The 4 Cs of Cardiac Arrest Care according to the 2010 A.H.A Guidelines
Field JM, Hazinski MF, Sayre MR, et al Circulation. 2010;122:S640-S656
The year 2010 marks the 50th anniversary of the introduction of cardiopulmonary resuscitation (CPR). During these past 50 years, tremendous research has been conducted to evaluate techniques, medications, and devices designed to advance the care of victims of cardiac arrest. The American Heart Association (AHA) developed the first CPR guidelines in 1966 and since that time has published frequent updates of the guidelines to help educate the public and medical establishment about optimal care for patients with cardiac arrest and other emergency cardiovascular conditions.
This past November, the newest set of guidelines pertaining to CPR and emergency cardiovascular care were published by the AHA in a supplement issue of Circulation. The guidelines consist of 16 parts. They address not only cardiac arrest, but also post-arrest care, dysrhythmias, acute coronary syndromes, stroke, cardiac arrest in special situations (eg, pregnancy, pulmonary embolism, etc), pediatric considerations, and ethics. Part I is a summary statement of the major changes in cardiac arrest and emergency cardiovascular care since the previous set of guidelines, which were published in 2005. The highlights of this "Executive Summary" are summarized below. For purposes of brevity, this discussion will focus on adult patients with acute cardiac conditions (cardiac arrest and dysrhythmias), excluding acute coronary syndromes, stroke, and pediatric considerations. The reader should note that the bulk of guideline recommendations, as in past years, are concentrated on victims of primary cardiac arrest and are not necessarily relevant to victims of pulmonary arrest (eg, drowning, drug overdose, etc).
Change from "A-B-C" to "C-A-B." A major change in basic life support is a step away from the traditional approach of airway-breathing-chest compressions (taught with the mnemonic "A-B-C") to first establishing good chest compressions ("C-A-B"). There are several reasons for this change.
Most survivors of adult cardiac arrest have an initial rhythm of ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), and these patients are best treated initially with chest compressions and early defibrillation rather than airway management.
Airway management, whether mouth-to-mouth breathing, bagging, or endotracheal intubation, often results in a delay of initiation of good chest compressions. Airway management is no longer recommended until after the first cycle of chest compressions -- 30 compressions in 18 seconds. The 30 compressions are now recommended to precede the 2 ventilations, which previous guidelines had recommended at the start of resuscitation.
Only a minority of cardiac arrest victims receive bystander CPR. It is believed that a significant obstacle to bystanders performing CPR is their fear of doing mouth-to-mouth breathing. By changing the initial focus of resuscitation to chest compressions rather than airway maneuvers, it is thought that more patients will receive important bystander intervention, even if it is limited to chest compressions.
Basic life support. The traditional recommendation of "look, listen, and feel" has been removed from the basic life support algorithm because the steps tended to be time-consuming and were not consistently useful. Other recommendations:
Hands-only CPR (compressions only -- no ventilations) is recommended for the untrained lay rescuers to obviate their fears of mouth-to-mouth ventilations and to prevent delays/interruptions in compressions.
Pulse checks by lay rescuers should not be attempted because of the frequency of false-positive findings. Instead, it is recommended that lay rescuers should just assume that an adult who suddenly collapses, is unresponsive and not breathing normally (eg, gasping) has had a cardiac arrest, activate the emergency response system, and begin compressions.
Pulse checks by healthcare providers have been de-emphasized in importance. These pulse checks are often inaccurate and produce prolonged interruptions in compressions. If pulse checks are performed, healthcare providers should take no longer than 10 seconds to determine if pulses are present. If no pulse is found within 10 seconds, compressions should resume immediately.
The use of end-tidal CO2 (ETCO2) monitoring is a valuable adjunct for healthcare professionals. When patients have no spontaneous circulation, the ETCO2 is generally ≤ 10 mm Hg. However, when spontaneous circulation returns, ETCO2 levels are expected to abruptly increase to at least 35-40 mm Hg. By monitoring these levels, interruptions in compressions for pulse checks become unnecessary.
CPR devices. Several devices have been studied in recent years, including the impedance threshold device and load-distributing band CPR. No improvements in survival to hospital discharge or neurologic outcomes have been proven with any of these devices when compared with standard, conventional CPR. Electrical therapies
Patients with VF or pulseless VT should receive chest compressions until a defibrillator is ready. Defibrillation should then be performed immediately.
Chest compressions for 1.5-3 minutes before defibrillation in patients with cardiac arrest longer than 4-5 minutes have been recommended in the past, but recent data have not demonstrated improvements in outcome.
Transcutaneous pacing of patients who are in asystole has not been found to be effective and is no longer recommended.
Advanced cardiac life support. Good basic life support, including high-quality chest compressions and rapid defibrillation of shockable rhythms, is again emphasized as the foundation of successful advanced cardiac life support. The recommendations for airway management have undergone 2 major changes: (1) the use of quantitative waveform capnography for confirmation and monitoring of endotracheal tube placement is now a class I recommendation in adults; and (2) the routine use of cricoid pressure during airway management is no longer recommended.
As they did in 2005, the AHA acknowledges once again that as of 2010, data are "still insufficient ...to demonstrate that any drugs improve long-term outcome after cardiac arrest."
Several important changes in recommendations for dysrhythmia management have occurred:
For symptomatic or unstable bradydysrhythmias, intravenous infusion of chronotropic agents (eg, dopamine, epinephrine) is now recommended as an equally effective alternative therapy to transcutaneous pacing when atropine fails;
As noted above, transcutaneous pacing for asystole is no longer recommended; and
Atropine is no longer recommended for routine use in patients with pulseless electrical activity or asystole.
Post-cardiac arrest care. Post-cardiac arrest care has received a great deal of focus in the current guidelines and is probably the most important new area of emphasis. There are several key highlights of post-arrest care:
Induced hypothermia, although best studied in survivors of VF/pulseless VT arrest, is generally recommended for adult survivors of cardiac arrest who remain unconscious, regardless of presenting rhythm. Hypothermia should be initiated as soon as possible after return of spontaneous circulation with a target temperature of 32°C-34°C.
Urgent cardiac catheterization and percutaneous coronary intervention are recommended for cardiac arrest survivors who demonstrate ECG evidence of ST-segment elevation acute myocardial infarction regardless of neurologic status. There is also increasing support for patients without ST-segment elevation on ECG who are suspected of having acute coronary syndrome to receive urgent cardiac catheterization.
Hemodynamic optimization to maintain vital organ perfusion, avoidance of hyperventilation, and maintenance of euglycemia are also critical elements in post-arrest care.
The AHA 2010 guidelines represent significant progress in the care of victims of cardiac arrest. Most important is the stronger emphasis on post-cardiac arrest care. Induced hypothermia is underscored, and perhaps the most important advance is the recommendation for urgent percutaneous coronary intervention in survivors of cardiac arrest. The wealth of data thus far indicate that post-arrest percutaneous coronary intervention may be the most significant advance toward improving survival and neurologic function since defibrillation was first introduced decades ago.
In reviewing these guidelines, I must admit, however, that I was disappointed that AHA hesitated to adopt the concepts of "cardiocerebral resuscitation" (CCR). CCR also promotes the "C-A-B" approach to resuscitation, but it fosters even further delays in airway intervention -- withholding any form of positive pressure ventilations, in favor of persistent chest compressions, for as long as 5-10 minutes after the cardiac arrest. The current guidelines recommend withholding positive pressure ventilation for a mere 18 seconds. First described in 2002, CCR has been studied more recently as well and demonstrated marked improvements in rates of resuscitation and neurologic survival.[2-4] I think that CCR should be incorporated into basic life support protocols for victims of primary cardiac arrest as quickly as possible to further improve outcomes.
Optimal management of cardiac arrest in the current decade can be summarized simply by "the 4 Cs": Cardiovert/defibrillate, CCR, Cooling, and Catheterization.
1. (00:02:31) Shunza - Nescafe Open Up
2. (00:04:16) Mike Hanopol - Panahon Na Naman
3. (00:04:08) Mike Hanopol and Rivermaya - Ulan
4. (00:03:38) Rivermaya - Laki Sa Layaw
5. (00:04:28) Rivermaya - Beep Beep
6. (00:02:57) Sampaguita - Baliw
7. (00:04:13) True Faith - Sayawan
8. (00:03:35) Sampaguita - Huwag Na Lang Kaya
9. (00:05:49) True Faith - Tao
10. (00:04:18) South Border and Hotdog - Ikaw Ang Miss Universe Ng Buhay Ko
11. (00:08:30) Hotdog - Love Of My Life
12. (00:02:47) South Border - Pers Lab
13. (00:05:38) Hotdog - Kahit Kailan
14. (00:04:04) Apo Hiking Society - Magasin
15. (00:02:21) Eraserheads - Pumapatak Ang Ulan
16. (00:04:53) Apo Hiking Society - Pare Ko
17. (00:03:23) Eraserheads - Blue Jeans
Playing Time.........: 01:11:27
Total Size...........: 66.56 MB
This one I find very interesting. This is really great. Imagine, through how a girl orders coffee one can understand a little bit of her while enjoying one's company on a date. Wow! Just read it!
Why is having coffee together best way to get to know someone? Simple: her preference tells you a bit about her, things you find out beyond the conversation. Therefore, what she has on the coffee date should tell you if you’re going to hit it off…
1. Black, no sugar - direct to the point kind of person, possibly aggressive, confident
2. Black, one or two sugars - not as aggressive as above, and is more approachable
3. Cream and sugar - she's simple in her tastes, possibly a homebody
4. Cream and sugar, sweet - the kind who likes to be pampered or likes to pamper others
5. With some ordinary flavoring (cinnamon, nutmeg, etc) - with some sense of adventure
6. With some exotic flavoring (mint, etc) - with a lot of adventure, maybe a bit eccentric, even
7. Frappucino-types - medyo kikay
8. Cappuccino – medyo class, la sofisticada
9. Espresso (single) – she’s something of the intellectual type
10. Espresso (double) - she’s something of the intellectual type and wants to last the night (hopefully, with you)
11. With chocolate (mocha, hazelnut, etc) - has a strong streak of the romantic
12. With brandy/ rum/ sherry - this publicly prim and proper lady sizzles in private
13. Strong brewed – the woman-on-top type (loves to be in-charge and take the lead)
14. Proper tea - a purist, bit of a perfectionist (baka naman di siya pinay?)
15. Tea in bags - like above, pero definitely, pinay to-its
16. Herbal infusions (chamomile, etc) - a bit of New Age girl in her (side note: they are the best kissers)
17. Non-coffee bean coffees (cardamom) and non-tea leaf teas (green, peppermint, strawberry, etc.) – same as above, but she loves to travel and try new things
18. Chocolate - what sort of nut drinks chocolate on a coffee date in a hot place like Pilipinas? Unless, of course, it's just before bed... mmmmmmm
19. Any hot coffee ordered lukewarm – this girl is only pretending to enjoy coffee, but likes you enough to go on a coffee date with you.
20. Milk - unless she has ulcers, a girl who has milk on a coffee date is just plain freaky. (We don't know why, they just are.)
New campaign of Australia to attract skilled migrants
Friday, 11 February 2011
In order to attract skilled migrants to Canberra, a new campaign named "Live in Canberra" will be launched by The Australian Capital Territory (ACT) Government between 9 February and 28 February 2011.
Accordingly, an ACT delegation will travel to Amsterdam, London, Cape Town, Durban, Dublin and Johannesburg. Together with the ACT Government's Skilled and Business Migration Program, the delegation will work to boost opportunities in Canberra and the city's lifestyle
Jon Stanhope, Chief Minister for the ACT stated that the campaign will "incorporate one immigration expo and 15 targeted skilled and business migration seminars"
"One-on-one meetings are scheduled in each city with skilled workers considering a move to Canberra and with locally based migration agents wishing to promote Canberra's opportunities to their clients," he said.
"The team will speak to people with skills that are in demand in Canberra's local industries including health, building and construction, finance, administration, management, engineering and Information and Communications Technology (ICT).
The ACT's economy currently ranks first in Australia and unemployment is close to record lows. According to Stanhope, Canberra must "continue to attract a steady flow of skilled workers to ensure our economy maintains its momentum."
If you are interested in Australian Visas, contact Migration Expert for information and advice on which visa is best suited to you. You can also try our visa eligibility assessment to see if you are eligible to apply for a visa to Australia.
For more info click on the link below:
Canadian visa applications for Yukon to be self-managed
Tuesday, 8 March 2011
A new agreement that gives the province of Yukon the role of self-managing the Temporary Foreign Worker Program within the Territory has been signed by The Governments of Canada and Yukon.
You can live & work in Canada! go >
According to the agreement, Yukon will be permitted to manage applications for the Canadian Temporary Foreign Worker Visa program within the province.
Yukon will be more responsible for helping foreign workers come to Canada via Temporary Foreign Worker Program. Yukon's Government can recommend overseas workers to immigrate to Canada without requiring a Service Canada assessment to determine if there are Canadians or permanent residents available to fill the vacant positions.
In an announcement on Feb 24, Patrick Rouble, Yukon Minister of Education and Minister of Energy, Mines and Resources expressed that the new agreement will offer more opportunities for Yukon to attract foreign labour.
“This agreement provides one more tool for Yukon’s labour market stakeholders to address Yukon’s labour market opportunities, both now and into the future,” said Minister Rouble.
“Our first priority is to work with underrepresented groups in Yukon to meet labour force demands and turn to temporary foreign workers when the need arises” he added.
If you are interested in Immigration to Canada, contact Migration Expert for information and advice on which visa is best suited to you. You can also try our visa eligibility assessment to see if you are eligible to apply for a visa to Canada.
A man went to a barbershop to have his hair cut and his beard trimmed.
As the barber began to work, they began to have a good conversation.
They talked about so many things and various subjects.
When they eventually touched on the subject of God, the barber said:
"I don't believe that God exists."
"Why do you say that?" asked the customer. "Well, you just have to go out in
the street to realize that God doesn't exist.
Tell me, if God exists, would there be so many sick people?
Would there be abandoned children?
If God existed, there would be neither suffering nor pain.
I can't imagine a loving God who would allow all of these things."
The customer thought for a moment, but didn't respond because he didn't want to start an argument.
The barber finished his job and the customer left the shop.
Just after he left the barbershop, he saw a man in the street with long, stringy, dirty hair and an untrimmed beard.
He looked dirty and unkempt. The customer turned back and entered the barber shop again and he said to the barber:
"You know what? Barbers do not exist."
"How can you say that?" asked the surprised barber.
"I am here, and I am a barber. And I just worked on you!"
"No!" the customer exclaimed. "Barbers don't exist because
if they did, there would be no people with dirty long hair and untrimmed
beards, like that man outside."
"Ah, but barbers DO exist! That's what happens when people do not come to me."
"Exactly!" affirmed the customer. "That's the point! God, too, DOES exist!
That's what happens when people do not go to Him and don't look to Him for help.
That's why there's so much pain and suffering in the world."
I love this! Let's keep it going! No catches. Just the peace in knowing that you were able to share God's love and wisdom to all those you have contact with and even bless someone you don't know.
1. Give God what's right -- not what's left. 2. Man's way leads to a hopeless end! - God's way leads to an endless hope. 3. A lot of kneeling will keep you in good standing. 4. He who kneels before God can stand before anyone. 5. In the sentence of life, the devil may be a comma--but never let him be the period. 6. Don't put a question mark where God puts a period. 7. Are you wrinkled with burden? Come to the church for a face-lift. 8. When praying, don't give God instructions - just report for duty. 9. Don't wait for six strong men to take you to church. 10. We don't change God's message -- His message changes us. 11. The church is prayer-conditioned. 12. When God ordains, He sustains. 13. WARNING: Exposure to the Son may prevent burning. 14. Plan ahead -- It wasn't raining when Noah built the ark. 15. Most people want to serve God, but only in an advisory position. 16. Suffering from truth decay? Brush up on your Bible. 17. Exercise daily -- walk with the Lord. 18. Never give the devil a ride -- he will always want to drive. 19. Nothing else ruins the truth like stretching it. 20. Compassion is difficult to give away because it keeps coming back. 21. He who angers you controls you. 22. Worry is the darkroom in which negatives can develop. 23. Give Satan an inch & he'll be a ruler. 24. Be ye fishers of men -- you catch them & He'll clean them.. 25. God doesn't call the qualified, He qualifies the called.
LORD God, bless the person reading this in whatever it is that You know he or she may be needing this day....) Live LIFE to the fullest, for we only live once...
Describe what happens during the four phases of sexual response described by stimuli Masters and Johnson
1.Excitement: internal or external
activation of the centralnervous system (CNS) deep breathing, increase in heart rate,blood pressure, and sexualtension; generalized vasocongestion skin flush, breast engorgement, nipple
erection, engorgement of labia and clitoris, vaginal transudation, and uterine tenting
2.Plateau: marked degree of vasocongestion throughout the body _ further engorgement ofthe labia, lower third of vagina, breast, and areolae. Secretion from the Bartholin glands, retraction of the clitoris, vagina lengthens with dilation of the upper two-thirds, muscle tension begins to build up
3.Orgasm: release of sexual tension, generalized myotonic contractions, perivaginal muscles and
Anal sphincter contract at precise intervals, vaginal and uterine contractions
4.Resolution: a gradual diminution of sexual tension and response
What is the biopsychosocial model of female sexual response?
The biopsychosocial nature of female sexual response is influenced by the dynamic interaction of four components: biologic, psychologic,sociocultural influences, and interpersonal relationships. All of these components must be addressed in order to achieve sexual satisfaction
What are the possible etiologies of sexual dysfunction?
1. Change in vascularity (atherosclerosis, pudendal artery insufficiency affecting vaginal
2. Neurogenic causes (spinal cord dysfunction or injuries)
3. Depression or anxiety disorders
4. Medications (selective serotonin reuptake inhibitor [SSRI], tricyclic antidepressants, H2 blocker, and some antihypertensive medication)
5. Psychosocial factors (prior history of sexual abuse, religious or cultural expectation, fear of rejection or intimacy, and distorted body image)
6. Hormonal changes (premature ovarian failure and menopause)
What is the prevalence of sexual dysfunction?
Studies show a range of 10–60%; the average is 43%
What are the types of female sexual dysfunction and what is the main symptom of each?
1. Sexual desire disorders:decreased sexual fantasy and/or desire, sexual aversion
2. Sexual arousal disorders: decreased genital vasocongestion and lubrication
3. Orgasmic disorders: anorgasmia
4. Sexual pain disorders: vaginismus, dyspareunia, noncoital sexual pain
How should the question of sexual dysfunction be addressed?
The evaluation should involve aninterview of the couple and each partner separately. A complete assessment should include past medical, psychological, sexual history and physical examination including gynecologic examination. Each patient should be asked if she has any
questions or concerns about her sexual activity. The most important aspect of taking a sexual history is to make the patient feel comfortable
Recurrent and persistent lack of sexual fantasies or desires orreceptivity to sexual activity that
causes personal distress
How should HSDD be evaluated?
Take a careful history including medications, medical illness, depression, substance abuse, and
stress. Thyroid test and prolactin levels may be indicated if there is any suggestion of hyperprolactinemia. Androgen levels are not useful in the majority of cases
How should HSDD be treated?
Physiologic causes should be assessed and managed. Further treatment may require individual therapy or relationship therapy
What is sexual aversion disorder?
It is characterized by a phobia with avoidance of sexual contact and severe anxiety associated with contemplation of sexual activity
What are sexual arousal disorders and how are they treated?
When women experience desire and orgasm, but lack signs of sexualstimulation, such as lubrication and genital vasocongestion. Treatment includes masturbation, vaginal lubricants, vibrator to increase stimulation, foreplay, distraction technique to alleviate anxiety, and/or
estrogen replacement therapy for postmenopausal women
What is orgasmic dysfunction and how is it treated?
A persistent delay in or absence of orgasm after sufficient stimulation and arousal resulting in distress or interpersonal difficulty. Treatment involves orgasm goal directed sexual
What types of orgasmic dysfunction exists?
Primary anorgasmia is found in 5–10% of women and is lifelong
Secondary anorgasmia is often related to relationship problems, medications, medical illness,
depression, substance abuse, and self-monitoring/anxiety during arousal
What types of sexual pain disorders exist and what are they?
Vaginismus (recurrent involuntary contraction of the vaginal musculature during vaginal penetration)
Dyspareunia (general pain that occurs before, during, or after intercourse)
What organic disorders must be ruled out when vaginismus is diagnosed?
What are the overall risks and benefits of female sterilization?
Risks: 1. Anesthesia/surgical complications
2. Ectopic pregnancy—failed procedures can result in an increased risk of ectopic pregnancies
3. Regret of the procedure (especially in younger people)
4. Does not stop the spread of HIV or other STIs Benefits:
1. Not coitally dependent
2. Decreased risk of ovarian cancer
3. No evidence of menstrual irregularity or dysmenorrhea
What are the risks and benefits of each of the female sterilization procedures?
Ligation is one of the oldest methods of sterilization with the lowest failure rate (0.8%) but it is not easilyreversed
Mechanical blockage with a clip is the most readily reversed method but it also has the highest failure rate (3.7%)
Coagulation-induced blockage with electrocautery is the fastestprocedure with a low failure rate(2.5%), but there is increased risk of electrical damage to surrounding structures
What are some advantages and disadvantages of a vasectomy?
Advantages: effectiveness is very high—typical first-year failure rate 0.15%; simpler, surgically safer, more cost-effective than female sterilization; Males share contraception responsibility with females
Disadvantages: does not protect against STIs
Is reversibility after a female sterilization procedure and vasectomy possible?
Reversibility after a female sterilization procedure is generally very difficult and has been reported as only 60% effective.
As for vasectomy, men are generally counseled that it is permanent. About 50–70% of men who have a reversal become fertile. The chance of becoming fertile decreases with increasing time after the procedure
If a woman in her early twenties with two children requests tubal sterilization, what is the next appropriate recommendation?
Considering the woman’s age, youmust inform her of the risk for regretof the procedure and of the permanence of tubal sterilization/ difficulty of reversal
What is the fertility awareness method?Predicting the time of month when a
woman is most fertile and abstaining during that time. Also known as the rhythm method
What three methods can be used to predict 1. Date of the last menstrual period:
fertility and which days are women days 8–19 of the cycle
presumed to be fertile?(peri-ovulation)
2. Changes in body temperature:
after menstruation until 3 days after an increase in basal body temperature by 0.5–1°F
3. Changes in cervical mucus: when the mucus becomes clear and stretchy (peri-ovulation) known as spinbarkeit
Why are fertility awareness methodsBecause people do not always
unreliable? abstain during this time and because there is always some chance offertility on the “non-fertile” days.
Body temperature and cervical mucus (especially if used together) are moreeffective than the calendar method because of irregular cycle lengths
What is the withdrawal method? The withdrawal method is when the male withdraws from the vagina before ejaculation. It is ineffective when not timed correctly or when the pre-ejaculatory fluid contains sperm
Is lactation an effective means of birthLactation is somewhat effective as a
control?means of birth control because of the prolactin-induced inhibition ofGnRH, which leads to a delay in return
to ovulation. Additional contraception should be used by breast- feeding women to prevent pregnancy
What factors affect the effectiveness of The number of times a woman breast
lactation as a means of birth control?feeds each day; How effective breast feeding is (i.e., how much milk she is producing); If the child is getting any supplemental feeding