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31. What is parenteral nutrition?
Parenteral nutrition is a way to feed the patient intravenously. It can be delivered centrally through a
central venous catheter, most commonly in the superior vena cava or peripherally (PPN) via a peripheral vein.
32. What is total parenteral nutrition (TPN)?
TPN is the delivery of all the required nutrients parenterally. It is a solution containing proteins, car-
bohydrates, fat, vitamins, and minerals. Because of the high osmolarity of the solution and the risk of
phlebitis, it is usually given centrally rather than peripherally. Consequently, solutions delivered peripherally need to be diluted and may not meet the complete nutritional requirements of the patients.
33. When are TPN and PPN indicated?
TPN is indicated when patients need long-term nutritional support but are not able to receive enteral
feedings (nonworking GI tract, shock, pancreatitis, bone marrow transplant, etc.). PPN is indicated in
patients requiring short-term nutritional support (<10 days) to restrict protein breakdown.
34. What are the complications of parenteral nutrition?
Hyperglycemia, fatty liver, hypercapnia, acute respiratory distress syndrome, GI mucosal atrophy (pre-
disposing the gut for bacterial translocation and septicemia). Catheter-related complications include
infections and pneumothorax.
BiBliography
Braidy HF, Ziccardi VB: Oral surgery, diet and nutrition. In Touger-Decker R, editor: Nutrition and oral medicine, ed 2, New
York, 2014, Humana Press, pp 333–347.
Kasper DL, Braunwald E, Fauci A, et al.: Harrison’s principles of internal medicine, ed 16, New York, 2004, McGraw-Hill.
Marino PL: The ICU book, ed 3, Philadelphia, 1998, Lippincott Williams & Wilkins.
Rolandelli RH, Bankhead R, Boullata J, et al.: Clinical nutrition: enteral and tube feeding, ed 4, Philadelphia, 2005, Saun-
ders.
Souba WW: Nutritional support, N Engl J Med 336:41–48, 1997.
Thomson AD: Mechanism of vitamin deficiency in chronic alcohol misusers and the development of the Wenicke-Korsakoff
syndrome, Alcohol & Alcoholism 35(Suppl. 1):2–7, 2000.
POSTOPERATIVE
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COMPLICATIONS
Amber Johnson, Dean M. DeLuke
1. What is a fever?
A fever (also known as pyrexia) is a reaction to a systemic inflammatory process that raises the core
body temperature to >38° C. It is a physiologic response to infection or inflammation.
2. What causes fever?
Pyrogenic cytokines (interleukin-1, tumor necrosis factor, and interferon) are released by macro-
phages that are activated during inflammation and infection. These cytokines act on the hypothalamic
thermoregulatory center and cause release of prostaglandins, resulting in fever.
3. What are the most common causes of fever in the first 24 hours after surgery?
• Aspirationpneumonia
• Anill-denedresponsetothesurgeryitself(aresponsetothesystemicinammatoryprocessas-
sociated with the surgical trauma)
Manysurgicaltextbooksstatethatatelectasisistheusualcauseofpostoperativefeverintherst48
hours, but this theory is not evidence based. Experimental studies have been performed in animals in
which induced atelectasis did not produce fever unless there was a coexisting pulmonary infection.
4. What are the most common causes of postoperative fever in the first 24 to
72 hours?
• Bacterialpneumonia
• Thrombophlebitis
• Anill-denedresponsetothesurgeryitself
Inalow-riskpatient,afeverwithintherst72hoursofsurgeryisusuallyaclinicallybenignprocess
and does not typically warrant a further work-up (cultures, chest X-rays, etc.) unless dictated by clini-
calndings.
5. What are the most common causes of fever 72 hours after surgery?
• Pneumonia
• Woundinfection
• Pulmonaryemboli
• Urinarytractinfection
• Intravenous(IV)catheterinfection
6. What are the five Ws of postoperative fever?
TheveWs are a summary of the possible causes of any postoperative fever: wind (atelectasis-
controversial,pneumonia),water(UTI),wound(surgicalsiteinfection),walking(thrombophlebitis,deep
venous thrombosis [DVT]/PE), and wonder drugs (reaction to medications).
7. When can the surgical site be considered the source of postoperative fever?
Typically, the surgical site should not be considered the primary source of postoperative fever until at
least48to72hoursaftersurgery.However,surgicalwoundinfectionmaydevelopbetween12hours
and7dayspostoperatively.
8. How are the development of fever and the patient’s heart rate interrelated?
For every 1° C rise in body temperature, there is a corresponding 9 to 10 beats/minute increase in the
patient’s heart rate.
9. Can fever be treated?*
Yes. Aspirin, acetaminophen, and ibuprofen are cyclooxygenase (COX) inhibitors that block the forma-
tionofprostaglandinE2inthehypothalamusandeffectivelycontrolfever.
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10. Should fever be treated?*
This is controversial. No evidence suggests that suppression of fever improves patient outcome.
Patients are more comfortable, however, and the surgeon receives fewer calls from the nurses.
11. Should fever be investigated?*
Yes. Fever indicates that something (frequently treatable) is going on. The threshold for inquiry
depends on the patient. A transplant patient with a temperature of 38° C requires scrutiny, whereas a
healthyyoungpersonwithanidenticaltemperatureof38°C24hoursafteranappendectomycanbe
ignored.
12. Summarize a fever work-up.*
• Orderbloodcultures,urineGramstainandculture,andsputumGram’sstainandculture.
• Lookatthesurgicalincisions.
• LookatoldandcurrentIVsitesforevidenceofsepticthrombophlebitis.
• Ifbreathsoundsareworrisome,obtainachestX-ray.
13. What are the most common late causes of postoperative fever?*
Septic thrombophlebitis (from an IV line) and occult (usually intraabdominal) abscesses tend to
present2weeksaftersurgery.
14. How often should IV catheter sites be changed to avoid infection?
Ingeneral,IVaccesssitesshouldbechangednomorefrequentlythanevery72to96hours,butthe
sites should be examined daily for signs of infection or phlebitis.
15. What are the common signs and symptoms of phlebitis?
• Pain
• Erythema
• Tenderness
• Streakingofthelimb
• Edema
16. What is the treatment for phlebitis?
• RemovetheIVcatheter.
• Elevatetheaffectedlimb.
• Applywarm,moistpackstotheinfectedsite.
• Ifinfectionissuspected,initiateIVantibioticsforappropriatestaphylococcuscoverage.
17. What are the most frequent respiratory complications following oral and
maxillofacial surgery?
• Pulmonaryatelectasis
• Aspirationpneumonia
• Pulmonaryembolus
18. Which group of patients is predisposed to the development of postoperative
atelectasis?
Postoperative atelectasis occurs more often in smokers than in any other subset of patients.
19. How can a patient improve atelectasis?
Deep breathing exercises, especially with incentive spirometry.
20. Where is the most common site for aspiration pneumonia to develop?
If aspiration pneumonia occurs, it is most likely to manifest itself initially in the patient’s right lung.
21. What are the risk factors for aspiration pneumonia?
• Reducedconsciousness(traumapatientswithlowGlasgowComaScale,patientsundersedationor
general anesthesia)
• DisordersoftheupperGItract(GERD,gastroparesis)
• Dysphagia
• Tracheostomy
• NPOstatus
*ReprintedfromHarkenAH:Whatdoespostoperativefevermean?InHarkenAH,MooreEE,editors:Abernathy’s surgical
secrets,ed6,Philadelphia,2009,Mosby.
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22. How can aspiration be prevented?
Aspiration can be prevented by avoiding general anesthesia in patients who have recently eaten,
positioning the patient correctly before endotracheal intubation, and using high-volume, low-pressure
cuffs on the endotracheal tube. If the risk of aspiration is high, metoclopramide or ondansetron should
be administered before surgery to minimize the incidence of aspiration pneumonia.
23. Which surgical patients are predisposed to aspiration?
Tracheostomy patients. Incidence as high as 80% has been reported.
24. Why does postoperative pneumonia develop?
After surgery, a patient’s host defense against pneumonia is compromised. This impairment is likely
caused by several factors: The cough mechanism may be impaired and may not effectively clear the
bronchial tree, the mucociliary transport mechanism may be damaged by endotracheal intubation, and
the alveolar macrophage may be compromised by a number of factors that may be present during and
after surgery (e.g., hypoxia, pulmonary edema, aspiration, or corticosteroid therapy). All these factors
may decrease the patient’s immune response to infection with pneumonia and increase the incidence
of postoperative pneumonia.
25. What is the primary pathogen in postoperative pneumonia?
Approximately half the pulmonary infections that follow surgery are caused by gram-negative bacilli,
which are usually acquired by aspiration of oropharyngeal secretions.
26. What is the treatment for postoperative pneumonia?
Appropriate antibiotic therapy, which can be determined through sputum culture and sensitivity, and
clearing of secretions through aggressive suctioning and chest physical therapy.
27. Where do most postoperative pulmonary emboli originate?
In the deep venous systems of the lower extremities, especially in non-ambulatory patients.
28. What is Virchow’s triad?
Virchow’s triad is the name given to the three chief causes of DVT: (1) damage to the endothelial lining
ofthevessel,(2)venousstasis,and(3)hypercoagulability(achangeinbloodconstituentsattributable
to postoperative increase in the number and adhesiveness of the patient’s platelets).
29. What are the classical clinical features of DVT?
• Calfswellingandtenderness
• Suddendyspnea
• Fever
• Tachypnea
• Chestpain
30. What is Homans’ sign?
Homans’signispaininthecalfthatiselicitedbyforceddorsiexionofthefoot.Itwasonceconsid-
ered pathognomonic for the presence of DVT, but this test is no longer taught because performing this
maneuver can increase the risk of movement of an existing thrombus.
31. What is the immediate treatment of DVT?
A patient who has developed DVT should be started immediately on systemic anticoagulation with
elevation of the affected limb. Subcutaneous heparin and low molecular weight heparin are choices to
consider. Thrombolytics are not indicated.
32. What are some common causes of postoperative bleeding?
• Incompletelyligatedorcauterizedvessels
• Woundinfection
• Coagulopathy
• Reboundeffectofhypotensiveanesthesia
33. What are some common causes of postoperative hypotension?
A good differential diagnosis for the development of hypotension should include intravascular hypovo-
lemia, rewarming vasodilation, myocardial depression, and hypothyroidism.
34. What are the most common causes of postoperative hypertension?
• Painandanxiety
• Hypoxia
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• Over-distentionofthebladder
• Hypercapnia
35. What are some possible treatment options for postoperative hypotension?
• Elevationofthelowerextremities
• Administrationofcarefullymonitoreduidboluses
• Administrationofvasopressors(e.g.,ephedrine)
36. What is the most common cardiac arrhythmia observed in the postoperative
period? Why?
The most common postoperative arrhythmia is the development of ventricular complexes or prema-
tureventricularcontractions(PVCs).Hypoxia,pain,oruidoverload,allofwhicharecommoninthe
postoperative period, can precipitate PVCs.
37. What are the common causes of postoperative cardiac arrhythmias?
Postoperative arrhythmias are generally related to reversible factors such as hypokalemia, hypoxemia,
alkalosis,anddigitalistoxicity,buttheycouldbetherstsignofpostoperativemyocardialinfarction.
Postoperativemyocardialinfarctionisrare,withanincidenceof0.7%forpatientswithoutpreexisting
cardiacdisease.However,incidenceincreasesto6%forpatientswithpreexistingcardiacdisease.
38. Why is postoperative myocardial infarction difficult to diagnose?
More than one third of postoperative myocardial infarctions are asymptomatic as a result of the
residual effects of anesthesia and analgesics administered postoperatively.
39. What is the most common cause of dysuria in the immediate postoperative
period?
The agents incorporated in the administration of general anesthesia can inhibit the micturitic reflex,
and the patient can suffer bladder distention, which itself may inhibit the ability to micturate.
40. What are some other causes of dysuria in the postoperative period?
• Positionalinhibition(manypatientsnditdifculttopassurinewhilesupine)
• Preexistingprostatism
• Inadequateuidreplacementduringsurgery,whichcreatesahypovolemicstate
41. What are the treatment options for postoperative dysuria in a patient with suprapubic pain and an obviously distended bladder elicited by palpation in the first 4
to 6 hours after surgery?
Treatment of postoperative dysuria should begin simply by having the patient stand by or sit on the
toilet while running water in the sink. If this does not help and there is no evidence of a hypovolemic
state, then the patient should be catheterized. If the residual measures >300 mL, then the catheter
should be left in overnight.
42. What are some risk factors for postoperative nausea and vomiting (PONV)?
Female gender, childhood history of PONV or motion sickness, non-smokers, intra and postoperative
opioid use, increased duration of surgery, gastric distention (e.g., swallowed blood), type of anesthetic
(volatile agents), and type of surgery (e.g., ear and eye surgery).
43. What is a seroma, and how can it be prevented?
A seroma is fluid (other than pus or blood) that has collected in the wound. Seromas often appear after
surgical procedures that involve elevation of skin flaps and transection of numerous lymphatic channels. The incidence of seromas can be decreased if proper pressure dressing is applied to the wound
after surgery.
44. What is the treatment for seroma?
Seromas should be evacuated either by needle aspiration or by incision and drainage because they
can delay healing and provide an excellent medium for bacterial growth. A pressure dressing should
be placed immediately after drainage to help seal lymphatic leaks and prevent additional accumulation of fluids.
45. What is a surgical wound infection?
Surgical wound infections or surgical site infections (SSIs) usually occur within 30 days of surgery. In
cases where a foreign body is left in situ, the onset of postoperative infection may be delayed much
longer, even occurring a year or more after surgery.
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46. What are the types of surgical wound infection?
Depending on the depth of tissue involvement, SSIs can be subdivided into three categories:
• Superficial incisional SSIs, involving only the skin and subcutaneous tissue
• Deep incisional SSIs, involving deep soft tissue layers, such as fascial or muscle layers of the
incision
• Organ space SSIs, involving any anatomic structure opened or manipulated during the operative
procedure.
47. What are the classic signs of superficial incisional SSI?
Signsofsupercialincisionalinfectionarecalor(heat),rubor(redness),tumor(swelling),dolor(pain),
and purulent drainage.
48. What are the signs of deep-space SSIs?
Deep-space infection should be suspected in the presence of systemic signs and symptoms: fever,
ileus,andshock.Denitivediagnosisofdeep-spaceSSIsmayrequireimagingstudies.
49. What are patient risk factors for SSIs?
Smoking, obesity, poor nutritional status, and advanced age.
50. What can surgeons do to decrease the risk of SSIs?
Perform proper hand washing, administer prophylactic antibiotics (given within 1 hour of surgical inci-
sion), eliminate dead space, minimize placement of foreign material (implants, suture material, etc.),
appropriately wash out wounds, and control hemorrhage.
51. Are certain wounds prone to infection?*
Each milliliter of human saliva contains 108 aerobic and anaerobic, gram-positive and gram-negative
bacteria. Therefore, all human bite wounds must be considered contaminated. Animal bite wounds
typically are less contaminated.
52. Do incisions become infected early after surgery?*
Theincisionmustbeexaminedinapatientwithafever(39°C)<12hoursaftersurgery.Lookfora
foul-smelling, serous discharge in a particularly painful wound (all incisions hurt) with or without
crepitus.Gram’sstainoftheserousdischargeforgram-positiverodsconrmsorexcludesthediagnosis of clostridial infection.
53. When do urinary tract infections (UTIs) occur?*
Thelongertheurethral(Foley)catheterisinplace,themorelikelyaurinarytractinfection(UTI)will
develop.Urologicinstrumentationatthetimeofsurgerymayacceleratetheprocessconsiderably.
Pathogensmigratealongtheoutsideoftheurethralcatheter,andby5to7daysaftersurgery,most
patients harbor infected urine.
54. How is a UTI diagnosed?*
Urineculturewith>105bacteria/mLdenesaUTI.Whitebloodcellsonurinalysisarehighly
suggestiveofUTI.
BiBliography
BariePS: Modern surgical antibiotic prophylaxis and therapy: less is more, Surg Infect1:23–29,2000.
HarkenAH:Whatdoespostoperativefevermean?InHarkenAH, Moore EE, editors: Abernathy’s surgical secrets,ed6,
Philadelphia,2009,Mosby.
HollingsworthJW,GovertJA:Feverinthecriticalcarepatient.InJafekBW,MurrowBW, editors: ENT secrets, ed 3, Phila-
delphia,2005,Hanley&Belfus.
KluytmansJ, Voss A: Prevention of postsurgical infections: some like it hot, Curr Opin Infect Dis15:427–432,2002.
LeighJM: Postoperative care. In Rowe NL,WilliamsIL, editors: Maxillofacial injuries, vol II. New York, 1985, Churchill
Livingstone.
Lesperance R, Lehman R, et al.: Early postoperative fever and the “routine” fever work-up: results of a prospective study,
J Surg Res171(1):245–250,2011.
Nicholau D: Postanesthesia recovery. In Miller R, editor: Basics of anesthesia,ed6,Philadephia,2011,Elsevier.
Meyer LE: Postoperative problems. In Kwan PH, Laskin DM, editors: Clinical manual of oral and maxillofacial surgery,ed2,
CarolStream,IL,1997,Quintessence.
*ReprintedfromHarkenAH:Whatdoespostoperativefevermean?InHarkenAH,MooreEE,editors:Abernathy’s surgical
secrets,ed6,Philadelphia,2009,Mosby.
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Myles PS,IaconoGA,HuntJO, et al.: Risk of respiratory complications and wound infection in patients undergoing ambula-
tory surgery, Anesthesiology97:842–847,2002.
Narayan M, Medinilla S: Fever in the postoperative patient, Emergency Med Clin N Am31:1045–1058,2013.
O’GradyN, et al.: Guidelines for the prevention of intravascular catheter-related infections,CDC,2011.
www.cdc.gov/hicpac/BSI/BSI-gudelines-2011.html.
Pellegrini CA:Postoperativecomplications.InWayL, editor: Current surgical diagnosis and treatment,ed6,LosAltos,CA,
1983, Lange.
Peterson SL:Surgicalwoundinfection.InHarkenAH, Moore EE, editors: Abernathy’s surgical secrets,ed6,Philadelphia,
2009,Mosby.
Singer AJ,QuinnJV,ThodeJrHC,etal.:TraumaSealStudyGroup:determinantsofpooroutcomeafterlacerationand
surgical incision repair, Plast Reconstr Surg110:429–435,2002.
INTRODUCTION TO
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MECHANICAL VENTILATION
AND ICU CARE
Alia Koch
1. When is it appropriate to mechanically ventilate a patient?
Mechanical ventilation is a clinically based decision. Patients who should be mechanically
ventilated are those with significant respiratory muscle fatigue, patients in respiratory distress,
patients who are unable to protect their own airway either secondary to swelling or those who have
depressed levels of consciousness, and patients with a metabolic acidosis, respiratory acidosis, or
significant hypoxemia.
2. What are the goals of mechanical ventilation?
To correct hypoxemia and to maintain alveolar ventilation.
3. What are the different ventilator settings?
• Assist-control ventilation (AC): This is an initial setting used for most patients. It is a safe mode
that ensures the patient receives a breath at a certain preset rate. Every time the patient initiates a
breath, the ventilator will deliver a breath to the patient. If the patient does not initiate a breath, the
ventilator will still deliver a breath of preset tidal volume at the predetermined rate.
• Synchronous intermittent mandatory ventilation (SIMV): This setting allows the patient to breathe
on his/her own and is used for weaning patients off the ventilator. It does not have a preset tidal
volume, only a preset breathing rate. If the patient takes a spontaneous breath, the mandatory
breath is given in synchrony by the ventilator. If the patient does not take a spontaneous breath, the
ventilator does provide a breath to the patient.
• Continuous positive airway pressure (CPAP): This setting only has predetermined positive end expi-
ratory pressure and pressure support. In other words, positive pressure is continuously given by the
ventilator. The patient otherwise breathes on his/her own. This setting is also used when weaning
patients from a ventilator.
4. How is correct intubation determined when a patient is on a ventilator?
Postintubation chest X-ray is used to determine location of the tip of the tube. The endotracheal
tube should sit approximately 3 to 5 cm above the carina. It is also important to hear bilateral breath
sounds on exam.
5. What criteria is used to determine if a patient is ready for extubation?
• Tidal volumes of more than 5 cc/kg
• Oxygen saturation of at least 90% with less than 5 cm H2O PEEP and FiO2 less than 40%
• Respiratory rate of less than 30 breaths/min
• Vital capacity of greater than 10 cc/kg
• Intact cough
6. What is PEEP?
PEEP is positive pressure maintained at the end of passive exhalation. It is used to keep alveoli open and
improve gas exchange. Usually, PEEP is used to prevent alveolar collapse and atelectasis; it is most commonly used in patients with Acute Respiratory Distress Syndrome (ARDS). PEEP also allows for a decrease
in inspired oxygen concentration, which decreases the risk of oxygen toxicity. If PEEP is too high, complications include barotrauma, pneumothorax, and low cardiac output secondary to decreased venous return.
7. What is an appropriate tidal volume in most patients on a mechanical ventilator?
Initially, patients can be set at 8 to 10 cc/kg; however, smaller tidal volumes are used in those patients
with ARDS.
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8. What inspiratory:expiratory ratio on a mechanical ventilator is most similar to a
normal respiratory pattern?
A ratio of 1:2.
9. What is used to prevent tracheal stenosis in intubated patients?
Cuffs on endotracheal tubes, which are large volume and low pressure.
10. What are the different types of shock?
• Cardiogenic, typically caused by myocardial infarction causing a decreased cardiac output and
increased systemic vascular resistance
• Hypovolemic, secondary to trauma and bleeding with decreased cardiac output and increased
systemic vascular resistance
• Distributive, typically secondary to neurogenic changes, sepsis, or anaphylaxis. This type of shock
will show increased cardiac output and decreased systemic vascular resistance
11. What are the stages of shock?
Initially, shock is reversible, and no signs are seen on exam. The compensatory stage is when the
body uses mechanisms to try to reverse the symptoms. Next is the progressive stage, when the shock
is no longer reversible. Compensatory mechanisms are not working, and worsening acidosis with
decreased organ perfusion is seen. Finally, the last stage is refractory, with organ failure and death.
12. How is shock treated?
Shock requires an ICU admission. Cardiogenic shock is treated with decreased afterload, increasing
cardiac output, and decreasing myocardial oxygen demand. Other forms of shock are treated with
aggressive fluid hydration and treatment of the underlying cause.
13. What are the indications of placing an arterial line?
• Inability to obtain noninvasive blood pressures
• Hemodynamic instability
• Rigorous blood pressure control is needed.
• Frequent arterial blood sampling is needed.
14. What are the indications for central line placement?
• Monitoring the central venous pressure
• Infusing concentrated vasopressors
• Delivering total parenteral nutrition
• Inability to gain peripheral venous access
15. What are the most common causes of postoperative fever in the intensive care
unit?
In the ICU, the most common are ventilator-associated pneumonia, vascular catheter-related infections, wound infections, and catheter-related urinary tract infections.
16. Which patients should be prophylaxed for stress ulcers?
Patients who have been mechanically ventilated for more than 48 hours, patients with a history of GI
ulcers or bleeding within the past year, patients with a coagulopathy, patients with traumatic brain
injury, patients with burn injuries, and patients with two or more minor criteria: sepsis, steroid therapy,
an ICU stay of more than a week, and occult GI bleeding for more than 5 days.
17. What are the contraindications to enteral feeding in the critically ill patient
population?
Contraindications include patients who are hemodynamically unstable or who are not fully
resuscitated, bowel obstruction, ileus, vomiting and diarrhea, major GI bleeding, and GI ischemia.
BASIC LIFE SUPPORT,
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ADVANCED CARDIAC LIFE
SUPPORT, AND ADVANCED
TRAUMA LIFE SUPPORT
Robert A. Strauss, Amber Johnson, Robert C. Lampert,
Shahid R. Aziz, John Wessel
BASIC LIFE SUPPORT*
1. What are the four steps of basic life support (BLS)?
1. Check responsiveness (also check for absent or abnormal breathing by scanning the chest for
movement).
2. Activate the emergency response system/get automated external defibrillator (AED).
3. Circulation (check the carotid pulse): if no pulse within 10 seconds, start CPR.
4. Defibrillate.
2. What is the new sequence of CPR?
CABD: Chest compressions, airway, breathing, defibrillation.
The 2010 guidelines emphasize chest compressions for both trained and untrained rescuers.
Chest compressions should be initiated prior to ventilation. If a person is not CPR trained, he or
she should provide Hands-Only (compression-only) CPR. This change of sequence allows for chest
compressions to be initiated sooner, increasing the patient’s chance of survival.
3. What is the American Heart Association (AHA) Emergency Cardiovascular Care
Adult Chain of Survival?
1. Immediate recognition of cardiac arrest and initiation of the emergency response system
2. Early CPR (emphasizing chest compressions)
3. Rapid defibrillation
4. Effective advanced life support
5. Integrated post-cardiac arrest care
4. At what point should EMS be activated with an adult victim?
Immediately upon finding an unresponsive adult. The victim should be checked for responsiveness
and breathing, and then the emergency response system should be activated and an AED should be
retrieved, if available. Return to the victim to check a pulse and begin CPR. Most adults in cardiac
arrest are in ventricular fibrillation (V-fib); therefore the time from collapse until defibrillation is the
single greatest factor in survival.
5. At what point should EMS be activated with an infant or child victim?
If the arrest was not witnessed, call EMS after five cycles (approx. 2 minutes) of CPR. It is believed
that many children develop respiratory arrest and bradycardia prior to cardiac arrest. During this
time (prior to progression to cardiac arrest), these younger victims have a higher survival rate if CPR
is started. Once a child progresses to cardiac arrest, his or her chance of survival is much lower. If
the arrest is sudden and witnessed, call EMS first.
6. What length of time is used when assessing for a pulse?
<10 seconds. If a pulse is not felt within 10 seconds, begin CPR. Assess the carotid pulse in children
and adult. Assess the brachial pulse in infants.
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*
Written by Robert Strauss and Amber Johnson.
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