Phase III of CPR is prolonged life support, a long-term resuscitation
G: Gauging (evaluation and critical care triage)
H: Humanizing the outcome by brain resuscitation measures
I: Intensive therapy for general life support.
In every emergency and critical care setting attempts should be made to quantitative the clinical material in terms of types and severity of insults at that time patients enter the emergency system such as hypoxia time prior to arrest, arrest time, CPR time, hypoxia time after arrest and total insult time.
The degree of unresponsiveness (depth of coma) and its change over time can and should be followed, at least as long as the patient is in the ICU after a cerebral insult. This may be accomplished by standard neurologic evaluation using the Glasgow Coma Scale base on eye opening, motor response and verbal response.
After several hours of long-term life support, the degree of recovery at each point in time should be noted of overall and cerebral performance capability. Briefly, the cerebral performance catagories:
1. Conscious and normal, without disability.
2. Conscious with moderate disability.
3. Conscious with severe disability.
4. Coma or vegetative state, without brain damage.
5. Brain death or death.
The patient's outcome in terms of survival and overall performance capability depends on the severity and duration of insult, the speed and quality of emergency resuscitation, and the early start and quality of brain-oriented, post resuscitation intensive therapy.
That is why after several hours of long-term, life support, the degree of recovery at each point in time should be noted of overall and cerebral performance capability, do brain resuscitation and/or protection.
Cerebral protection - preemptive use of therapeutic interventions to improve neurological outcome in patients who will be at risk for cerebral ischemia. The primary objective is prevention of the deleterious effects of ischemia.
Cerebral resuscitation - refers to therapeutic interventions initiated after an ischemic events. The goal is treatment is ischemia and attenuation of neuronal injury.
General intensive care monitoring are invasive blood pressure monitoring, pulse oxymetri, continous ECG, SO2, Temperature, urine output, serum lactate, arterial blood gases, ureum creatinin, glucose, chest x ray.
Advance haemodynamic monitoring is achocardiographym cardiac output monitoring
Cerebral monitoring are EEG for early detection and treatment of seizure activity, CT/MRI
There are also need to monitor patient's airway and breathing, circulation, treatment of Hypothermia, treatment of hyperpyrexia, glucose control and seizure control.
1. Lecture on Prolonged Life Support Block 4.2
2. Skills lab manual book of Prolonged Life Support Block 4.2
Communicating with others is an essential skill in business dealings, family affairs, and romantic relationships. Do you often find yourself misunderstanding others? Do you have difficulty getting your point across clearly? When it comes to communication, what you say and what you don't say are equally important. Being a good listener is quite crucial.
Good communication is very important. Not only in the aspect of social life, but it is also play an important role in the culture, religion and also community based aspect.
Communication is seen as the central to our everyday ideas about what makes life worth living (Katherine Miller, 2002)
What is communication?
Communication is a process when information is enclosed , channeled and imparted by a sender to a receiver via some medium. The receiver then decodes the message and gives the sender a feedback. All forms of communication require a sender, a message, and an intended recipient, however the receiver need not be present or aware of the sender's intent to communicate at the time of communication in order for the act of communication to occur.
Communication requires that all parties have an area of communicative commonality. There are verbal means using language and there are nonverbal means, such as body language, sign language, and eye contact, through media like pictures, graphics and sound, and writing.
According to Miller 1966, the most highest level of communication is when a source transmits a message to receiver with conscious intent that can affect the latter’s behavior.
There are 4 principles of Interpersonal Communication (Donnel King, 2000), which are:
We can't escape from communicate. The very attempt not to communicate communicates something. Even not through words, but it can be from tone of voice and gesture, posture or facial expression.Through these channels, we constantly receive communication from others. Remember a basic principle of communication in general: people are not mind readers. Another way to put this is: people judge you by your behavior, not your intent.
We can't really take back something once it has been said. The effect must inevitably remain. Like malay proverb says 'terlajak perahu boleh di undur, terlajak kata buruk padahnya' have a same meaning with Russian proverb "Once a word goes out of your mouth, you can never swallow it again."
No form of communication is simple. Because of the number of variables involved, even simple requests are extremely complex. We don't actually swap ideas, we swap symbols that stand for ideas. This also complicates communication. Words (symbols) do not have inherent meaning; we simply use them in certain ways, and no two people use the same word exactly alike.
Psychological context - which is who you are and what you bring to the interaction.
Relational context - which concerns your reactions to the other person.
Situational context - where place you are communicating. It may be different between in a room and in a bar.
Environmental context - physical "where" you are communicating. The example like furniture, location, noise level, temperature, season and time of day.
Cultural context - all the learned behaviors and rules that affect the interaction. Different culture will give different understanding about certain things. It also influence by the knowledge, open-minded and also experience.
After ABC procedure is already stable, then the process proceed with DEF in Advanced Cardiac Life Support.
D - defibrillator, drugs
E - electrocardiography (ECG)
F - fluids
For the complete algorithm of BLS and Pulseless arrest algorithm - the use of shockable (defibrillator) and non-shockable, view the image below:
BLS adult algorithm
Pulseless Arrest Algorithm
How to used Defibrillator?
1. Turn on defibrillator by select the energy level at 360J for monophasic, or 120J to 200J for biphasic.
2. Set lead select switch on paddles
3. Apply gels to paddles or position conductor pads on patient's chest
4. Position the paddles on patients (sternum-apex)
5. Check the monitor and assess the rhythm (ventricular fibrillation (VF) / ventricular tachycardia (VT) / asystole / pulseless electrical activity (PEA) )
6. Announce to the team members 'charging defibrillator'
7. Press 'charge' button on the paddles.
8. When it is fully charges, shout out before each shock:
- I going to shock in three. One I'm clear
- Two, you're clear
- Three everybody is clear. *make sure no one is touching the patients, bed or any equipment like ventilator, IVs, oxygen tube etc
9. If paddles are used, apply 25 pounds of pressure
10. Press 'shock' button
11. Immediately resume CPR, begin with compressions, 5 cycles then re-shock (if possible)
1. Skills lab manual on Advanced Cardiac Life Support.
Post traumatic stress disorder or PTSD is a severe anxiety disorder that can develop after exposure to any event that results in psychological trauma. It is included death of the lovely one, physical sexual and psychological abuse, man-made or natural disaster and so on, overwhelming the individual's ability to cope.
From both criteria from ICD-9 and DSM-IV, the symptoms need to be last more than one month and cause significant impairment in social, occupational, or other important areas of functioning.
There are also some factors that influence the vulnerabilities of PTSD:
Pre-Trauma factors -
A history of prior traumatization
Underdeveloped protective skills
Personality negative thought patterns
Biology/ hereditery factor
Recent life stressors
Initial distress at the time of trauma
Post-Trauma Factors -
Recovery environment - lack of support from family, friends and community
Conspiracy of silence
Lack of treatment or ineffective treatment
According to Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV-TR), it can be summerize as:
Exposure to a traumatic event
This must have involved both loss of physical integrity or risk of serious damage, to self or others, and an intense negative emotional response.
One or more of these must be present in the victim: flashback memories, recurring distressing dreams, and any objects or subjects that be remainder to the traumatic event cause intense psychological and physical disturbance.
Persistent avoidance and emotional numbing
This involves a sufficient level of avoidance of stimuli associated with the trauma, such as certain thoughts or feelings, or talking about the events, avoidance of behaviors, places, or people that might lead to distressing memories, inability to recall major parts of the trauma or decreased involvement in significant life activities.
Persistent symptoms of increased arousal not present before
These are all physiological response issues, such as difficulty falling or staying asleep, or problems with anger, concentration, or hypervigilance.
Duration of symptoms for more than 1 month
If all other criteria are present, but 30 days have not elapsed, the individual is diagnosed with Acute stress disorder.
The symptoms must lead to clinically significant distress or impairment to life activity, such as social relations, occupational activities and others.
Psychological therapy - basic counselling and education, cognitive behavioral therapy(changing behavioral or negative thinking of the patients) and also Eye movement desensitization and reprocessing (EMDR) is specifically targeted as a treatment for PTSD.
SSRIs (selective serotonin reuptake inhibitors) are considered to be a first-line drug treatment include citalopram, escitalopram, fluoxetine, and fluvoxamine.
Beta blockers -Propranolol - similarly to clonidine, may be useful if there are significant symptoms of "over-arousal"
Alpha-adrenergic agonists -clonidine- to reduce traumatic stress symptoms that it may have benefit in preventing PTSD.
Benzodiazepines- can be used with caution for short-term anxiety relief, hyperarousal, and sleep disturbance.
1. Lecture note on Post Traumatic Stress disorder management by dr Bambang Hastha Yoga.
I know some of you love travelling. But do you know that even travelling can give you bad impact besides lost a lot of money?
Travel medicine is a branch of science that focus on the disease that a traveler can get besides high risk of opportunity disease when you travel to other country. Travellers are thus exposed to a variety of health risks in unfamiliar environments. Most such risks, however, can be minimized by suitable precautions taken before, during and after travel.
The traveller in high risk of travel-related disease, depends on: 1. Mode of transport - there is difference risk when you travel with airplanes and cruise, and any otherr transportation like train and cars (risk like accident, longer time of journey related with deep vain thrombosis and so on) 2. Destination(s) - where accommodation, hygiene and sanitation, medical care and water quality are of a high standard pose relatively few serious risks to the health of travellers, unless there is pre-existing illness. Besides, they should be aware of the endemic of the disease, occurrence of any disease outbreaks in their destination countries, unforeseen natural or manmade disasters. 3. Duration and season of travel - duration of visit may determine whether the traveller is subjected to marked changes in temperature and humidity or to prolonged exposure to atmospheric pollution. season of the certain country also play important role because some season like winter have low opportunity of communicable disease, but high in systemic disease like frost bite or hypothermia. 4. Purpose of travel - the purpose of travel like conference and business trip is usually held in the city, with good accommodation, clean water supply and well- organized food have lower risks than do hiking, camping and do researches in the rural area. 5. Standards of accommodation and food hygiene - the clean, well-managed accommodation with good services hotel and resort have lower risk of transmittion of disease than poor dirty motel with no cleaner services provided. Food also important aspect of travel disease since poor food hygiene contains a lot of bacteria and virus related to typhoid, hepatitis A and diarrhea. 6. Behaviour of the traveller - behavior like keep good hygiene and sanitation, used proper attire for certain activity like shoes, long pants and long sleeves shirt to avoid from be bitten with mosquito, used repellent, always wash your hand before and after eat and also eat the clean and cooked food to avoid food related disease. 7. Underlying health of the traveller - previous history of disease and current diseases like heart related disease like congestive heart failure and heart attack, and respiration relate disease like asthma.
Travellers also can prepared some first aid kits before travelling that consist of:
antiseptic wound cleanser, bandages, emollient eye drop, insect repellent, insect bite treatment, antihistamine cream or tablets, nasal decongestant, oral rehydration salts, scissors and safety pins, simple analgesic (e.g. paracetamol), sterile dressing, clinical thermometer, sunscreens and earplugs
Besides, depends on the individual needs and destination:
antidiarrhoeal medication (to include an antibiotic, an antimotility drug and oral dehydration sachets with appropriate written instructions regarding their use), broad spectrum antibiotics (e.g. flucloxacillin, amoxicillin), antifungal powder, antimalarial medication, bednet and adequate supplies of condoms and the oral contraceptive.
1. Vaccination - Contact the nearest travel medicine centre or a physician as early as possible, preferably 4–8 weeks before departure. For certain country, you can get free of charges for typhoid and hepatitis A vaccination. For typhoid vaccination, the duration and last for 3 years and for hepatitis A vaccination, first injection can last for 12 months. So you need second injection after 6-12 months from first injection, that can last for 20 years.
2. Malaria - Request information on malaria risk, prevention of mosquito bites, possible need for appropriate preventive medication and emergency reserves, and plan for bednet and insect repellent. There are also prophylaxis injection for malaria to reduce the risk, not to eliminate it because some countries have different resistant of malaria medication.
3. Food hygiene - Eat only thoroughly cooked food and drink only well-sealed bottled or packaged cold drinks. Boil drinking-water if safety is doubtful. If boiling is not possible, a certified well-maintained filter and/or disinfectant agent can be used.
4. Specific local diseases - Consult the appropriate sections of this volume as well as www.who.int and national travel health web sites.
On 27th Nov 2010, I went to visit Posko Maguwoharjo (I still got problem to spell and pronounce it!) -temporary shelter for the Merapi Eruption victims- with some of my batchmates. Although it was a short visit, and we only be able to talk with a few evacuee there and gave a very little help, but it was very memorable moment.
A picture is worth a thousand words.
So I give you six. And a countless words.
Lets meet my friends that join the visit as well. And hear their story.