1. RC (UK)
RESUSCITATION COUNCIL (UK)
RESUSCITATION COUNCIL
(QAT)
ADVANCED LIFE SUPPORT
2/15/2003 , 1
INTRODUCTION
Dr.Montaser Ismail
MRCP, Arab Board of Cardiology

2. RC (UK)
Cardiovascular Disease
• In Europe cardiovascular disease accounts for
40% of all deaths < 75 yrs
• In QAT cardiovascular disease accounts for 29%
of all deaths all ages.
• One third of all people developing an MI die
before reaching hospital
• Presenting rhythm in most of these cases is
VF/VT
• In-hospital cardiac arrest more likely non-VF/VT
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Chain of Survival
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CAUSES AND PREVENTION
OF CARDIORESPIRATORY
ARREST
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Causes of cardiorespiratory arrest
1. Airway obstruction
• CNS depression
• Blood, vomit, foreign body
• Trauma
• Infection, inflammation
• Laryngospasm
• Bronchospasm
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6. RC (UK)
Causes of cardiorespiratory arrest
2. Breathing inadequacy
• Decreased respiratory drive
–CNS depression
• Decreased respiratory effort
–neurological lesion
–muscle weakness
–restrictive chest defect
• Pulmonary disorders
–pneumothorax, lung pathology6

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Causes of cardiorespiratory arrest
3. Cardiac abnormalities
Primary
• Ischaemia
• Myocardial infarction
• Hypertensive heart
disease
• Valve disease
• Drugs
• Electrolyte abnormalities
Secondary
• Asphyxia
• Hypoxaemia
• Blood loss
• Septic shock
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Recognition of patients at risk
• History, examination, investigations
• Clinical indicators of deterioration
before in-hospital cardiac arrest in 80%
–tachypnoea
–tachycardia
–hypotension
–reduced conscious level
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Medical Emergency Team (MET)
Calling Criteria
• Airway -threatened
• Breathing
–Respiratory arrest
–RR < 5 or RR >36
• Circulation
–cardiac arrest
–PR < 40 or PR >140
–Systolic BP < 90
• Neurology
–sudden fall in
GCS > 2
• Any other worries
RR = respiratory rate
PR = pulse rate
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Airway obstruction
Symptoms and signs
• Difficulty breathing,
distressed, choking
• Shortness of breath
• Stridor, wheeze,
gurgling
• See-saw respiratory
pattern
Actions
• Suction,
positioning
• BLS manoeuvres
• Advanced airway
intervention
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Breathing inadequacy
Symptoms and signs
• Short of breath,
anxious, irritable
• Decrease in
conscious level
• Tachypnoea
• Cyanosis
Action
• Oxygen
• Ventilatory support
• Treat underlying
cause where possible
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Cardiac abnormalities:
Acute Coronary Syndromes
Clinical syndromes form spectrum
of the same disease process:
Unstable angina
↓
Non-Q wave myocardial infarction
↓
Q wave myocardial infarction
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Immediate treatment in all
acute coronary syndromes
• “MONA”
–Morphine (or diamorphine)
–Oxygen
–Nitroglycerine (GTN spray or tablet)
–Aspirin 300 mg orally
(crushed/chewed)
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Patients with ST segment
elevation MI or MI with LBBB
Early coronary reperfusion therapy:
• Thrombolytic therapy
–streptokinase
–alteplase
• Percutaneous transluminal coronary
angioplasty (PTCA)
• Coronary artery bypass surgery (CABG)
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CARDIAC MONITORING
&
RHYTHM RECOGNITION
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Which patients?
• Cardiac arrest or other important
arrhythmias
• Chest pain
• Heart failure
• Collapse / syncope
• Shock / hypotension
• Palpitations
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How to monitor the ECG (1):
Monitoring leads
• 3-lead system
approximates to I, II, III
• Colour coded
• Remove hair
• Apply over bone
• Lead setting (II)
• Gain
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How to monitor the ECG (2):
Defibrillator paddles
• Suitable for “quick-
look”
• Movement artefact
• Risk of spurious
asystole
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How to monitor the ECG (3):
Adhesive monitoring electrodes
• “Hands-free”
monitoring and
defibrillation
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12-lead ECG
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12-lead ECG
• 3D electrical activity from heart
• More sophisticated ECG
interpretation
• ST segment analysis
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• Depolarisation
initiated in SA node
• Slow conduction
through AV node
• Rapid conduction
through Purkinje
fibres
Basic electrocardiography (1)
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Basic electrocardiography
(2)
• P wave = atrial
depolarisation
• QRS = ventricular
depolarisation (< 0.12 s)
• T wave = ventricular
repolarisation
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How to read a rhythm strip
1. Is there any electrical activity?
2. What is the ventricular (QRS) rate?
3. Is the QRS rhythm regular or irregular?
4. Is the QRS width normal or prolonged?
5. Is atrial activity present?
6. How is it related to ventricular activity?
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ECG rhythm interpretation
• Effective treatment often possible
without precise ECG diagnosis
• Haemodynamic consequences of any
given rhythm will vary
• Treat the patient not the rhythm
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What is the ventricular rate?
• Normal 60-100 min-1
• Bradycardia < 60 min-1
• Tachycardia > 100 min-1
Rate = 300
Number of large squares between
consecutive QRS complexes*
* At standard paper speed of 25 mm sec-1
, 5 large squares = 1 second
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Is the QRS rhythm regular or
irregular?
• Unclear at rapid heart rates
• Compare R-R intervals
• Irregularly irregular = AF
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Is the QRS width normal or
prolonged?
• Normal QRS:
–< 0.12 s (< 3 small squares)
–originates from above bifurcation of
bundle of His
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• Prolonged QRS (> 0.12 s) arises from:
–ventricular myocardium, or
–supraventricular with aberrant
conduction
Is the QRS width normal or
prolonged?
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A broad complex tachycardia
should be assumed to be
ventricular in origin unless there
is a very good reason to suspect
otherwise.
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Is atrial activity present?
• P waves (leads II and V1)
• Rate, regularity, morphology
• Flutter waves
• Atrial activity may be revealed by
slowing QRS rate with adenosine
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How is atrial activity related
to ventricular activity?
• Consistent, fixed PR interval
• Variable, but recognisable pattern
• No relationship - atrioventricular
dissociation
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Heart Block: First Degree
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Heart Block: Second Degree
Möbitz Type I (Wenckebach) Block
Möbitz Type II Block
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Heart Block: Third Degree
• Site of pacemaker:
–AV node 40 - 50 min-1
–Ventricular myocardium 30 - 40 min-1
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37. RC (UK)
DEFIBRILLATION
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Mechanism of defibrillation
• Definition
“The termination of fibrillation or
absence of VF/VT at 5 seconds after
shock delivery”
• Critical mass of myocardium
depolarised
• Natural pacemaker tissue resumes
control
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Defibrillation
Success depends on delivery
of current to the myocardium
Current flow depends upon:
• Electrode position
• Transthoracic impedance
• Energy delivered
• Body size
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Transthoracic Impedance
Dependent upon:
• Electrode size
• Electrode/skin interface
• Contact pressure
• Phase of respiration
• Sequential shocks
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Manual Defibrillation
Relies upon:
• Operator recognition of
ECG rhythm
• Operator charging
machine and delivering
shock
• Can be used for
synchronised
cardioversion
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45. RC (UK)
Defibrillator Safety
• Never hold both paddles in one hand
• Charge only with paddles on
casualty’s chest
• Avoid direct or indirect contact
• Wipe any water from the patient’s
chest
• Remove high-flow oxygen from zone
of defibrillation
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Synchronised cardioversion
• Convert atrial or ventricular tachyarrhythmias
• Shock synchronised to occur with the R wave
• Short delay after pressing discharge buttons -
keep defibrillator electrodes in place
• Conscious patients: sedation or anaesthesia
• Check mode if further shock/s required
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Automated external defibrillators
• Analyse cardiac
rhythm
• Prepare for shock
delivery
• Specificity for
recognition of
shockable rhythm
close to 100%
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49. RC (UK)
Automated external
defibrillators
Advantages:
• Less training required
–no need for ECG interpretation
• Suitable for “first-responder”
defibrillation
• Public access defibrillation (PAD)
programs
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50. RC (UK)
Biphasic Defibrillators
• Require less energy for defibrillation
– smaller capacitors and batteries
– lighter and more transportable
• Repeated < 200 J biphasic shocks
have higher success rate for
terminating VF/VT than escalating
monophasic shocks
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51. RC (UK)
AIRWAY
MANAGEMENT
AND VENTILATION

2/15/2003 , 51

52. RC (UK)
Common causes of airway
obstruction
• Upper Airway
–tongue
–soft tissue oedema, foreign
material
–blood, vomit
• Larynx
–laryngospasm, foreign material
• Lower Airway
–secretions, oedema, blood52

53. RC (UK)
Recognition of airway
obstruction
• LOOK for chest/abdominal
movement
• LISTEN at mouth and nose for
breath
sounds, snoring, gurgling
• FEEL at mouth and nose for
expired air53

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Opening the airway
• Head tilt
• Chin lift
• Jaw thrust
• CAUTION! – cervical spine
injury
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Head Tilt and Chin Lift
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Jaw Thrust
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Suction
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Simple airway adjuncts

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Oropharyngeal Airway

60. RC (UK)
Nasopharyngeal Airway

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Mouth to mask
ventilation
Advantages:
• Avoids direct person to
person contact
• Decreases potential for
cross infection
• Allows oxygen
enrichment
Limitations:
• Maintenance of airtight61

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Bag-valve-mask, 2-person
ventilation
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63. RC (UK)
Ventilation using self inflating
bag
Advantages
• Avoids direct person to person
contact
• Allows oxygen supplementation –
up to 85%
• Can be used with facemask, LMA,
Combitube, tracheal tube

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Ventilation using self inflating
bag
Limitations
When used with a facemask:
• Risk of inadequate ventilation
• Risk of gastric inflation
• Need two persons for optimal use
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Advanced Airway
Management

66. RC (UK)
The Laryngeal Mask
Airway

67. RC (UK)
The Laryngeal Mask
Airway
Advantages
• Rapidly and easily inserted
• Variety of sizes
• More efficient ventilation than
facemask
• Avoids the need for laryngoscopy
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68. RC (UK)
The Laryngeal Mask
Airway
Limitations
• No absolute guarantee against
aspiration
• Not suitable if very high inflation
pressures needed
• Unable to aspirate airway

69. RC (UK)
The Laryngeal Mask
Airway
Fig 1
Fig 2 Fig 3

70. RC (UK)
The Laryngeal Mask
Airway

71. RC (UK)
Tracheal Intubation

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Tracheal Intubation
Advantages
• Allows ventilation with up to 100% O2
• Isolates airway, preventing aspiration
• Allows aspiration of the airway
• Alternative route for drug
administration
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Limitations
• Training and experience essential
• Failed insertion, oesophageal
placement
• Potential to worsen cervical cord or
head injury
Tracheal Intubation

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Needle
Cricothyroidotomy
Indication
• Failure to provide an airway by
any other means
Complications
• Malposition of cannula
– Emphysema
– Haemorrhage
– Oesophageal perforation
• Hypoventilation
• Barotrauma
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Cardiac Arrest Rhythms and
ALS Universal
Treatment Algorithm

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Ventricular fibrillation
• Bizarre irregular waveform
• No recognisable QRS complexes
• Random frequency and amplitude
• Unco-ordinated electrical activity
• Coarse / fine
• Exclude artifact
– movement
– electrical interference

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Pulseless ventricular tachycardia
• Monomorphic VT
–Broad complex rhythm
–Rapid rate
–Constant QRS morphology
• Polymorphic VT
–Torsade de pointes

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83. RC (UK)
Asystole
• Absent ventricular (QRS) activity
• Atrial activity (P waves) may persist
• Rarely a straight line trace
• Consider fine VF

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Pulseless Electrical Activity
• Clinical features of cardiac arrest
• ECG normally associated with an
output

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Cardiac Arrest
Precordial Thump if appropriate
BLS Algorithm if appropriate
Attach Defib-Monitor
Assess
Rhythm
+/- Check Pulse
VF/VT Non-VF/VT
Defibrillate X 1
CPR 2 min
CPR 2 min
During CPR
Correct reversible causes
If not already:
•check electrodes, paddle position
and contact
•attempt / verify airway & O2
i.v. access
•give epinephrine every 3 min
Consider:
amiodarone, atropine / pacing buffers
Potential reversible causes:
•Hypoxia
•Hypovolaemia
•Hypo/hyperkalaemia & metabolic disorders
•Hypothermia
•Tension pneumothorax
•Tamponade
•Toxic/therapeutic disorders
•Thrombo-embolic & mechanical obstruction
Universal ALS
Algorithm

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89. RC (UK)
Precordial thump
• Indication:
–witnessed or
monitored
cardiac arrest

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Cardiac Arrest
Precordial Thump if appropriate
BLS Algorithm if appropriate
Attach Defib-Monitor
Assess
Rhythm
+/- Check Pulse
VF/VT Non-VF/VT

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Look Listen & Feel
X 10 seconds

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30 : 2

93. RC (UK)
Assess
Rhythm
+/- Check Pulse
VF/VT
Defibrillate X 1
CPR 2 min
Ventricular Fibrillation/
Pulseless Ventricular
Tachycardia

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• Deliver 1 shocks in <
30 seconds
• Continue CPR for 2
minutes regardless.
VF / VT
SHOCK maximum
(200 – 360) joules

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During CPR
Correct reversible causes
If not already:
• check electrodes, paddle position and
contact
• attempt / verify: airway & O2
i.v. access
• give epinephrine every 3-5 min (every other
cycle of CPR)
Consider:
amiodarone, atropine / pacing, buffers

96. RC (UK)
Chest compressions,
airway and ventilation
• Secure airway:
–tracheal tube
–LMA
–Combitube
• Once airway secured, do not
interrupt chest compressions for
ventilation

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Intravenous access and drugs
VF/VT
• Central veins versus peripheral
• Epinephrine 1 mg i.v. or 2-3 mg
tracheal tube
• Consider amiodarone 300 mg if
VF/VT persists after 3rd shock
• Alternatively - lidocaine 100 mg
• Consider magnesium 8 mmol

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*or biphasic equivalent
VF/VT (continued)
• Epinephrine every 3-5
minutes
• Consider bicarbonate
50 mmol if pH < 7.1
• Consider paddle
positions
Shock maximum
(200 – 360) J

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Non-VF/VT
CPR 2 min
Assess
Rhythm
+/- Check Pulse
Asystole
Pulseless Electrical
Activity

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Potential reversible causes:
•Hypoxia
•Hypovolaemia
•Hypo/hyperkalaemia & metabolic disorders
•Hypothermia
•Tension pneumothorax
•Tamponade
•Toxic/therapeutic disorders
•Thrombo-embolic & mechanical obstruction

101. RC (UK)
Asystole
• Confirm:
–check leads - view via leads I and II
–check gain
• Epinephrine 1 mg every 3-5 minutes
• Atropine 3 mg i.v. or 6 mg via tracheal tube
(once)

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Pulseless electrical activity
• Exclude/treat reversible causes
• Epinephrine 1 mg every 3-5 minutes
• Atropine 3 mg if PEA with rate < 60 min-1

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POST RESUSCITATION
CARE
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The return of spontaneous
circulation
is the first step in the
continuum of resuscitation
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Post Resuscitation Care
The goal:
• Normal cerebral function
• Stable cardiac rhythm
• Adequate organ perfusion
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Continued resuscitation:
airway and breathing
Aim: to ensure a clear airway, adequate
oxygenation and ventilation
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Aim: the maintenance of normal sinus
rhythm and a cardiac output
adequate for perfusion of vital
organs
Continued resuscitation:
circulation
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Continued resuscitation:
neurological assessment
• Glasgow Coma Scale
• Pupils
• Limb tone and movement
• Posture
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Further assessment
Monitoring
• History
• ECG
• Pulse oximetry
• Blood pressure
• End tidal carbon dioxide
• Urine output
• Temperature
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Further assessment
Investigations
• Full blood count
• Biochemistry
• 12-lead ECG
• Chest X-ray
• Arterial blood gases
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Post Resuscitation Care
Chest X-ray
• Fractured ribs, pneumothorax,
aspiration, sub-diaphragmatic gas
• Tracheal tube
• CVP line
• Chest drain
• Nasogastric tube
• Pacing wire
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112. RC (UK)
Transfer of the patient
Aim: to facilitate a safe transfer of the
patient between the site of
resuscitation and an appropriate
place of definitive care (critical care
area)
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Supporting relatives
• Clear explanation of what they will
see
• Clear explanation of the events
leading to the arrest
• Direct not to interfere
• Use simple language
• Ensure they are supported by a
member of the team
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114. RC (UK)
Dealing with the
recently bereaved
• Early contact with one person,
usually a nurse
• Provision of a suitable room
• Recognising the grief response
• Encouraging and arranging
viewing of the body
• Establishing religious
requirements114

115. RC (UK)
Dealing with the
recently bereaved
Possible responses to grief:
• Acute emotional distress
• Anger
• Denial
• Guilt
• Catatony
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116. RC (UK)
‫لــكـــم‬ ‫شكــــرا‬
Thank You