Advanced Life Support194.27.141.99/dosya-depo/ders-notlari/oktay-demirkiran/Advanced_Li… · • Bizarre irregular waveform • No recognisable QRS complexes • Random frequency

ERC

Advanced Life Support

Doç.Dr.Oktay DEMİRKIRAN

ERC

Chain of survival

ERC

CARDIAC MONITORING &

RHYTHM RECOGNITION

ERC

Objectives

To understand:• Indications & techniques for ECG

monitoring• Basic electrocardiography• How to read a rhythm strip

–cardiac arrest rhythms–peri-arrest arrhythmias

ERC

Which patients?• Cardiac arrest or other important

arrhythmias• Chest pain• Heart failure• Collapse / syncope• Shock / hypotension• Palpitations

ERC

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

ERC

How to monitor the ECG (2):Defibrillator paddles

• Suitable for “quick-look”• Movement artefact• Risk of spurious

asystole

ERC

Cardiac arrest rhythms

• Ventricular fibrillation• Pulseless ventricular tachycardia• Asystole• Pulseless Electrical Activity (PEA)

ERC

How to monitor the ECG (3):Adhesive monitoring electrodes

• “Hands-free”monitoring and defibrillation

ERC

12-lead ECG

ERC

12-lead ECG

• 3D electrical activity from heart• More sophisticated ECG

interpretation• ST segment analysis

ERC

• Depolarisation initiated in SA node

• Slow conduction through AV node

• Rapid conduction through Purkinje fibres

Basic electrocardiography (1)

ERC

Basic electrocardiography (2)

• P wave = atrialdepolarisation

• QRS = ventricular depolarisation (< 0.12 s)

• T wave = ventricular repolarisation

ERC

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

– movement– electrical interference

ERC

Pulseless ventricular tachycardia

• Monomorphic VT–Broad complex rhythm–Rapid rate–Constant QRS morphology

• Polymorphic VT–Torsade de pointes

ERC

Asystole

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

ERC

Pulseless Electrical Activity

• Clinical features of cardiac arrest• ECG normally associated with an

output

ERC

How to read a rhythm strip1. 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?

ERC

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

ERC

What is the ventricular rate?• Normal 60-100 min-1

• Bradycardia < 60 min-1

• Tachycardia > 100 min-1

Rate = 300Number of large squares between consecutive QRS complexes*

* At standard paper speed of 25 mm sec-1, 5 large squares = 1 second

ERC

Is the QRS rhythm regular or irregular?

• Unclear at rapid heart rates• Compare R-R intervals• Irregularly irregular = AF

ERC

DEFIBRILLATION

ERC

Cardiac ArrestPrecordial Thump if appropriate

BLS Algorithm if appropriate

Attach Defib-Monitor

AssessRhythm

+/- Check PulseVF/VT Non-VF/VT

Defibrillate X 3as necessary

CPR 1 minCPR 3 min*

* 1 min if immediatelyafter defibrillation

During CPRCorrect reversible causes

If not already:•check electrodes, paddle position and contact•attempt / verify: airway & O2,

i.v. access•give epinephrine every 3 min•give amiodarone after 3 unsuccessful shocks

Consider: buffers, magnesium, atropine

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

Universal ALSAlgorithm

ERC

Unresponsive?

Open airwayLook for signs of life

Call resuscitation team

CPR 30:2Until Defib-Monitor Attach

AssessRhythm

Shockable(VF/pulslessVT)

Non shockable(PEA/ Asystole)

1 Shock150-3600J biphasic or

360 J monophasic

Immediately resume:CPR 30:2 for

2 min


2 min


•check electrodes, paddle position and contact•attempt / verify: airway & O2,

i.v. accessGive interrupted compressions when airwaysecure•give epinephrine every 3-5 min

Consider: amiodarone, magnesium, atropine



ERC

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

ERC

DefibrillationSuccess depends on delivery of current to the myocardium

Current flow depends upon:• Electrode position • Transthoracic impedance• Energy delivered• Body size

ERC

Transthoracic Impedance

Dependent upon:• Electrode size• Electrode/skin interface• Contact pressure• Phase of respiration• Sequential shocks

ERC

Defibrillators• Design

– Power source– Capacitor– Electrodes

• Types– Manual– Automated– Monophasic or Biphasic waveform

ERC

Defibrillator waveforms

Damped Monophasic Truncated Biphasic

ERC

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

ERC

Goals for in-hospital defibrillation

• “Healthcare providers with a duty to perform CPR should be trained, equipped, and authorised to perform defibrillation”

• “The goal should be a collapse-to-shock interval of less than 3 minutes in all areas of the hospital”

ERC

Automated external defibrillators• Analyse cardiac

rhythm• Prepare for shock

delivery• Specificity for

recognition of shockable rhythm close to 100%

ERC

Automated external defibrillators

Advantages:• Less training required

– no need for ECG interpretation • Suitable for “first-responder” defibrillation• Public access defibrillation (PAD)

programs

ERC

Automated External Defibrillation• Attach adhesive

electrodes• Follow audible and visual

instructions• Automated ECG analysis

- stand clear • Charges automatically if

shockable rhythm • +/- manual override

ERC

Assess VictimAccording to BLS guidelines

BLSIf AED not immediately available

Switch defibrillator ONAttach electrodes

Follow spoken/visual directions

ANALYSEShock

IndicatedNo shockIndicated

After every 3 shocks

CPR 1 minute

If nocirculation

CPR 1 minute

AED Algorithm

ERC

AED Use:• Airports• Bus terminals• Shopping malls• Hotels• Schools• Hospital wards• Aircrafts

ERC

Manual Defibrillation

Relies upon:• Operator recognition of

ECG rhythm• Operator charging machine

and delivering shock• Can be used for

synchronised cardioversion

ERC

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

ERC

Shock Energy• Initial shock energy 200 J*, repeat

once if unsuccessful • Subsequent shocks at 360 J*• Shocks delivered in groups of three• If defibrillation restores the patient’s

circulation and VF/VT recurs, start again at 200J*

*or biphasic equivalent

ERC

Defibrillation

A series of 3 shocks should be delivered rapidly, do not interrupt the sequence for CPR or a pulse check unless:

• Possible restoration of cardiac output• Uncertain ECG rhythm

ERC

Manual Defibrillation (1)• Diagnose VF/VT from

ECG and signs of cardiac arrest

• Select correct energy level• Charge paddles on patient• Shout “stand clear”• Visual check of area• Check monitor• Deliver shock

ERC

Manual Defibrillation (2)• Reassess rhythm• Keep paddles on chest between shocks• Increase energy level

– use assistant, or– replace paddle/s in defibrillator and select

energy level yourself• No BLS between shocks unless prolonged

delays

ERC

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

ERC

Pulseless VT is treated with an unsynchronised shock using

the VF protocol

ERC

Stres points

• Wet chest• Hairy chest• Plasters• “Pacemaker”

ERC

Summary• Defibrillation is the only effective means

of restoring cardiac output for the patient in VF or pulseless VT

• Defibrillation must be performed promptly, efficiently and safely

• New technology has improved machine performance and simplified use

ERC

ALS UNIVERSAL TREATMENT ALGORITHM

ERC

Objectives

To understand:• Treatment of patients in:

–ventricular fibrillation and pulseless ventricular tachycardia

–asystole or pulseless electrical activity (non-VF/VT rhythms)

ERC

Unresponsive?

Open airwayLook for signs of life

Call resuscitation team

CPR 30:2Until Defib-Monitor Attach

AssessRhythm

Shockable(VF/pulslessVT)

Non shockable(PEA/ Asystole)

1 Shock150-200J biphasic or

360 J monophasic


2 min


2 min


•check electrodes, paddle position and contact•attempt / verify: airway & O2,

i.v. accessGive interrupted compressions when airwaysecure•give epinephrine every 3-5 min

Consider: amiodarone, magnesium, atropine



ERC

• Attempt defibrillation. Give one shock of 150-200 J biphasic (360 J monophasic).• Immediately resume chest compressions (30:2) without reassessing the rhythm or feeling for

a pulse• Continue CPR for 2 min, then pause briefly to check the monitor:

– If VF/VT persists • Give a further (2nd) shock of 150-360 J biphasic (360 J monophasic). • Resume CPR immediately and continue for 2 min. • Pause briefly to check the monitor. • If VF/VT persists give adrenaline 1 mg IV followed immediately by a (3rd) shock of

150-360 J biphasic (360 J monophasic). • Resume CPR immediately and continue for 2 min. • Pause briefly to check the monitor. • If VF/VT persists give amiodarone 300 mg IV followed immediately by a (4th)

shock of 150-360 J biphasic (360 J monophasic). • Resume CPR immediately and continue for 2 min. • Give adrenaline 1 mg IV immediately before alternate shocks (i.e. approximately

every 3-5 min).• Give further shocks after each 2 min period of CPR and after confirming that

VF/VT persists.

ERC

– If organised electrical activity compatible with a cardiac output is seen, check for a pulse• If a pulse is present, start post-

resuscitation care• If no pulse is present, continue CPR and

switch to the non-shockable algorithm– If asystole is seen, continue CPR and

switch to the non-shockable algorithm.

ERC




AssessRhythm

+/- Check Pulse

VF/VT Non-VF/VT

ERC

Precordial thump

• Mechanical shock

• Indication:–witnessed or

monitored cardiac arrest

ERC

Precordial thump

• Lower half of the sternum• From a height of about 20 cm• In first 10 seconds

ERC

In-hospital Basic Life Support Patient Collapsed

Shout for HELP and assess responsiveness

Not responsive Responsive

Call cardiac arrest team / Get defibrillatorStart BLS if defibrillator not immediately

available

Call for medical assistance

Definite Pulse and Breathing Present?

Apply pads / monitorDefibrillate if appropriate

Ventilate with oxygenChest compressions

ALS on arrival of Cardiac Arrest Team

Airway manoeuvresOxygen, monitor, i.v.

Find notesPrepare handover

YesNo

ERC




AssessRhythm

+/- Check Pulse

VF/VT Non-VF/VT

ERC

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

– movement– electrical interference

ERC

Pulseless Ventricular Tachycardia

• Monomorphic VT–Broad complex rhythm–Rapid rate–Constant QRS morphology

• Polymorphic VT–Torsade de pointes

ERC

AssessRhythm

VF/VT

Defibrillate X 3as necessary

CPR 1 min

Ventricular Fibrillation/Pulseless Ventricular Tachycardia

ERC

Assess the rhytm

Shockable(VF / pulseless VT)

Shockable150-200 J Biphasic or

360 J monophasic

Immediately resume:CPR 30:2

2 min(without reassesing the rhytm or feeling a pulse)

ERC

Check the monitor

VF / pulseless VT persist

2nd shock150-200 J Biphasic or

360 J monophasic


2 min


Adrenaline 1 mg (IV)

3rd shock150-200 J Biphasic or

360 J monophasic


2 min

Check the monitor


Amiodarone 300 mg (IV)

4th shock150-200 J Biphasic or

360 J monophasic


2 min

Adrenaline 1 mg (İV)Every 3-5 min


2 min

ERC

• Drug-shock-CPR-rhytm check

ERC


If not already:• check electrodes, paddle position and contact• attempt / verify: airway & O2

i.v. access• give epinephrine / adrenaline every 3 min• give amiodarone after 3 unsuccessful shocks

Consider: buffers, magnesium, atropine

ERC


ERC

Chest compressions, airway and ventilation

• Secure airway:–Tracheal tube–Laryngeal mask airway (LMA)–Combitube

• Once airway secured, if possible, do not interrupt chest compressions for ventilation

ERC

Intravenous access and drugs VF/VT

• Central veins versus peripheral• Epinephrine / adrenaline 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 (2g)

ERC

Epinephrine/AdrenalineActions:α agonist arterial vasoconstriction ↑ systemic vascular resistance ↑ cerebral and coronary blood flow β agonist ↑ heart rate

↑ force of contraction↑ myocardial O2 demand(may increase ischaemia)

ERC

Amiodarone

Actions:

• Lengthens duration of action potential• Prolongs Q-T interval• Mild negative inotrope - may cause

hypotension

ERC

Magnesium

Actions:• Hypomagnesaemia often co-exists

with hypokalaemia• Depresses neurological and

myocardial function• Acts as a physiological calcium

blocker

ERC

Sodium BicarbonateActions:

• Alkalinising agent (increases pH)But may:– increase carbon dioxide load– inhibit release of oxygen to tissues– impair myocardial contractility– cause hypernatraemia

ERC

Non-VF/VT

CPR 3 min** 1 min if immediately

after defibrillation

AssessRhythm

+/- Check Pulse

AsystolePulseless Electrical Activity (PEA)

ERC

Assess the rhytm

CPR30:2

Check the leads are attachedwithout stopping CPR


Atropine 3 mg (İV)

CPR 2 min30:2

(Until airway secured)

VF/VT recurs

Shockable rhytm algoritm


ERC

Asystole

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

ERC

Asystole

• Confirm:– check leads (view via leads I and II)– check ‘gain’

• Epinephrine / adrenaline 1 mg i.v. every 3 minutes

• Atropine 3 mg i.v. (or 6 mg via tracheal tube)

ERC

Atropine

Actions:

• Blocks effects of vagus nerve• Increases sinus node automaticity• Increases atrioventricular conduction

ERC

‘Spurious’ asystole

• Only occurs after shock delivered and subsequent monitoring with paddles and gel pads

• More likely with increasing number of shocks and high chest impedance

• Displays apparent ‘asystole’• Confirm rhythm with monitoring leads

ERC


• Clinical features of cardiac arrest• ECG normally associated with an

output

ERC


• Exclude / treat reversible causes• Epinephrine / adrenaline 1 mg every 3

minutes• Atropine 3 mg if PEA with rate < 60 min-1

(6mg via tracheal tube)

ERC

Non-VF/VT immediately after defibrillation

• Withhold epinephrine /adrenaline and atropine - check rhythm and pulse after 1 minute of CPR –delay in recovery of monitor display–electrical stunning - few seconds of

true asystole after defibrillation–myocardial stunning - temporarily

impaired contractility

ERC

DRUG DELIVERY DURING CPR

ERC

Objectives

• Understand the reasons for venous access

• Review the equipment used • Outline the routes used for

venous access• Understand the associated

complications

ERC

Access to the circulation allows:

• Drug administration

• Fluid administration

• Taking blood samples

• Insertion of a pacing wire

ERC

Peripheral venous access

• Upper limb–Dorsum of the hand–Forearm, antecubital fossa

• Neck–External jugular vein

ERC

Complications of peripheral venous access

Early• Failure to cannulate vein• Haematoma formation• Extravasation of drugs, fluid• Damage to surrounding

structures• Air embolus• Shearing/fracture of cannula

or needle

Late• Thrombophlebitis• Cellulitis

ERC

Central venous access

• Internal jugular vein

• Subclavian vein

ERC

Complications of central venous cannulation

• Arterial puncture• Haematoma• Haemothorax• Pneumothorax• Air embolism• Damage to surrounding structures• Arrhythmias

ERC

Tracheal administration of drugs

• Inability to cannulate a vein• Need for tracheal tube in situ• Adjustment of dose and volume• Dispersal into bronchial tree

ERC

Tracheal administration of drugs

Drugs that canbe given via the trachea:

• Epinephrine• Lidocaine• Atropine• Naloxone

Drugs that cannot be given via the trachea

• Amiodarone• Sodium bicarbonate• Calcium

ERC

Summary• If a peripheral cannula is in place and

working, use it initially

• Central veins are the route of choice if expertise is available, but beware of complications

• The tracheal route can be used with appropriate adjustment of dose

ERC

DRUGS

ERC

Objectives

• To understand the indications, doses and actions of drugs used in resuscitation

• To understand the indications, doses and actions of some of the common drugs used to treat peri-arrest arrhythmias

ERC

EpinephrineIndications:

• All cardiac arrest rhythms• Bradycardia• Special circumstances:

–anaphylaxis

ERC

EpinephrineDose:• 1 mg intravenous 10 ml 1:10,000 (1 ml

1:1,000) every 2-3 mins during resuscitation• 2-3 mg via tracheal tube• 2–10 mcg min-1 for atropine resistant

bradycardia• 0.5ml 1:1,000 i.m., 3-5 ml 1:10,000 i.v.

in anaphylaxis, depending on severity

ERC

EpinephrineActions:α agonist arterial vasoconstriction ↑ systemic vascular resistance ↑ cerebral and coronary blood flow

β agonist ↑ heart rate↑ force of contraction↑ myocardial O2 demand(may increase ischaemia)

ERC

Atropine

Indications:

• Asystole• Symptomatic bradycardias• PEA (rate < 60 beats min-1)

ERC

AtropineDose:• Asystole / PEA (rate < 60 beats min-1)

– 3 mg i.v., once only– 6 mg via tracheal tube

• Bradycardia– 0.5 mg i.v., repeated as necessary,

maximum 3 mg

ERC

AtropineActions:• Blocks effects of vagus nerve

• Increases sinus node automaticity

• Increases atrioventricular conduction

ERC

Amiodarone

Indications:

• Refractory VF / Pulseless VT• Haemodynamically stable VT• Other resistant tachyarrhythmias

ERC

AmiodaroneDose:

• Refractory VF / Pulseless VT– 300 mg in 20 ml 5% dextrose, bolus i.v.

• Stable tachyarrhythmias– 150 mg in 20 ml 5% dextrose over 10 mins– Repeat 150 mg if necessary– 300 mg in 100 ml 5% dextrose over 1 hour

ERC

Amiodarone

Actions:

• Lengthens duration of action potential• Prolongs Q-T interval• Mild negative inotrope - may cause

hypotension

ERC

MagnesiumIndications:

• Shock refractory VF (with possible hypomagnesaemia)

• Ventricular tachyarrhythmias (with possible hypomagnesaemia)

• Torsades de pointes

ERC

MagnesiumDose:

Shock Refractory VF• 2–4 ml 50% (4–8 mmol) i.v. over 1-2 mins• Can be repeated after 10-15 minutes

Other circumstances• 5 ml of 50% (10 mmol) i.v. over 30 mins

ERC

Magnesium

Actions:

• Depresses neurological and myocardial function

• Acts as a physiological calcium blocker

ERC

LidocaineIndications:

• Refractory VF / Pulseless VT– when amiodarone is unavailable

• Haemodynamically stable VT– as an alternative to amiodarone

ERC

LidocaineDose:• Refractory VF / Pulseless VT

– 100 mg i.v.– further boluses of 50 mg, max 200 mg

• Haemodynamically stable VT– 50 mg i.v.– further boluses of 50 mg, max 200 mg

• Reduce dose in elderly or hepatic failure

ERC

Sodium Bicarbonate

Indications:

• Severe metabolic acidosis (pH < 7.1)• Hyperkalaemia• Special circumstance

–Tricyclic antidepressant poisoning

ERC

Sodium Bicarbonate

Dose:

• 50 mmol (50 ml of 8.4% solution) i.v.

ERC

Sodium BicarbonateActions:• Alkalinizing agent (increases pH)

But may:– increase carbon dioxide load– inhibit release of oxygen to tissues– impair myocardial contractility– cause hypernatraemia– interact with adrenaline

ERC

Calcium

Actions:• Essential for normal cardiac contraction• Excess may lead to arrhythmias• The trigger for cell death in the ischaemic myocardium •Excess may impair cerebral recovery

ERC

CalciumIndications:• Pulseless electrical activity caused by:

– severe hyperkalaemia– severe hypocalcaemia– overdose of calcium channel blocking

drugsDose• 10 ml 10% calcium chloride (6.8 mmol)

Do not give immediately before or after sodium bicarbonate

ERC

Adenosine

Indications:

• Broad complex tachycardia, uncertain aetiology

• Paroxysmal supraventricular tachycardia

ERC

AdenosineDose:

• 6 mg intravenously, by rapid injection

If necessary, three further doses each of 12 mg can be given every 1–2 mins

ERC

Adenosine

Actions:• Slows conduction across the AV node

Must only be used in a monitored environment

ERC

NaloxoneDose:

• 0.2 - 2.0 mg i.v.• May need to be repeated up to a

maximum of 10 mg• May need an infusion

ERC

Naloxone

Indications:

• Opioid overdose• Respiratory depression secondary to

opioid administration

ERC

NaloxoneActions:

• Opioid receptor antagonist• Reverses all opioid effects, particularly

respiratory and cerebral• May cause severe agitation in opioid dependence

ERC

Summary

• Indications, dose and actions of drugs used during cardiac arrest

• Indications, dose and actions of drugs used in the management of peri-arrest arrhythmias

Advanced Life SupportChain of survivalCARDIAC MONITORING �& �RHYTHM RECOGNITIONObjectivesWhich patients?How to monitor the ECG (1):�Monitoring leadsHow to monitor the ECG (2):�Defibrillator paddlesCardiac arrest rhythmsHow to monitor the ECG (3):�Adhesive monitoring electrodes12-lead ECG12-lead ECGBasic electrocardiography (1)Basic electrocardiography (2)Ventricular fibrillationPulseless ventricular tachycardiaAsystolePulseless Electrical ActivityHow to read a rhythm stripECG rhythm interpretationWhat is the ventricular rate?Is the QRS rhythm regular or irregular?DEFIBRILLATIONMechanism of defibrillationDefibrillationTransthoracic ImpedanceDefibrillatorsDefibrillator waveformsBiphasic DefibrillatorsGoals for in-hospital defibrillationAutomated external defibrillatorsAutomated external defibrillatorsAutomated External DefibrillationAED Use:Manual DefibrillationDefibrillator SafetyShock EnergyDefibrillationManual Defibrillation (1)Manual Defibrillation (2)Synchronised cardioversionStres pointsSummaryALS UNIVERSAL �TREATMENT ALGORITHM�ObjectivesPrecordial thumpPrecordial thumpVentricular FibrillationPulseless Ventricular TachycardiaChest compressions, airway and ventilationIntravenous access and drugs �VF/VTEpinephrine/AdrenalineAmiodaroneMagnesiumSodium BicarbonateAsystoleAsystoleAtropine‘Spurious’ asystolePulseless Electrical ActivityPulseless Electrical ActivityNon-VF/VT immediately after defibrillationDRUG DELIVERY DURING CPRObjectivesPeripheral venous accessComplications of peripheral �venous accessCentral venous accessComplications of central venous cannulationTracheal administration �of drugsTracheal administration of drugsSummary�DRUGSObjectivesEpinephrineEpinephrineEpinephrineAtropineAtropineAtropineAmiodaroneAmiodaroneAmiodaroneMagnesiumMagnesiumMagnesiumLidocaineLidocaineSodium BicarbonateSodium BicarbonateSodium BicarbonateCalciumCalciumAdenosineAdenosineAdenosineNaloxoneNaloxoneNaloxoneSummary

Documents

Advanced Life Support194.27.141.99/dosya-depo/ders-notlari/oktay-demirkiran/Advanced_Li… · • Bizarre irregular waveform • No recognisable QRS complexes • Random frequency