Annals of emergency medicine
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Since 1985, it has become apparent that the key to survival from adult sudden cardiac death is prompt defibrillation. Any delay from the time of collapse to the initial countershock will decrease the likelihood of survival. It also has been determined that CPR performed by lay rescuers is not begun promptly and, once started, often is performed for more than one minute before the emergency medical services (EMS) system is accessed, which significantly delays the time to defibrillation. ⋯ Therefore, a rescuer should perform one minute of rescue support before activating the EMS system (a concept termed phone fast). It is recognized that this change is dependent upon a national EMS system that is still evolving. It is hoped that this change to phone first and phone fast will provide an impetus for rapid development of the EMS infrastructure.
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The ethics panel of the American Heart Association recommended that ethical values, including patient autonomy and provider advocacy, should guide the provision of advanced cardiac life support (ACLS) and emergency cardiac care (ECC). The panel developed guidelines regarding the institution and withdrawal of basic life support, ACLS, and the criteria for the determination of death. A discussion of futility, No-CPR orders, living wills, advance directives, and their impact on ECC is included.
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Emphasis on a clear airway is a primary requisite for effective CPR. Airway control in the trauma victim needs special consideration of the possibility of associated cervical vertebrae and spinal cord injury; thus, modification of the patient positioning for transport is essential. Emphasis on visualization of chest movement is the most important factor in assessing adequacy of ventilation. ⋯ Methods to measure end-tidal CO2 as a valuable check for tube position is a useful adjunct but must not be relied upon. Foreign body management continues to be controversial and remains unchanged for the present; ie, the infant < 1 year of age the recommendations are back blows followed by chest thrusts. Above 1 year of age, abdominal thrusts (Heimlich maneuver) is recommended.
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The concept of the chain of survival for children has been extended to include prevention, bystander CPR, prehospital CPR, and acute care. Two clinical cases are presented as examples. The current status and possible weaknesses in each link of the chain are discussed, and suggestions are made for possible research initiatives.
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Cardiac arrest from electrical shock or lightning strike is associated with significant mortality and requires modification and extension of standard advanced life support measures to achieve successful resuscitation. Patients who experience electrical shock or lightning strike may sustain cardiac and respiratory arrest secondary to the direct effects of current. However, the majority of victims have associated multisystem involvement, including neurologic complications, cutaneous burns, and associated blunt trauma. ⋯ Unique considerations include vigorous fluid resuscitation and spinal immobilization for victims of electrical shock and reversal of normal multiple casualty triage priorities when managing several lightning strike victims. Because the majority of victims are relatively young and seldom have significant underlying cardiac disease, the chance for successful resuscitation may be greater for patients who experience sudden death from electrical shock or lightning strike than for those with other causes of cardiac arrest, even among patients with initial rhythms traditionally unresponsive to therapy. Although numerous specialized aspects are required for the successful management of victims of electrical shock and lightning strike, the following article focuses on the unique considerations necessary for immediate care of cardiac arrest victims, with emphasis on the underlying mechanisms of sudden death and currently recommended guidelines for resuscitation.