The New 2018 SCCM PADIS Guidelines: Quick Hits of Recommendations for Sedatio...Intensive Care Society
Dr. Needham is Professor of Pulmonary and Critical Care Medicine, and of Physical Medicine and Rehabilitation at the Johns Hopkins University in Baltimore, USA. He is Director of the “Outcomes After Critical Illness and Surgery” (OACIS) Research Group and core faculty with the Armstrong Institute for Patient Safety and Quality, both at Johns Hopkins. From a clinical perspective, he is an attending physician in the medical intensive care unit at Johns Hopkins Hospital and Medical Director of the Johns Hopkins Critical Care Physical Medicine and Rehabilitation program.
Dr. Needham received his MD degree from McMaster University in Hamilton, Canada, and completed both his residency in internal medicine and his fellowship in critical care medicine at the University of Toronto. He obtained his PhD in Clinical Investigation from the Bloomberg School of Public Health at Johns Hopkins University. Notably, prior to his medical training, he completed Bachelor and Master degrees in Accounting and practiced in a large international accounting firm, with a focus in the health care field.
Dr. Needham is Principal Investigator on a number of NIH research grants and has authored more than 250 publications. His research interests include evaluating and improving ICU patients’ long-term physical, cognitive and mental health outcomes, including research in the areas of sedation, delirium, early physical rehabilitation, and knowledge translation and quality improvement.
The New 2018 SCCM PADIS Guidelines: Quick Hits of Recommendations for Sedatio...Intensive Care Society
Dr. Needham is Professor of Pulmonary and Critical Care Medicine, and of Physical Medicine and Rehabilitation at the Johns Hopkins University in Baltimore, USA. He is Director of the “Outcomes After Critical Illness and Surgery” (OACIS) Research Group and core faculty with the Armstrong Institute for Patient Safety and Quality, both at Johns Hopkins. From a clinical perspective, he is an attending physician in the medical intensive care unit at Johns Hopkins Hospital and Medical Director of the Johns Hopkins Critical Care Physical Medicine and Rehabilitation program.
Dr. Needham received his MD degree from McMaster University in Hamilton, Canada, and completed both his residency in internal medicine and his fellowship in critical care medicine at the University of Toronto. He obtained his PhD in Clinical Investigation from the Bloomberg School of Public Health at Johns Hopkins University. Notably, prior to his medical training, he completed Bachelor and Master degrees in Accounting and practiced in a large international accounting firm, with a focus in the health care field.
Dr. Needham is Principal Investigator on a number of NIH research grants and has authored more than 250 publications. His research interests include evaluating and improving ICU patients’ long-term physical, cognitive and mental health outcomes, including research in the areas of sedation, delirium, early physical rehabilitation, and knowledge translation and quality improvement.
Do Not Resuscitate Orders : What They Mean ?SMSRAZA
Most doctors working in Acute areas know when and how to do CPR. However, most get stuck when it comes to ' When not to do CPR' due to cultural, social, ethical and legal issues attached.
This presentation covers various aspects of OHCA scenarios, including incidence, outcome, challenges, solutions, hen to initiate CPR, protocols, Termination, ECPR, and other issues are covering in details. Explore regional experiences in training and OHCA results as well.
Neuro Intensive Care - Prognostication post Cardiac Arrest: Sara GraySMACC Conference
Sara Gray discusses the complex topic of prognostication post cardiac arrest in neuro intensive care. There is a short list of things that keep Sara up at night. She describes a specific cardiac arrest nightmare she has. She is looking after a patient post cardiac arrest. They remain in a coma after cooling. As they meet brain death criteria and they are an organ donor, they are transferred to the operating room. Whilst there, they regain spontaneous respirations.
Although this is terrifying, these situations do happen! And cases like this defy all efforts at accurate prognostication in post cardiac arrest patients. Prognostication matters. It matters for the patient, their family and got judicious resource management.
The trouble is, that varying guidelines around the world do not agree.
In patients who have not been cooled, then you may start prognostication 72 hours post return of spontaneous circulation (ROSC). Before that time the brain may not have had adequate time to heal from the arrest and the clinical indicators may not be accurate.
In the hypothermia group there is differing guidelines. Some guidelines suggest doing it the same way – prognostication after 72 hours. Others suggest 72 hours after achieving normothermia. This equates to 4.5 days.
Why the difference? Different medicolegal environments may play a part. However, as Sara explains, some guidelines may be guided by concern over the emerging data about people who wake up late.
Sara fears looking a family in the eye and telling them the patient won’t wake up and being wrong.
Her advice is to wait 4.5 days. She then recommends starting with a subgroup of patients with a low motor score on GCS. From there you can use indicators with the best accuracy which are bilateral absence of pupillary response, corneal reflex, and somatosensory evoked potentials. Bilateral absence of all three equals a dire prognosis.
For more like this, head to our podcast page. #CodaPodcast
Advanced cardiac life support or advanced cardiovascular life support (ACLS) refers to a set of clinical interventions for the urgent treatment of cardiac arrest, stroke and other life-threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.
430 Chapter 17 Death and DyingCase 17-1When Parents Refu.docxblondellchancy
430 Chapter 17 Death and Dying
Case 17-1
When Parents Refuse to Give Up1
Nine-year-old Yusef Camp began experiencing symptoms soon after eating a pickle bought
from a street vendor. He felt dizzy and fell down, he could not use his legs, and he began
to scream. By 10:00 p.m., he was hallucinating and was transported to the DC General
Hospital by ambulance. He went into convulsions. His stomach was pumped, and they
found traces of marijuana and possibly PCP. He soon stopped breathing, and by the next
morning, brain scans showed no activity.
Four months later, Yusef’s condition had not changed. The physicians believed his brain
was not functioning and wanted to pronounce him dead based on brain criteria. Several
difficulties were encountered, however. First, there was some disagreement among the
medical personnel over whether his brain function had ceased completely. Second, at that
time the District of Columbia had no law authorizing death pronouncement based on
brain criteria. It was not clear that physicians could use death as grounds for stopping
treatment. Most important, Ronald Camp, the boy’s father, protested vigorously any sug-
gestion that treatment be stopped. A devout Muslim, he said, “I could walk up and say
unplug him; but for the rest of my life I would be thinking, was I too hasty? Could he have
recovered if I had given it another 6 months or a year? I’m leaving it in Almighty God’s
hand to let it take whatever flow it will.”
The nurses involved in Yusef’s care faced several problems. Maggots were found
growing in Yusef’s lungs and nasal passages. His right foot and ankle became gangre-
nous. He showed no response to noises or painful stimuli. The nurses had the responsi-
bility not only for maintaining the respiratory tract and the gangrenous limb, but also for
providing the intensive nursing care needed to maintain Yusef in debilitated condition
on life support systems. Had the aggressive care been serving any purpose, they would
have been willing to provide it no matter how repulsive the boy’s condition was and in
spite of there being many other patients desperately needing their attention. However,
some of the nurses caring for Yusef were convinced that they were doing no good what-
soever for the boy. They believed they were only consuming enormous amounts of time
and hospital resources in what appeared to be a futile effort. In the process, other
patients were not getting as much care as would certainly be of benefit to them. Could
the nurses or the physicians argue that care should be stopped because he was dead?
Could they overrule the parents’ judgment about the usefulness of the treatment even
if he were not dead? Could they legitimately take into account the welfare of the other
patients and the enormous costs involved when deciding whether to limit their atten-
tion to Yusef?
1Weiser, B. (1980, September 5). Boy, 9, may not be “brain dead,” new medical examiner
shows. Washington Post, ...
Do Not Resuscitate Orders : What They Mean ?SMSRAZA
Most doctors working in Acute areas know when and how to do CPR. However, most get stuck when it comes to ' When not to do CPR' due to cultural, social, ethical and legal issues attached.
This presentation covers various aspects of OHCA scenarios, including incidence, outcome, challenges, solutions, hen to initiate CPR, protocols, Termination, ECPR, and other issues are covering in details. Explore regional experiences in training and OHCA results as well.
Neuro Intensive Care - Prognostication post Cardiac Arrest: Sara GraySMACC Conference
Sara Gray discusses the complex topic of prognostication post cardiac arrest in neuro intensive care. There is a short list of things that keep Sara up at night. She describes a specific cardiac arrest nightmare she has. She is looking after a patient post cardiac arrest. They remain in a coma after cooling. As they meet brain death criteria and they are an organ donor, they are transferred to the operating room. Whilst there, they regain spontaneous respirations.
Although this is terrifying, these situations do happen! And cases like this defy all efforts at accurate prognostication in post cardiac arrest patients. Prognostication matters. It matters for the patient, their family and got judicious resource management.
The trouble is, that varying guidelines around the world do not agree.
In patients who have not been cooled, then you may start prognostication 72 hours post return of spontaneous circulation (ROSC). Before that time the brain may not have had adequate time to heal from the arrest and the clinical indicators may not be accurate.
In the hypothermia group there is differing guidelines. Some guidelines suggest doing it the same way – prognostication after 72 hours. Others suggest 72 hours after achieving normothermia. This equates to 4.5 days.
Why the difference? Different medicolegal environments may play a part. However, as Sara explains, some guidelines may be guided by concern over the emerging data about people who wake up late.
Sara fears looking a family in the eye and telling them the patient won’t wake up and being wrong.
Her advice is to wait 4.5 days. She then recommends starting with a subgroup of patients with a low motor score on GCS. From there you can use indicators with the best accuracy which are bilateral absence of pupillary response, corneal reflex, and somatosensory evoked potentials. Bilateral absence of all three equals a dire prognosis.
For more like this, head to our podcast page. #CodaPodcast
Advanced cardiac life support or advanced cardiovascular life support (ACLS) refers to a set of clinical interventions for the urgent treatment of cardiac arrest, stroke and other life-threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.
430 Chapter 17 Death and DyingCase 17-1When Parents Refu.docxblondellchancy
430 Chapter 17 Death and Dying
Case 17-1
When Parents Refuse to Give Up1
Nine-year-old Yusef Camp began experiencing symptoms soon after eating a pickle bought
from a street vendor. He felt dizzy and fell down, he could not use his legs, and he began
to scream. By 10:00 p.m., he was hallucinating and was transported to the DC General
Hospital by ambulance. He went into convulsions. His stomach was pumped, and they
found traces of marijuana and possibly PCP. He soon stopped breathing, and by the next
morning, brain scans showed no activity.
Four months later, Yusef’s condition had not changed. The physicians believed his brain
was not functioning and wanted to pronounce him dead based on brain criteria. Several
difficulties were encountered, however. First, there was some disagreement among the
medical personnel over whether his brain function had ceased completely. Second, at that
time the District of Columbia had no law authorizing death pronouncement based on
brain criteria. It was not clear that physicians could use death as grounds for stopping
treatment. Most important, Ronald Camp, the boy’s father, protested vigorously any sug-
gestion that treatment be stopped. A devout Muslim, he said, “I could walk up and say
unplug him; but for the rest of my life I would be thinking, was I too hasty? Could he have
recovered if I had given it another 6 months or a year? I’m leaving it in Almighty God’s
hand to let it take whatever flow it will.”
The nurses involved in Yusef’s care faced several problems. Maggots were found
growing in Yusef’s lungs and nasal passages. His right foot and ankle became gangre-
nous. He showed no response to noises or painful stimuli. The nurses had the responsi-
bility not only for maintaining the respiratory tract and the gangrenous limb, but also for
providing the intensive nursing care needed to maintain Yusef in debilitated condition
on life support systems. Had the aggressive care been serving any purpose, they would
have been willing to provide it no matter how repulsive the boy’s condition was and in
spite of there being many other patients desperately needing their attention. However,
some of the nurses caring for Yusef were convinced that they were doing no good what-
soever for the boy. They believed they were only consuming enormous amounts of time
and hospital resources in what appeared to be a futile effort. In the process, other
patients were not getting as much care as would certainly be of benefit to them. Could
the nurses or the physicians argue that care should be stopped because he was dead?
Could they overrule the parents’ judgment about the usefulness of the treatment even
if he were not dead? Could they legitimately take into account the welfare of the other
patients and the enormous costs involved when deciding whether to limit their atten-
tion to Yusef?
1Weiser, B. (1980, September 5). Boy, 9, may not be “brain dead,” new medical examiner
shows. Washington Post, ...
Approach to internship (mbbs in bangladesh perspective)Pritom Das
Some slides are taken from different textbooks of medicine like Davidson, Kumar and Clark and Oxford, and some from other presentations made by respected tutors. These resources are free for use, and I do not claim any copyright. Hoping knowledge remains free for all, forever.
Judicial approach in medical negligence in malaysiaSiti Azhar
It gives a overview on the current judicial approach on medical negligence cases in Malaysia. The opinion formed in this is the personal opinion of the writer.
Disaster and Mass Casualty Incidents (updated 7th July 2020)Chew Keng Sheng
A new updated slide on an overview of disaster management in Malaysia, including the formation of NADMA as the dedicated agency to coordinate disaster management in Malaysia.
Predatory publishing is a relatively recent phenomenon that seems to be exploiting some key features of the open access publishing model, sustained by collecting APCs that are far less than those found in legitimate open access journals. This CME aims to introduce to the participants on the phenomenon of predatory journals, why they continue to thrive, characteristics that are suggestive of a predatory journal, and how one can take step to minimize the risk of faling into predatory journal publication
A short sharing on doctor-patient communication to First year medical students in Universiti Malaysia Sarawak, to be supplemented with anecdotal accounts.
This slide was first presented during the Malaysian 1st Emergency Medicine Annual Scientific Meeting, in conjunction with the Academy of Medicine Malaysia, Academy of Medicine Singapore and the Academy of Medicine Hong Kong Tripartite Meeting in Aug 2016.
Sensitivity, specificity and likelihood ratiosChew Keng Sheng
A short tutorial on sensitivity, specificity and likelihood ratios. In this presentation, I demonstrate why likelihood ratios are better parameters compared to sensitivity and specificity in real world setting.
ACLS 2015 Updates - The Malaysian PerspectiveChew Keng Sheng
This set of slide was presented during the Kelantan Resuscitation Update 22 Nov 2015 in accordance to the latest ACLS/ILCOR 2015 Guidelines. However, I have emphasized on certain important aspects relevant within the Malaysian context. Nonetheless, in general, there are no major changes for this year 2015
My talk in April 2015 in Malaysia on Best Practices and Resuscitation Workflow. The new 2015 resuscitation guidelines is expected to be released in Oct 2015.
My talk in April 2015 Malaysia on Best Practices and Resuscitation Workflow. The new 2015 resuscitation guidelines is expected to be released in Oct 2015.
New or Presumed New LBBB To Be Treated As a STEMI Equivalent? A Contra Argume...Chew Keng Sheng
My 6-page notes to go along with the "debate" of whether new or presumed new LBBB per se (without any other qualification) should be treated as STEMI equivalent
An introduction to the rationale and the two types (Write-in and Select-Menu) of Key Feature Questions. This presentation is based on an original article by Page and Bordage (1995).
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
1. Resuscitation
ETHICAL
DILEMMAS K.S. Chew
School of Medical Sciences
Universiti Sains Malaysia
2. Emergency Procedures Without Written Consent - The
Doctrine of Necessity
Three Groups of Incompetent
Five Things To Be Explained To the
Patients to Give Informed
Patient in an Informed Consent
Consent
Four Basic Five Essential
Biomedical Elements of a Valid
Bolam Test
Informed Consent
Principles
Bolitho Test
Proving Medical
General Concepts of
Negligence
Biomedical Ethics
3. Principle #1 AutonomyDoes my action
Four Basic
impinge on an individual's personal
1
autonomy?Do all relevant parties consent to
Principles
my action?Do I acknowledge and respect
that others may choose differently?
Of Ethics
Principle #2 BeneficenceWho benefits from
2 my action and in what way?
4
Principle #3: Non-maleficene
Principle #4:
Justice Which parties may be harmed by my action?
What steps can I take to minimise this harm?
Is my Have I communicated risks involved in a truthful
proposed and open manner?
3
action
equitable?
How can I
Beauchamp TL, Childress JF. Principles of biomedical Ethics.
make it more
4th ed. Oxford: Oxford University Press, 1994.
equitable?
5. Biomedical Ethics
in Resuscitation
A whole of gamut of
complicated dilemma
Successful v Unsuccessful
(70 - 95%)
Prolonging
Suffering
Persistent Vegetative State
Patient’s right to
die in dignity
Decisions in matter of
seconds!
6. Case Scenario 1
You are rushing to catch your flight in another 30 minutes. As
you are heading to your departing gate, you witness a crowd of
people, and one of them actually recognizes you as a doctor
and says that a man has just collapsed and they need your
help in the resuscitation.
However, two things are going on in your mind - you have not
been performing CPR for a long time since your ACLS course
5 years ago and you have a plane to catch. What would you
do? If you do not help out in the resuscitation process, would
you be liable for medical negligence in the future?
7. Case Scenario 2
A building has collapsed. You are called in to
help out with the disaster. At the disaster site,
a man has stopped breathing at a distance
not far from where you are standing. The
relatives over there are shouting for you to
come over and help. However, you realize
that some rocks are still falling from where
the man is trapped. Would be liable to be
sued if you do not?
8. Case Scenario 3
A 80-year old man with history of frequent exacerbation of
COPD is diagnosed with acute pulmonary edema,
currently complicated with respiratory failure Type 2. All
other treatment modalities fail to prevent his deterioration.
You know that his prognosis is not good but he needs
mechanical ventilation to support his worsening respiratory
effort.
1. Would you have intubated him?
2. If the relatives insist on you to actively resuscitate him
but you do not, would you be liable to be sued?
9. Case Scenario 4
A 50-year old, previously healthy and active sportsman, is
admitted for sudden onset of chest pain. He collapses
while being treated in the emergency department. You
start CPR and defibrillation promptly. Realizing what you
are doing, the wife intervenes and insists that you stop the
resuscitation process. She says that he has verbally stated
his wish that he does not want to be actively resuscitated
and a prolonged suffering the moment he dies.
What would you do?
10. Case Scenario 5
A 40-year old, previously healthy, army is involved in a
serious car accident. On arrival to the emergency
department, his GCS is 7/15. He is mechanically
ventilated. His vital signs are good. A CT scan brain is
done - showing a massive intraparenchymal bleeding over
the right hemisphere with midline shift and generalized
cerebral edema. Clinical re-assessment 30 minutes later
shows that the patient is manifesting signs of increased
ICP and transtentorial herniation. In view that his prognosis
may not be good and that the ward resources are limited,
the managing team decides to withdraw his support
system in A&E. What do you think?
11. Cardiopulmonary
Resuscitation: Ethical Issues
Resuscitation Decisions
Resuscitation Decisions
for out-of- hospital
for in-hospital settings
settings
1. to initiate resuscitation
1. to initiate
2. NOT to initiate
resuscitation
resuscitation
2. NOT to initiate
3. to terminate
resuscitation
resuscitation
3. to terminate
4. to withdraw life
resuscitation
support system (rarely)
12. GENERAL PRINCIPLES GOVERNING
RESUSCITATION DECISION
Is governed by two important principles:
A. The Principle of Patient Autonomy
Advanced directives (DNAR)
If patient preferences uncertain, emergency
conditions should be treated until those preferences
are known
13. GENERAL PRINCIPLES GOVERNING
RESUSCITATION DECISION
B. The Principle of Futility
Definition: If the purpose of a medical treatment
cannot be achieved, the treatment is considered
futile.
The key determinants - duration remaining in
cardiac arrest, length and quality of life expected
14.
15. “Physicians are NOT obliged to
provide care when there is
scientific and social consensus
that the treatment is
ineffective.”
- American Heart Association
16. “Whereas patients have a
right to refuse treatment, they
do not have automatic right to
demand treatment; they
cannot insist that
resuscitation must be
attempted in any
circumstances”
- European Resuscitation
Council
17. “It is wise for a doctor to
seek a second opinion in
making a momentous
decision to with-hold
resuscitation for fear of the
doctor’s own personal
values, or the questions of
available resources might
influence his/her decision.”
- European Resuscitation
Council
18. Doctor’s Personal Factors
Influencing Resuscitation Decision
“Most doctors will err on the side of
intervention in children for emotional reasons,
even though the overall prognosis is often
worse in children than in adults.”
- European Resuscitation Council
19. DO NOT ATTEMPT RESUSCITATION
(DNAR) ORDER
DNAR order means just that - in the event of
cardiopulmonary arrest, CPR should not be
attempted at all.
Other treatment should be continued; e.g.
pain relief, sedation on required basis in
terminal illnesses.
20. Criteria For NOT to Start
CPR for In-Hospital Setting
# 3 No
physiologic
al benefit
expected
(futility)
#2 Patient with signs of
irreversible death (rigor
#1 Patient
mortis, decapitation,
decomposition, dependent with DNAR
order
lividity)
21.
22. “If something is worth
doing, it is worth doing it
well”
“If the resuscitation process is worth
doing, it is worth doing it well”
Treat the resuscitation process seriously.
Respect the solemn moment for the patient and
relatives
Do not laugh or joke when resuscitation is
going on
“not merely about drawing the
curtain.....”
23. Criteria To STOP CPR
For In-Hospital Setting
#1
Patients
with DNAR
Order
In general, resuscitation should be
continued as long as VF persists.
And resuscitation should be
terminated when ongoing asystole for
#2 On
more than 20 minutes in the absence
of a reversible cause, and with all Grounds of
measures of BLS and ACLS in place Extra panel
futility*
24. Criteria For NOT Starting CPR
In Out-of-Hospital Setting
Paramedics are trained to start CPR at the very
first instance upon a victim in cardiac arrest with
the exception of:
1. A person with obvious clinical signs of
irreversible death (e.g. rigor mortis, dependent
lividity, decapitation, decomposition)
2. A person with clear DNAR order
3. Attempts to perform CPR would place the
rescuer at risk of danger/physical injuries
25. Criteria To STOP CPR In Out-
of-Hospital Setting
1. Restoration of effective, spontaneous
circulation and ventilation
2. Care is transferred to a more senior-level
emergency medical professional
3. The rescuer is unable to continue because of
exhaustion
4. Reliable criteria indicating irreversible death
5. A valid DNAR order is presented
26. Withdrawing Life Support
1. Not usually done in A&E department
2. Often in intensive care units for clinical
brain death patients
3. Patient in deep coma for >24 hrs, after
ruling out potentially reversible causes
4. Done by two specialists (usually
anesthesiologists, neurologists,
neurosurgeons) on two assessments (6hrs
apart)
5. Detailed criteria can be found in MMC Brain
death Guidelines
27. If you or your team have made
the decision to withdraw a life
support system in emergency
department, you should also
be responsible to document
and sign your decisions and to
answer any doubts from the
family. Do not push the job to
another team.
28. SURROGATE DECISION MAKERS
(IN ORDER OF PRIORITY)
1. Spouse
2. Adult child
3. Parent
4. Any relative
5. Person nominated as the person caring for the
incapacitated patient
6. Specialized care professionals
Must act in best interest of patient
29. Conclusion
Decision making in cardiopulmonary resuscitation
can be very complex due to the diversity of the
cases
It may have to be made in matters of seconds!
If in doubt, always err on for the patient’s benefit
Always treat the patient with dignity and respect
If you do not want this to be done to your own
family member, you do not want it to be done on
your patient
