracheal tube position in the trachea, and to confirm the positions of other devices (eg. nasogastric tubes).

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Advanced Life Support - Medications

Medications for Cardiac Arrest

Several decades of evaluation and research have shown that there is no pharmacological agent that significantly influences overall mortality in cardiac arrest. Despite the lack of evidence of benefit, however, it is still deemed reasonable to continue with the use of several agents in cardiac arrest.

Adrenaline
May be considered in all cardiac arrest rhythms. Shockable Rhythm Give 1mg IV after 2nd shock, then after every 2nd cycle (3 to 5 minutes). Non Shockable Rhythm Give 1mg IV immediately, then after every 2nd cycle (3 to 5 minutes).

Amiodarone
May be considered in refractory Ventricular Fibrillation or Ventricular Tachycardia (VF or VT that is not responsive to defibrillation), after the 3rd shock. Give 300mg IV once. Should ideally be diluted to a volume of 20ml with 5% Dextrose, but if time does not permit, can be given as a slow push.

Atropine
Not recommended in Cardiac Arrest. May be considered in bradycardia. Give 0.5 mg to 1 mg (500 mcg to 1000 mcg) every 3 to 5 minutes. Maximum cumulative dose is 3 mg (3000 mcg).

Calcium Chloride
Routine use in Cardiac Arrest is not recommended. May be considered in Hyperkalaemia, Hypocalcaemia, or Calcium Channel blocker toxicity. Give 10 mmol Calcium Chloride. IV canula patency must be present, otherwise administration should be through a patent central catheter.

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Advanced Life Support - Medications

Magnesium
May be considered in cardiac arrest due to Hypomagnesemia and Torsades de Pointes. Give 5 mmol Magnesium Sulphate diluted in 100ml 5% Dextrose or Saline over 1 to 2 minutes.

Sodium Bicarbonate
Not recommended for routine use in Cardiac Arrest May be considered in life-threatening hyperkalemia, severe metabolic acidosis, or tricyclic antidepressant overdose. Give 50 mmol (50ml of 8.4%) Sodium Bicarbonate as a slow push

Vasopressin
This drug is not used in cardiac arrests at Concord Hospital.

In previous studies, endotracheal administration of cardiac arrest drugs was associated with a worse outcome, when compared to intravenous (IV) administration, and considerably more drug was needed to achieve equipotency. Endotracheal administration may be considered in situations where intravenous access is not available. The latest ARC guidelines have recommended the intraosseous route as an alternative if intravenous access is not obtainable, but this should only be performed by staff trained to use this technique.

Medications can be given using the intraosseous or endotracheal route, if intravenous access is not available. The following drugs can be given using the endo-tracheal route: Adrenaline Atropine Lignocaine
Dilution with water may achieve better absorption.

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Advanced Life Support - Rhythm Interpretation

Rhythm Interpretation
This section is designed to demonstrate what the various rhythms look like on the defibrillator. It is not meant to be a complete guide to rhythm interpretation. The major management strategies are listed.

Sinus Rhythm

Ventricular Fibrillation (VF)

Management Follow ALS Algorithm Defibrillate with 1 shock every 2 minutes while in VF If refractory to defibrillation: Consider using Adrenaline and Amiodarone

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Advanced Life Support - Rhythm Interpretation

Ventricular Tachycardia (VT)

Management (Pulseless VT) Follow ALS Algorithm Defibrillate with 1 shock every 2 minutes while in VT If refractory to defibrillation: Consider using Adrenaline and Amiodarone

Asystole
Management Follow ALS Algorithm Consider using Adrenaline

Pulseless Electrical Activity (PEA)

Defined as electrical activity being present without any detectable pulse or cardiac output. Management Follow ALS Algorithm Consider using Adrenaline

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Paediatric BLS and ALS

Paediatric Basic and Advance Life Support

This manual and courses at Concord Hospital are not specifically designed to teach CPR in children or neonates, but this brief section has been included to give some general guidance.

Paediatric Basic Life Support

Though there have been controversial changes in other countries, the ARC has decided to make Paediatric BLS guidelines the same as those in adults. As a result, there are no major difference between the Adult and Paediatric BLS guidelines.

Compression-ventilation ratio
The compression-ventilation ratio of 30 : 2 is the same in children and adults.

Chest compression depth

The chest compression depth in children is still one third the antero-posterior diameter of the chest, which is approximately 5cm in children and 4 cm in infants.

Paediatric Advance Life Support

The ARC has made some changes to the guidelines for Paediatric ALS. Some of these changes recognize that children are more likely to have a respiratory precipitant for an arrest, and therefore place more emphasis on ventilation.

Compression-ventilation ratio when using bag and mask ventilation or an advanced airway
The compression-ventilation ratio can be changed to 15 : 2 in children when performed by ALS trained healthcare workers using bag and mask ventilation, laryngeal mask ventilation or invasive ventilation using an endotracheal tube.

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Paediatric BLS and ALS

Defibrillation (see page 41)

For Children older than 8 years (> 8 years): Use Adult Defibrillation Guidelines For Children aged 8 years or younger (< 9 years): Defibrillation dose is 4 J/kg (Biphasic or Monophasic) The childs weight can be estimated using the formula shown on page 41 If the weight is unknown a standard dose of 50 J can be used instead If Paediatric pads are used there will be no need to manually adjust the defibrillator as the dose will automatically be lowered.

Medication Doses
Medications in cardiac arrest should be adjusted for patient size. Medication doses for the common cardiac arrest drugs are as follows: Adrenaline 10 mcg/kg Amiodarone 5 mg/kg Sodium Bicarbonate 0.5-1 mmol/kg

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References

References
1 2 3 4 5 6 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular care Science with Treatment Recommendations. Circulation 2010; 122: S250-S638. European Resuscitation Council Guidelines for Resuscitation 2010. Resuscitation 2010; 81: 12191451. 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation 2005; 112: III-1-III-4 Australian Resuscitation Council - Guidelines. www.resus.org.au Department of Health Infection Control Policy. PD2005_247 Sect 14.4 Morgan GE, Mikhail MS. Anesthesiology, 2nd Ed 1996.

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