CPR

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Adult BLS Sequence 

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A Change From A-B-C to C-A-B Figure 1 AHAECC Adult Chain of Survival The Inks in the nen AHA Chain of Sumviva areas follows: 1, Immediate recognition of cardiac arest and activation ofthe ‘emergency response system 2. Early CPR with an emphasis on chest compressions ‏سيد‎ ll ‏مت‎ ‎3, Rapid defibrillation 4, Effective advanced life support 4, Integrated post-cardiac arrest care 

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Immediate Recognition and Activation of the Emergency Response System If a lone rescuer finds an unresponsive adult (ie, no movement or response to stimulation) or witnesses an adult who suddenly collapses,the rescuer should check for a response by ‏مح جاخ بع در مر ور دعر‎ victim on tha ‏ملع :وهای‎ 

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The trained or untrained bystander should—at a minimum—activate the community emergency ltébporictimyalsorhas absent or abnormal breathing (ie, only gasping), the rescuer should assume the victim is in cardiac arrest. AF Sok Listen, and Feel” removed from the BLS algorithm 

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6609۳۱۲/۵۲ 0۴ 6 ۷ Recognition of cardiac arrest is not always straightforward, especially for laypersons. Therefore, these adult BLS Guidelines focus on: recognition of cardiac arrest 

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* Once the Jay bystander recognizes that the victim is unresponsive, that bystander must immediately to activate the emergency response system. * Once the healthcare provider recognizes that the victim is unresponsive with no breathing or no normal breathing (ie, only gasping) the healthcare provider will activate the emergency response system. * After activation, rescuers should 

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Recognition of cardiac arrest unresponsive with no ۱1 ‏ای ایا با باایه-‎ breathing (ie, only gasping 

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Pulse Check * The lay rescuer should not check fora pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim Is not breathing normally. * The healthcare provider should take no more than 10 second to check for a pulse and, if the rescuer does not definitely feel a pulse within that time period, the rescuer should start chest compressions. 

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Managing the Airway As previously stated, a significant change in these Guidelines is to recommend the initiation of chest compressions before ventilations (CAB rather than ABC). This change reflects the growing evidence of the importance of chest compressions and the reality that setting up airway equipment takes time. This new emphasis on CAB helps clarify that airway maneuvers should be performed quickly and efficiently so that interruptions in chest compressions are minimized and chest ee ey ee ‏ا‎ 

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Open the Airway: Lay Rescuer The trained lay rescuer who feels confident that he or she can perform both compressions and ventilations should open the airway using a head tilt-chin lift maneuver (Class Ila, LOE B). For the rescuer providing Hands-Only CPR, there is insufficient evidence to recommend the use of any specific passive airway (such as hyperextending the neck to allow passive ventilation). 

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Open the Airway: Healthcare Provider A healthcare provider should use the head tilt- chin lift maneuver to open the airway of a victim with no evidence of head or neck trauma. Between 0.12 and 3.7% of victims with blunt trauma have a spinal injury, and the risk of Spinal injury is increased if the victim has a craniofacial injury, a Glasgow Coma Scale score of 8, or both. 

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For victims with suspected spinal injury, rescuers should initially use manual spinal motion restriction (eg, placing 1 hand on either side of the patient’s head to hold it still) rather than immobilization devices (Class IIb, LOE C141,142). Spinal immobilization devices may interfere with maintaining a patent airway, but ultimately the use of such a device may be necessary to maintain spinal alignment during transport. ۱۴ healthcare providers suspect a cervical spine injury, they should open the airway using a jaw thrust without head extension (Class IIb, LOE C133). Because maintaining a patent airway and providing adequate ventilation are priorities in CPR (Class I, LOE C), use the head tilt-chin lift maneuver if the jaw thrust does not adequately open the airway. 

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Figure 36-1. The ead titjaw ht manene provides 3 pate ‘upper airway by sitchin muscles atucked ‏ما‎ the tong, thas Paling the tongue evay from th posterior pharynx. Forward di Dlaemest of the mandible accomplished by gasping the anges of he mandible and iin with both hans, seeing to place the mani forward while ing the bead backward 

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Rescue Breathing @ Deliver each rescue breath over 1 second (Class Ila, LOE C). @ Give a sufficient tidal volume to produce visible chest rise. @ Use a compression to ventilation ratio of 30 chest compressions to 2 ventilations. @ When an advanced airway (ie, endotracheal tube, Combitube, or laryngeal mask airway [LMA]) is in place during 2- person CPR, give 1 breath every 6 to 8 seconds without ‘attempting to synchronize breaths between compressions (this will result in delivery of © to 10 breaths/minute). 064 تس ۲ ۱۲ 

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Studies in anesthetized adults (with normal perfusion) suggest that a tidal volume of 8 to 10 ml/kg maintains normal oxygenation and elimination of CO2. During CPR, cardiac output is 25% to 33% of normal, So oxygen uptake from the lungs and CO2 delivery to the lungs are also reduced. As a result, a low minute ventilation (lower than normal tidal volume and respiratory rate) can maintain effective oxygenation and ventilation. For that reason during adult CPR tidal volumes of approximately 400 to 500 mL (6 to 7 mL/kg) should suffice. This is consistent with a tidal volume that produces visible chest rise. 

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Excessive ventilation is unnecessary and can cause gastric inflation and its resultant complications, such as regurgitation and aspiration. More important, excessive ventilation can be harmful because it increases intrathoracic pressure, decreases venous return to the heart, and diminishes cardiac output and survival. In summary, rescuers should avoid excessive Ventilation (too many breaths or too large a volume) during CPR. 

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During CPR the primary purpose of assisted Ventilation is to maintain adequate oxygenation; the secondary purpose is to eliminate CO2. As noted above, during the first minutes of ‘Sudden VF cardiac arrest, rescue breaths are not as important as chest compressions because: the oxygen content in the noncirculating arterial blood remains unchanged until CPR is started; the blood oxygen content then continues to be adequate during the first several minutes of CPR. In addition, attempts to open the airway and give rescue breaths (or to access and set up 

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For victims of prolonged cardiac arrest both ventilations and compressions are important because over time oxygen in the blood is consumed and oxygen in the lungs is depleted (although the precise time course is unknown). Ventilations and compressions are also important for victims of asphyxia arrest, such as children and drowning victims, because they are hypoxemic at the time of cardiac ا ۱ 

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Mouth-to-Mouth Rescue Breathing Mouth-to-mouth rescue breathing provides oxygen and ventilation to the victim. To provide mouth-to-mouth rescue breaths, open the victim’s airway, pinch the victim’s nose, and create an airtight mouth-to-mouth Seal. Give 1 breath over 1 second, take a “regular” (not a deep) breath, and give a second rescue breath over 1 second (Class IIb, LOE C). Taking a regular rather than a deep breath prevents the rescuer from getting dizzy or lightheaded and prevents overinflation of the ‎ae‏ ا ا ا 

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if an adult victim with spontaneous circulation (ie, strong and easily palpable pulses) requires support of ventilation, the healthcare provider should give rescue breaths at a rate of about 1 breath every 5 to 6 Seconds, or about 10 to 12 breaths per minute. Each breath should be given over 1 second regardless of whether an advanced airway is in place. Each breath should cause visible chest 

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Mouth-to-Barrier Device Breathing Some healthcare providers and lay rescuers state that they may hesitate to give mouth-to-mouth rescue breathing and prefer to use a barrier device. The risk of disease transmission through mouth to mouth ventilation is very low, and it is reasonable to initiate rescue breathing with or without a barrier device. When using a barrier device the rescuer should not delay chest compressions while setting up the device. 

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Mouth-to-Nose and Mouth-to-Stoma Ventilation Mouth-to-nose ventilation is recommended if Ventilation through the victim’s mouth is impossible (eg, the mouth is seriously injured), the mouth cannot be opened, the victim is in water, or a mouth-to-mouth seal is difficult to achieve A case series suggests that mouth-to-nose ventilation in adults is feasible, safe, and effective. Give mouth-to-stoma rescue breaths toa victim with a tracheal stoma who requires 

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Ventilation With Bag and Mask 

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Bag-Mask Ventilation Bag-mask ventilation is a challenging skill that requires considerable practice for competency. Bag-mask ventilation is not the recommended method of ventilation for a Jone rescuer during CPR. It is most effective when provided by 2 trained and experienced rescuers. One rescuer opens the airway and seals the mask to the face while the other squeezes the bag. Both rescuers watch for visible chest rise. The rescuer should use an adult (1 to 2 L) bag to deliver approximately 600 mL tidal volume for adult victims. This amount is usually sufficient to produce visible chest 

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If the airway is open and a good, tight seal is established between face and mask, this volume can be delivered by squeezing a 1-L adult bag about two thirds of its volume ora 2-L adult bag about one third of its volume. As long as the patient does not have an advanced airway in place, the rescuers should deliver cycles of 30 compressions and 2 breaths during CPR. The rescuer delivers ventilations during pauses in compressions and delivers each breath over 1 second (Class Ila, LOE C). The healthcare provider should use supplementary oxygen (O2 concentration TANS, at a minimiim flow rate af 10 ta 73 

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Ventilation With an Advanced Airway When the victim has an advanced airway in place during CPR, rescuers no longer deliver cycles of 30 compressions and 2 breaths (ie, they no longer interrupt compressions to deliver 2 breaths). Instead, continuous chest compressions are performed at a rate of at least 100 per minute without pauses for ventilation, and ventilations are delivered at the rate of 1 breath about every 6 to 8 seconds (which will deliver approximately 8 to 10 breaths per minute). 

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ACLS Adult Advanced Cardiovascular Life Support 

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Adjuncts for Airway Control and Ventilation 

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Ventilation and Oxygen Administration During CPR During low blood flow states such as CPR, oxygen delivery to the heart and brain is limited by blood flow rather than by arterial oxygen content. Therefore, rescue breaths are less important than chest compressions during the ©) eo of resuscitation from witnessed VF cardiac arrest and could reduce CPR ef due to interruption in chest comnraccinnc and tha inrranaca in 

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Thus, during the first few guinutes of witnessed cardiag @rrest a lone rescuer should Wot interrupt chest compressions for ventilation( 600 chest compressions ). Advanced airway placement in ‘Cardiac arrest should not delay initial CPR and defibrillation for 

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Oxygen During CPR 

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Although prolonged 05160 @00% inspired oxygen (Fio,=1.0) Was potential toxicity, there is insufficient evidence to indicate that this occurs during brief periods of adult CPR. Empirical use of 100% inspired oxygen during CPR optimizes arterial oxyhemoglobin content and in turn oxygen delivery; therefore, mse of 100% insnired oxvaen 

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Passive Oxygen Delivery During CPR Positive-pressure ventilation has been a mainstay of CPR but recently has come under scrutiny because of the potential for increased intrathoracic pressure to interfere with circulation due to reduced venous return to the heart. In the out-of-hospital setting, = =—— ‏عونا‎ delivery via mask with an Opened airway during the first 6 

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Chest compressions cause air to be expelled from the chest and oxygen to be drawn into the chest passively due to the elastic recoil of the chest. In theory, because ventilation requirements are lower than normal during cardiac arrest, oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway. At thistimethereis == PPR bm erro rt tho ‏نش بوروس‎ 

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Bag-Mask Ventilation Hag-mask ventilation is an @eceptable method of providing Ventilation and oxygenation during ١55 ‏داغيط‎ 3 that requires practice for continuing competency. All healthcare providers should be familiar with the use of the bag-mask device. 

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iin ventilations are performed Basa When a second provider is available, bag-mask ventilation may be used by a trained and experienced provider. But bag-mask ventilation is most effective when performed by 2 trained Oné provideropensthe airway and seals the mask to the face while the other squeezes the bag. 

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۲85 ventilation is particulary welprul when placement of an @avanced airway is delayed or unsuccessful. The provider should use an adult (1 to 2 L) bag and the provider should deliver approximately 600 mL of tidal volume sufficient to produce ۱۱۱5۶ 5 0۷۲ 1 This volume of ventilation is 

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The provider should be sure to open the airway adequately With a (ead tilt-chin li, lifting the jaw against the mask and holding the mask against the face, creating a tight seal. During CPR give 2 breaths (each 1 second) during a brief (about 3 to 4 seconds) pause after every 30 chest compressions. 

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Airway Adjuncts 

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Oropharyngeal Airways Although studies have not specifically considered the use of oropharyngeal airways in patients with cardiac arrest, airways may aid in the delivery of adequate ventilation with a bag-mask device by preventing the 

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Incorrect insertion of an oropharyngeal airway can displace the tongue into the hypopharynx, causing airway obstruction. To facilitate delivery of ventilations with a bag-mask device, oropharyngeal airways can be used in unconscious (unresponsive) patients with no cough or الى مد عه عن ج427 ‎i pian‏ 

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Nasopharyngeal Airways Nasopharyngeal airways are useful in patients with airway obstruction or those at risk for developing airway obstruction, particularly when conditions such as a clenched jaw prevent placement of an oral airway. Nasopharyngeal airways are better tolerated than oral airways in patients who are not deeply unconscious. Airway bleeding can occur in up to 30% of patients following insertion of a nasopharyngeal airway. Two case reports of inadvertent intracranial 

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Nasopharyngeal Airways 

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As with all adjunctive equipment, safe use of the nasopharyngeal airway requires adequate training, practice, and retraining. No studies have specifically examined the use of nasopharyngeal airways in Cardiac arrest patients. To facilitate delivery of ventilations with a bag-mask device, the nasopharyngeal airway can be used in patients with an obstructed airway. In the presence of known or suspected Basal skull fracture or severe 

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Advanced Airways Ventilation with a bag and mask or with a bag through an advanced airway (eg, endotracheal tube or supraglottic airway) is acceptable during CPR. Because there are times when ventilation with a bag-mask device is inadequate, ideally ACLS providers also should be trained and experienced in insertion of an موسوم ص قح ص ص هو دم و قح سر 

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Providers must ‏ىت !دأ 0۴۱6 2۷۷۵۲۵ عط‎ and benefits of insertion of an edvanced airway during a resuscitation attempt. There are no studies directly addressing the timing ۴ 311 >) placement and outcome during resuscitation from cardiac arrest. Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions, intubation frequently is associated 

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8 20۴۱۷9۲۱ ]ها وه۲مباک ه 0۴ ۱۱۱۵۵۶ ۲0 2/6۲۸۵ ۲۱۱/۱۵۵/2 «ااتعععع ناد 010۳6 عط 6۵0 2۳00 ۰۲/۲7 ۱ ‎without interrupting chest‏ ‎compressions.‏ Ina registry study of 25,000 in-hospital Cardiac arrests, earlier time to invasive airway (<5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival. 

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A recent study found that delayed endotracheal intubation combined with passive oxygen delivery and minimally interrupted chest compressions was associated with improved neurologically intact survival. Intubation attempts should be interrupted to provide oxygenation and ventilation as needed. 

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It may be helpful for providers to master one primary method of airway control. Providers should have a second (backup) strategy for airway management and ventilation if they are unable to establish the first- choice airway adjunct. Bag-mask ventilation may serve as that backup strategy. 

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Assessment by physical examination consists of visualizing chest expansion bilaterally and listening over the epigastrium (breath sounds should not be heard) and the lung fields bilaterally (breath sounds should be equal and adequate). A device also should be used to confirm correct placement. mentinuous waveform capnography ia recommended in addition to clinical assessment as the most reliable ees ww ‏اليه و‎ 

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Once an advanced airway is in place, the 2 providers should no longer deliver cycles of CPR (ie, compressions interrupted by pauses for ventilation). Instead the compressing provider should give continuous chest mempressions at a rate of at 163۹5۶ ‏اد‎ without pauses for ventilation. (2015= 100 - 120/min) The provider delivering ventilation 

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Providers should == wn excessive ventilation rate because doing so can compromise venous return and cardiac output during CPR. The 2 providers should change compressor and ventilator roles approximately every 2 minutes to prevent compressor fatigue and deterioration in quality and rate of chest compressions. When multiple providers are SS Sa Rei i eg gt ee 

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Supraglottic Airways walike endotracheal intubation, farubation with a supraglottic airway 0088 Not require visualization of the _ -, so both initial training and maintenance of skills are easier. Also, because direct visualization is not necessary, a supraglottic airway is inserted without interrupting compressions. 

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Supraglottic airways that have been studied in cardiac arrest are the laryngeal mask airway (LMA), the esophageal-tracheal tube (Combitube) and the laryngeal tube. During CPR performed by providers trained in its use, the supraglottic airway is a reasonable alternative to bag-mask ventilation and endotracheal intubation. 

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Laryngeal Mask Airway The laryngeal mask airway provides a wore secure and reliable means of Ventilation than the face mask. Although the laryngeal mask airway does not ensure absolute protection against aspiration, studies have shown that regurgitation is less likely with the laryngeal mask airway than with the bag- mask device and that aspiration is uncommon. When compared ۱۷۵ ۱۵ 7 ___, the laryngeal mask airway provides 

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Because insertion of the laryngeal mask airway does not require laryngoscopy and visualization of the vocal cords, training in its placement and use is simpler than that for endotracheal intubation. The laryngeal mask airway also may have advantages over the endotracheal tube 0 > ive patient is limited,there isa possibility of unstable neck injury, 3 appropriate positioning of the ee eee ‏وم جر‎ oh ten ‏بلح‎ al ipa hy jy eee 

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After successful insertion, 2 smal! proportion of patients cannot be ventilated with the laryngeal mask airway. With this in mind, it is important for providers to have an alternative strategy for airway management. For healthcare professionals trained units use, the laryngeal mask airway jen acceptable alternative to bag- ۱۱ Ventilation or endotracheal ee ‏ور موم و اد ور ود مور راد رمومروٌّ و‎ in 

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Endotracheal Intubation The endotracheal tube was once considered the optimal method of managing the airway during cardiac arrest. However, intubation attempts by unskilled providers can produce , such as trauma to ie meeeaarynx, interruption of Eemeeressions and ventilations for ۱ ۲ ‏رده‎ jong periods, and fmeeeinia from prolonged intima 

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Miller Blades Macintosh Blades 

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The endotracheal tube keeps the airway patent, permits , enables delivery of a high concentration of oxygen, provides an alternative route for the administration of some drugs, facilitates delivery of a selected tidal volume, and, with use of a cuff may protect the airway ‎acniratinn‏ ووو مرس 

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Indications for emergency endotracheal intubation : (1)the inability of the provider to ventilate the unconscious patient adequately with a bag and mask and (2) the absence of airway protective reflexes (coma or cardiac arrest). During CPR providers should minimize the number and duration of interruptions in chest compressions, with a goal to limit interruptions to no more than 10 seconds. 

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۱۱۲۱/۳۵/06 ۲۵۳ 5۳۵۲۵906 ۱۱۱6۴ 5۱08 ۶۵0 ‏۵سا‎ 7۱6665537۷ ١ _ , Whereas (eruptions 0 wedotracheal intubation can be 7 if the intubating provider is prepared to begin the intubation attempt-—ie, insert the laryngoscope blade with the tube ready at hand—as soon as the compressing provider 0 Id be interrupted only for the time required by the intubating provider to visualize the vocal cords and insert the tube; this Is ideally less than 10 seconds. 

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The compressing provider should be prepared to resume chest compressions immediately after the tube is passed through the vocal cords. If the initial intubation attempt is unsuccessful, a second attempt may be reasonable, but ear/y eensideration should be given to The risk of tube misplacement, displacement, or obstruction is high, especially when the patient is moved. 

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Thus, even when the endotracheal tube is seen to pass through the vocal cords and tube position is verified by chest expansion and auscultation during positive-pressure ventilation, providers should obtain additional confirmation of placement using waveform capnography or esophageal detector device (EDD). However, no single confirmation technique is completely reliable. Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method oF confirming and monitoring correct placement of an endotracheal tube. 

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Clinical Assessment to Confirm Tube Placement Providers should perform a thorough assessment of endotracheal tube position immediately after placement. This assessment should not require interruption of chest compressions. Assessment by physical examination consists of visualizing chest expansion bilaterally and |istening over the (breath sounds should not ۱ ‏و ح مج مح‌جورر/ ج بخ کح ود ( اس دح مر‎ 2 

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A device should also be used to confirm correct placement in the trachea. If there is doubt about correct tube placement, use the laryngoscope to visualize the tube passing through the vocal cords. If still in doubt, remove the tube and provide bag-mask ventilation until the tube can be 

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Use of Devices to Confirm Tube Placement Providers should always use 1317 clinical assessment and devices to confirm endotracheal tube location immediately after placement and throughout the resuscitation. 

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Exhaled CO, Detectors. Detection of exhaled CO, is one of several independent methods of confirming endotracheal tube position. Continuous waveform capnography is recommended in addition to Clinical assessment aS (08 0 

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0; => Meatabolism =p 0: Ventilation ¢zm CO: qm Transport 

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When exhaled CO, is detected (positive reading for CO,) in cardiac arrest, it is usually a reliable indicator of tube position in the trachea. 

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Postintubation Airway Management After inserting and confirming correct placement of an endotracheal tube, the provider should record the depth of the tube as marked at the tron 1) oF gums and secure it. There is significant potential for endotracheal tube movement with beadi tleaiamaoni tartagsé6 eaddtveutreal thepatientrismewvel frone tmelocation tejanothenhy is recommended as discussed above. 

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The endotracheal tube should be secured with tape or a commercial device. Devices and tape should be applied in a manner that avoids compression of the front and sides of the neck, which may impair venous return from the brain. After tube confirmation and fixation, obtain a chest x-ray (when feasible) to confirm that the end of the endotracheal tube is properly positioned above the carina. 

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Ventilation After Advanced Airway Placement However, positive-pressure ventilation increases intrathoracic pressure and may reduce venous return and cardiac output, especially in patients with hypovolemia or obstructive airway disease. Ventilation at high respiratory rates (=25 breaths per minute) is common during resuscitation from cardiac arrest. 

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Because cardiac output is lower than normal during cardiac arrest, the need for ventilation is reduced. Following placement of an advanced airway, the provider delivering ventilations should perform 1 breath every 6 to 8 seconds (8 to 10 breaths per minute) without pausing in applying chest compressions (unless ventilation is inadequate when compressions are not paused), Monitoring respiratory rate coupled with real-time feedback during CPR 

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