Acute coronary disorders Drugs in cardiopulmonary resuscitation

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Acute coronary disordersDrugs in cardiopulmonary
resuscitation

• Advanced Life Support (ALS) algorithm

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Acute coronary syndromes
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Definitions

• The acute coronary syndromes comprise
• Unstable angina
• Non-Q wave myocardial infarction
• Q wave myocardial infarction
• These process is triggering
• Hemorrhage into the plaque causing it to swell
  and restrict the lumen of the artery
• Contraction of smooth muscle within the artery
  wall causing further constriction of the lumen
• Thrombus formation on the surface of the plaque,
  which may lead ultimately to complete obstruction
  of the lumen of the coronary artery

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Unstable angina

• Angina a pain resulting from myocardial
  ischaemia and is felt usually in or across the
  centre of the chest as tightness or an
  indigestion-like ache, radiates into the throat,
  arms, back or epigastrium, sometimes is perceived
  as discomfort

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Unstable angina

• Defined by one or more of
• Angina of effort occuring over few days with
  increasing frequency,
• Episodes of angina occuring recurrently and
  unpredictably, may be relatively short-lived or
  be relieved temporarily by sublingual glyceryl
  trinitrate,
• An unprovoked and prolonged episode of the chest
  pain raising suspicion of myocardial infarction
  but without ECG evidence

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Unstable angina

• The ECG may
• Be normal
• Show evidence of acute myocardial ischaemia (ST
  segment depression)
• Show non-specific abnormalities (e.g. T wave
  inversion)

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Non-Q wave myocardial infarction

• The clinical syndrome presenting with symptoms
  suggestive of acute MI and non-specific ECG
  abnormalities
• Often ST segment depression
• T wave inversion
• Lab tests are positive indicating that
  myocardial damage has occured
• Treatment essentially the same like in the
  unstable angina

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Q wave myocardial infarction

• The clinical syndrome presenting with prolonged
  chest pain, accompanied by acute ST segment
  elevation
• Laboratory evidence of myocardial damage in the
  form of raised cardiac enzymes or other
  biochemical markers creatine kinase (CK),
  aspartate transaminase (AST), lactate
  dehydrogenase (LDH), cardiac troponins (TrI, TrT)
• Clinical examination limited benefit, severe
  chest pain may provoke sweating, pallor,
  tachycardia, nausea

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Q wave myocardial infarction
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Immediate treatment

• General measures in all acute coronary syndromes
• Rapid initial assessment
• Provide prompt relief of symptoms
• Limit myocardial damage and risk of the cardiac
  arrest
• Coronary reperfusion therapy thrombolytic
  therapy, percutaneous transluminal coronary
  angioplasty (PTCA), coronary artery bypass graft
  (CABG) surgery

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MONA initial general treatment

• M morphine, titrated intravenously to avoid
  sedation and respiratory depression
• O oxygen, in high concentration
• N nitroglycerine, as sublingual glyceryl
  trinitrate (tablet or spray)
• A aspirin, 300mg orally as soon as practicable
• Patients with cardiac pain will be more
  comfortable sitting up !!!

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Peri-arrest arrhythmias

• Cardiac arrhythmias - well rocognised
  complications of myocardial infarction
• The treatment of all arrhythmias poses two basic
  questions
• How is the patient?
• What is the arrhythmia?
• The presence or absence of certaine adverse signs
  or symptoms will dictate the appropriate
  treatment

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Adverse signs of peri-arrest arrhythmias

• Clinical evidence of low cardiac output pallor,
  sweating, cold, clammy extremities, impaired
  consciousness, hypotension
• Excessive tachycardia very high rates (gt150
  beats/min) reduce coronary flow resulting in
  myocardial ischeamia
• Excessive bradycardia may not be tolerated by
  patients with poor cardiac reserve (lt60
  beats/min)
• Heart failure arrhythmias reduce the efficiency
  of the heart as a pump (pulmonary oedema)

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Treatment options

• Have determined the rhythm and find the presence
  or absence of adverse signs
• Options available in the immediate treatment of
  arrhythmias
• Antiarrhythmic drugs absence of adverse signs
• DC shock to attempt cardioversion converting a
  tachycardia to sinus rhythm
• Cardiac pacing treating symptomatic bradycardias

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Bradycardia heart rate lt 60/min

• Adverse signs
• Systolic blood pressure lt 90 mmHg
• Heart rate lt 40/min
• Ventricular arrhytmias requiring suppresion
• Heart failure
• Treatment
• Atropine
• Cardiac pacing presence the risk os asystole

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Narrow Complex Tachycardia

• Adverse sins
• Systolic blood pressure lt 90 mmHg
• Chest pain
• Heart failure
• Impaired consciousness
• Heart rate gt 200 beats/min
• Treatment
• Antiarrhythmic drugs esmolol, amidarone
• DC shock

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Broad Complex Tachycardia

• Adverse signs
• Rate gt 150/min
• Chest pain
• Heart failure
• Systolic blood pressure lt 90 mmHg
• Treatment
• Amidarone, lidocaine
• DC shock

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Atrial fibrillation

• Adeverse signs
• Rate gt 150/min
• Ongoing chest pain
• Critical perfusion
• Breathlessness
• Treatment
• Anticoagulation, beta-blockers, digoxin,
  amiodarone
• Synchronised DC shock

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DRUGSfor cardiac arrest
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• There are 3 groups of drugs relevant to the
  management of cardiac arrest
• Vasopressors
• Anti-arrhytmics
• Other drugs
• Drugs should be considered only after initial
  shocks have been delivered and chest compressions
  and ventilation have been started.

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Adrenaline (epinephrine)primery agent for the
management of cardiac arrest

• Its primary efficacy is due to effects
• ?-adrenergic arterial vasoconstriction
• ? systemic vascular resistance
  
• ? coronary and cerebral perfusion
  pressures
• ?-adrenergic ? coronary blood flow
• ? force of contraction
• ? myocardial O2 consumption
• (may increase ischaemia)

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Adrenaline

• Indications
• The first drug used in cardiac arrest of any
  ethiology
• Second-line treatment for cardiogenic shock
• Preferred in the special circumstances
• anaphylaxis

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Adrenaline

• Dose
• 1 mg intravenous (1 ml sol. 11,000) every 3-5
  min of CPR
• 2-3 mg diluted to 10ml with sterile water via
  tracheal tube
• 210 mcg/min continous infusion for atropine
  resistant bradycardia, hypotensive patients
• 0.5ml 11,000 i.m., 3-5 ml (sol.110,000) i.v. -
  in anaphylaxis, depending on severity

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Vasopressin

• Naturally occuring antidiuretic hormone
• High doses powerful vasoconstricor that acts by
  stimulation of smooth muscle V1 receptors
• AHA recommended vasopressin as an alternative
  to adrenaline for the treatment of adult
  shock-refractory VF
• Dose 40 U (comp. 1mg adrenaline)
• Currently insufficient evidence of improvement
  in survival to discharge

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Anti-arrhythmics
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Amiodarone

• - membrane-stabilising drug that increases
• duration of the action potential
• refractory period in atrial and vetricular
  myocardium
• mild negative inotropic action - may cause
  hypotension
• appers to improve the response to defibryllation

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Amiodarone

• Indications
• Refractory VF / Pulseless VT
• Haemodynamically stable VT
• Other resistant tachyarrhythmias

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Amiodarone

• Dose
• Refractory VF / Pulseless VT
• 300 mg diluted in 5 dextrose to a volume of
  20ml,
• Stable tachyarrhythmias
• 150 mg in 5 dextrose over 10 min
• Repeat 150 mg if necessary
• 300 mg in 100 ml 5 dextrose over 1 hour

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Lidocaine

• Membrane-stabilising drug that acts by
• increasing the myocyte refractory period
• decreases vetricular automaticity
• Suppresses ventricular ectopic activity mainly
  in arrhythmogenic tissues, minimally with
  electrical activity of normal tissues
• Lidocaine toxicity
• paraesthesia
• drowsiness
• confusion
• convulsions

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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
• initial 100 mg i.v. (1 1.5mg/kg)
• further boluses 50mg,
• Haemodynamically stable VT
• 50 mg i.v.
• further boluses of 50 mg,
• Total dose should not exceed 3mg/kg during the
  firt hour
• Reduce dose in elderly or hepatic failure

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Adenosine

• Naturally occuring purine nucleotide
• Slows conduction across the AV node,
• Has little effect other myocardial cells
• Has short duration of action
• May reveal the underlying atrial rhythms by
  slowing the ventricular response
• Should be used in a monitored environment only

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Adenosine

• Indications
• Undiagnosed narrow complex tachycardia
• Paroxysmal supraventricular tachycardia

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Adenosine

• Dose
• 6 mg intravenously, by rapid injection to achieve
  adequate and effective blood levels
• If necessary, three further doses each of 12 mg
  can be given every 12 min

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Magnesium sulphate

• Constituent involved in ATP generation in muscle,
  neurochemical transmission
• decreases acetylcholine release
• reduces the sensivity of the motor endplate
• improves the contractile response
• limits infarct size
• acts as a physiological calcium blocker
• Hypomagnesaemia contribute to arrhythmias and
  cardiac arrest !!!

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Magnesium sulphate

• Indications
• Shock refractory VF
• (in the presence of possible hypomagnesaemia)
• Ventricular tachyarrhythmias
• (in the presence of possible hypomagnesaemia)
• Digoxin toxicity
• (hypomagnesaemia increases myocardial digoxin
  uptake)

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Magnesium sulphate

• Dose
• Shock Refractory VF
• Initial dose 2g (4 ml (8 mmol)) of 50
  magnesium sulphate i.v. over 1 2 min
• It may be repeated after 10-15 min

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Other drugs

• OXYGEN high concentration should be given to
  all patients in cardiac arrest

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Atropine

• Antagonises the action of the parasympthatetic
  neurotransmitter acetylcholine at muscarinic
  receptors
• blocks effects of the vagus nerve on SA and AV
  nodes
• increases sinus node automaticity
• increases atrioventricular conduction

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Atropine

• Indications
• Asystole
• PEA (rate lt 60 beats/min)
• Sinus, atrial or node bradycardia unstable
  haemodynamic condition

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Atropine

• Dose
• Asystole / PEA (rate lt 60 beats/min)
• 3 mg i.v., single bolus
• 6 mg via tracheal tube
• Bradycardia
• 0.5 mg i.v., repeated as necessary, maximum 3 mg

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Theophylline

• Phosphodiesterase inhibitor that
• Increases tissue concentrations of cAMP and
  releases adrenaline from adrenal medulla
• Has chronotropic and inotropic action

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Theophylline

• Indications
• Asatolic cardiac arrest
• Peri-arrest bradycardia refractory to atropine
• Doses
• Recommended for adults 250 500mg (5mg/kg)
• (narrow therapeutic window, optimal plasma
  concentration 10 20mg/l)
• Side effects arrhythmias, convulsions

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Sodium Bicarbonate (Buffer)

• Indications
• Severe metabolic acidosis (pH lt 7.1)
• Hyperkalaemia
• Special circumstance
• Tricyclic antidepressant poisoning

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Sodium Bicarbonate (Buffer)

• Agent used in treatment of acidaemia in cardiac
  arrest but generate carbon dioxide, which
  diffuses rapidly into cells
• exacerbates intracellular acidosis
• produces a negative inotropic effect on ischaemic
  myocardium
• causes hypernatraemia
• Compromises circulation and brain
• interact with adrenaline

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Sodium Bicarbonate

• Dose
• 50 mmol (50 ml of 8.4 solution) i.v.

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Calcium

• Constituent essential for normal cardiac
  contraction, but
• high plasma concentrations are harmful to the
  ischaemic myocardium and impair cerebral recovery
• excess may lead to arrhythmias

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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)
• May be repeated
• (Do not give immediately before or after sodium
  bicarbonate)

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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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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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Routealternative routes for drug delivery

• If a peripheral cannula is in place and working,
  use it initially
• Central veins are the route of choice if
  expertise is available
• The tracheal route can be used with appropriate
  adjustment of dose
• Intraosseous route drugs will achieve adequate
  plasma concentrations, safe and effective, may be
  used for children and adults

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Tracheal administration of drugs

• Drugs that can be given via the trachea
• Adrenaline
• Lidocaine
• Atropine
• Naloxone

• Drugs that cannot be given via the trachea
• Amiodarone
• Sodium bicarbonate
• Calcium

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European Resuscitation Council Guidelines for
Resuscitation

• Adult advanced life support
• ALS Algorithm

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Call Resuscitation Team
Open Airway Look for signs of life
Unresponsive ?
CPR 302 Until defibrillator / monitor attached
Assess Rhythm
Shockable (VF/ Pulsless VT)
Non-shockable (PEA / Asystole)

• During CPR
• Correct reversible causses
• Check electrode position and contact
• Attempt / verify
• IV access
• Airway and oxygen
• Give uninterrupted compressions when airway
  secure
• Give adreanline every 3-5 mins
• Consider amiodarone, atropine, magnesium

1 Shock 150-360 J biphasic lub 360 J monophasic
Immediately resume CPR 302 For 2 min
Immediately resume CPR 302 For 2 min

Reversible causes Hipoxia Tension pneumothorax
Hipovolaemia Tamponade cardiac Hipo/Hiperkalaem
ia / Metabolic Toxins Hipothermia Thrombosis
(coronary or pulmonary)
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Confirm Cardiac Arrest
Call Resuscitation Team
CPR 302 Until defibrillator / monitor attached
Precordial thump
Assess rhythm

• The interventions that contribute to improved
  survival after CA
• Early defibryllation (VT/VF)
• Prompt and effective bystander basic life support
  (BLS)
• Advanced airway intervention and the delivery of
  drugs have not been shown to increase survival
  after cardiac arrest (CA)
• During ALS attention must be focused on early
  defibrillation and high-quality, uninterrupted
  BLS

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Precordial thump

• Indication
• witnessed or monitored cardiac arrest
• (defibrillator is not immediately to hand)
• A precordial thump is most likely to be sucessful
  in converting VT
• Converting VF to sinus rhythm is much less likely

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Shochable rhythms (ventricular fibryllation /
pulsless ventricular tachycardia)
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Assess rhythm

• If shockable rhythm is confirmed
• Charge the defibrillator
• Give one shock (biphasic or monophasic energy)
• Resume CPR immediately after shock without
• reassessing the rhythm for 2 min(CV ratio 302)
• Check the monitor
• If there is still VF/VT give next shock
• Resume CPR immediately - 2min
• Check the monitor
• If there is still VF/VT give adrenaline followed
• immediately by a third shock
• Resumption of CPR
• SEQUENCE
• DRUG shock CPR rhythm check
• Minimise the delay between stopping chest
• Compressions and delivery of shock

Shockable (VF/pulsless VT)
1 Shock 150-360 J (biphasic) or 360 J (monophasic)
Immediately resume CPR 302 for 2 min
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ERC Guidelines 2005Cardiac arrest VF/VT

• Adrenaline give immediately before the shock
• 1 mg every 3-5min (start followed the third
  shock)
• Amiodarone if VT/VF persists after third shock
• 300 mg iv bolus during rhythm analysis before
• delivery of the fourth shock
• Drug shock CPR rhythm check SEQUENCE

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STOP of the algorithm

• If signs of life return during CPR movement,
  normal breathing or coughing
• Check the monitor
• Organised rhythm present
• Check for a pulse
• Pulse palpable
• ROSC
• Continue post-resuscitation care (PRC)
• Pulse not present
• Continue CPR

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• During CPR
• Correct reversible causses
• Check electrode position and contact
• Attempt / verify
• IV access
• Airway and oxygen
• Give uninterrupted compressions when airway
  secure
• Give adreanline every 3-5 mins
• Consider amiodarone, atropine, magnesium

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Airway and ventilation

• Personnel skilled in advanced airway management
• Attempt laryngoscopy and tracheal intubation
• Personnel not skilled
• Laryngeal mask (LMA)
• Laryngeal tube (LT)
• Combitube
• After airways insertion
• Attempt to deliver continous chest compressions,
  uninterrupted durin ventilation
• Ventilate the lungs at 10 breaths per min

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Intravenous access and drugs

• Central venous drug delivery
• Peripheral venous drug delivery flush cannula
  of 20ml fluid and elevate of the extremity
• Intraosseous route alternative route for
  vascular access in children (drug dose like in iv
  access)
• Tracheal route dose of adrenaline is 3mg
  diluted to 10ml with sterile water

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Non-shockable rhythms (PEA and asystole)
Assess rhythm
Non-shockable (PEA / asystole)
Immediately resume CPR 302 for 2 min
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Asystole

• Start CPR (CV ratio 302)
• Check that the leads are attached correctly
• Give adrenaline as soon iv access is achieved 1
  mg every 3 - 5 mins
• Atropina 3 mg i.v. will provide max. vagal
  blokade
• Secure the airway
• After 2 min CPR
• No change in ECG appearance resume CPR
• Organised rhythm is present check the pulse
• Pulse is present begin PRC
• Pulse is not present resume CPR

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Pulseless electrical activity (PEA)

• Start CPR (CV ratio 302)
• Check that the leads are attached correctly
• Give adrenaline
• Atropine 3 mg i.v. rhythm rate lt 60/min
• Secure the airway
• Check potentially reversible causes (4 Hs, 4Ts)
• After 2 min CPR
• No change in ECG appearance resume CPR
• Organised rhythm is present check the pulse
• Pulse is present begin PRC
• Pulse is not present resume CPR

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• Potentially reversible causes
• Hypoxia
• Hypovolaemia
• Hypo / hyperkalaemia, metabolic disorders
• Hypothermia
• Tension pneumothorax
• Cardiac tamponade
• Toxins
• Thrombosis (coronary or pulmonary)

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Post Resuscitation Care

• The goal
• Normal cerebral function
• Stable cardiac rhythm
• Adequate organ perfusion

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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