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ECG analysis Other factors is usually performed automatically 100mg kamagra mastercard, but some machines ● Use screens to provide some dignity for the require activation by pressing an “analyse” button cheap kamagra 100mg otc. Do not check for a pulse or other signs of a circulation between the three shocks. This will be timed by the machine, after clinical experience with automated external defibrillators. Alternatively, this procedure may start automatically, ● Davies CS, Colquhoun MC, Graham S, Evans, T, Chamberlain D. Defibrillators in public places: the introduction of a national Shocks should be repeated as indicated by the AED. Check the patient every minute to ensure that signs ● International guidelines 2000 for cardiopulmonary of a circulation are still present. Use of automated external defibrillators by the AED scheme so that data may be extracted from the a US airline. Ensure all supplies are replenished ready for the ● Resuscitation Council (UK). The diagram of the algorithm for the use of AEDs is adapted from ● Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman Resuscitation Guidelines 2000, London: Resuscitation Council (UK), RG. PEA was formerly known as electromechanical dissociation but, by international agreement, PEA is now the preferred term. In the community, VF is the commonest mode of cardiac arrest, particularly in patients with coronary disease, as Asystole: baseline drift is present. The ECG is rarely a completely straight line in asystole described in Chapter 2. Asystole is the initial rhythm in about 10% of patients and PEA accounts for an even smaller proportion, probably less than 5%. The situation is different in hospital, where the primary mechanism of cardiac arrest is more often asystole or PEA. These rhythms are much more difficult to treat than VF and carry a much worse prognosis. Asystolic cardiac arrest Suppression of all natural or artificial cardiac pacemakers in asystolic cardiac arrest leads to ventricular standstill. Under normal circumstances an idioventricular rhythm will maintain The onset of ventricular asystole complicating complete heart block cardiac output when either the supraventricular pacemakers fail or atrioventricular conduction is interrupted. Myocardial disease, electrolyte disturbance, anoxia, or drugs may suppress this idioventricular rhythm and cause asystole. Excessive vagal activity may suddenly depress sinus or atrioventicular node function and cause asystole, especially when sympathetic tone is reduced—for example, by blockers. Asystole will also occur as a terminal rhythm when VF is not successfully treated; the amplitude of the fibrillatory waveform declines progressively as myocardial energy and oxygen supplies are exhausted and asystole supervenes. When asystole occurs under these circumstances virtually no one survives. Onset of asystole due to sinoatrial block The chances of successful resuscitation are greater when asystole occurs at the onset of the arrest as the primary rhythm rather than as a secondary phenomenon. Diagnosis and electrocardiographic appearances Asystole is diagnosed when no activity can be seen on the electrocardiogram (ECG). Atrial and ventricular asystole usually coexist so that the ECG is a straight line with no recognisable deflections representing myocardial electrical activity. This straight line may, however, be distorted by baseline drift, electrical interference, respiratory movements, and artefacts arising from cardiopulmonary resuscitation (CPR). A completely straight line on the monitor screen often means If the ECG appears as a straight line the leads, gain, and electrical that a monitoring lead has become disconnected. As VF is so readily treatable and resuscitation is more likely to be successful, it is vital that great care is taken before diagnosing asystole to the exclusion of VF. The electrocardiographic leads and their connections must all be checked, as must the gain and brilliance of the monitor. All contact with the patient should cease briefly to reduce the possibility of interference. Persistent P waves due to atrial depolarisation are seen 16 Asystole and pulseless electrical activity recorded when the monitor has the facility to do this, or the defibrillator monitor electrodes should be moved to different positions. BP 0 On occasions, atrial activity may continue for a short time after the onset of ventricular asystole. In this case, the ECG will ECG show a straight line interrupted by P waves but with no evidence of ventricular depolarisation.

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If auscultation shows that gas is entering one lung only buy kamagra 100 mg lowest price, usually the right order 100mg kamagra visa, withdraw the tube by 1cm while listening over the lungs. If this leads to improvement, the tip of the tracheal tube was lying in the main bronchus. If no improvement is seen then the possible causes include pneumothorax, diaphragmatic hernia, or pleural effusion. Severe bradycardia If the heart rate falls below 60 beats/min, chest compression must be started by pressing with the tips of two fingers over sternum at a point that is one finger’s breadth below an imaginary line joining the nipples. If there are two rescuers it is preferable for one to encircle the chest with the hands and compress the same point with the thumbs, while the other carries out ventilation. The chest should be compressed by about Bag mask for neonatal resuscitation one third of its diameter. Give one inflation for every three chest compressions at a rate of about 120 “events” per minute. If no improvement is seen within 10-15 seconds the umbilical vein should be catheterised with a 5 French gauge catheter. This is best achieved by transecting the cord 2-3cm away from the abdominal skin and inserting a catheter until blood flows freely up the catheter. The same dose of adrenaline (epinephrine) can then be given directly into the circulation. Although evidence shows that sodium bicarbonate can make intracellular acidosis worse, its use can often lead to improvement, and the current recommendation is that the baby should then be given 1-2mmol/kg of body weight over two to three minutes. Those who fail to respond, or who are in asystole, require further doses of adrenaline (epinephrine) (10-30mcg/kg). This can be given either intravenously or injected down the tracheal tube. It is reasonable to continue with alternate doses of adrenaline (epinephrine) and sodium bicarbonate for 20 minutes, even in those who are born in apparent asystole, Paediatric face masks. Resuscitation efforts should not be continued beyond 20 minutes unless the baby is making at least intermittent respiratory efforts. Pharyngeal suction Naloxone therapy ● Rarely necessary unless amniotic fluid Intravenous or intramuscular naloxone (100 mcg/kg) should stained with meconium or blood and the be given to all babies who become pink and have an obviously baby asphyxiated satisfactory circulation after positive pressure ventilation but fail ● Can delay onset of spontaneous respiration for a long time if suction is aggressive to start spontaneous respiratory efforts. Often the mothers have ● Not recommended by direct mouth suction a history of recent opiate sedation. Alternatively, naloxone can or oral mucus extractors because of be given down the tracheal tube. If naloxone is effective then congenital infection an additional 200 micrograms/kg may be given intramuscularly to prevent relapse. Naloxone must not be given to infants of mothers addicted to opiates because this will provoke severe withdrawal symptoms. Meconium aspiration A recent large, multicentre, randomised trial has shown that vigorous babies born through meconium should be treated conservatively. The advice for babies with central nervous system depression and thick meconium staining of the liquor remains—that direct laryngoscopy should be carried out immediately after birth. If this shows meconium in the pharynx and trachea, the baby should be intubated immediately and suction applied directly to the tracheal tube, which should then be withdrawn. Provided the baby’s heart rate remains above 60 beats/min this procedure can be repeated until meconium is no longer recovered. Hypovolaemia Acute blood loss from the baby during delivery may complicate resuscitation. It is not always clear that the baby has bled, so it is important to consider this possibility in any baby who remains pale with rapid small-volume pulses after adequate gas The goal of all deliveries—a healthy new born baby. Most babies respond well to a Steve Percival/Science Photo Library bolus (20-25ml/kg) of an isotonic saline solution. It is rarely necessary to provide the baby with blood in the labour suite. Pre-term babies Further reading Babies with a gestation of more than 32 weeks do not differ ● International guidelines 2000 for cardiopulmonary resuscitation from full-term babies in their requirement for resuscitation. Part 11 At less than this gestation they may have a lower morbidity and neonatal resuscitation. International guidelines for neonatal policy of routine intubation for all babies with a gestation of resuscitation: an excerpt from the guidelines 2000 for less than 28 or 30 weeks leads to an improved outcome.

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If assessment methods rely solely on factual future practice tutoring process recall then PBL is unlikely to succeed in the curriculum order kamagra 50 mg with amex. All Integration—PBL facilitates an Other resources—Large numbers integrated core curriculum of students need access to assessment schedules should follow the basic principles of Motivation—PBL is fun for students the same library and testing the student in relation to the curriculum outcomes and and tutors order kamagra 100 mg visa, and the process computer resources should use an appropriate range of assessment methods. Tutors should give feedback or use formative or “Deep”learning—PBL fosters deep deprived access to a summative assessment procedures as dictated by the faculty learning (students interact with particular inspirational assessment schedule. It is also helpful to consider assessment of learning materials, relate teacher who in a traditional concepts to everyday activities, curriculum would deliver the group as a whole. The group should be encouraged to and improve their lectures to a large group reflect on its PBL performance including its adherence to the understanding) Information overload—Students process, communication skills, respect for others, and individual Constructivist approach—Students may be unsure how much contributions. Peer pressure in the group reduces the likelihood activate prior knowledge and self directed study to do and of students failing to keep up with workload, and the award of a build on existing conceptual what information is relevant group mark—added to each individual’s assessment schedule— knowledge frameworks and useful encourages students to achieve the generic goals associated with PBL. Conclusion PBL is an effective way of delivering medical education in a Further reading coherent, integrated programme and offers several advantages over traditional teaching methods. AMEE medical education guide number 15: problem-based learning: a practical guide. Med Teacher adult learning theory, including motivating the students, 1999;21:130-40. Effectiveness of problem-based learning them a role in decisions that affect their own learning. Problem based learning: why curricula are likely to panacea for teaching and learning in medicine, and it has show little effect on knowledge and clinical skills. Importantly, though, students from PBL curriculums seem to have better knowledge retention. PBL also generates a more stimulating and challenging educational environment, and the beneficial effects from the generic Christ and St John with Angels by Peter Paul Rubens is from the collection of attributes acquired through PBL should not be underestimated. When questioned, she said she was eating well but had of pain in his chest. One hour after the pain started On further questioning she admitted to feeling increasingly hot he collapsed and his colleagues called an ambulance. When he and shaky and to having muscle weakness in her legs, particularly arrived at the local accident and emergency department, Mr JB when climbing stairs. She was normally well and had not seen the was pale, sweaty, and in severe pain. Examination showed: A blood test showed the following results: Blood pressure 80/60 mm Hg Free thyroxine 49. She was treated with carbimazole and propranolol for streptokinase, he had a cardiac arrest. Electrocardiography the first month of treatment followed by carbimazole alone. Despite all efforts, resuscitation After discussing the therapeutic options, she opted to have failed. The scenario is complex for indications, mode of action, and potential side effects students with limited clinical experience. The faculty learning objectives Notes relate to public health and epidemiological aspects of ischaemic heart This scenario is part of a core endocrinology and metabolism module for disease. For increased impact, the faculty illustrated the case with a third year undergraduate medical students. Students would be unlikely to arrive at the same relate to the scenario; the problem is relevant to the level of study and objectives, probably concentrating on clinical aspects of acute myocardial integrates basic science with clinical medicine. The combination of basic infarction and its management science, clinical medicine, and therapeutics should lead to extensive discussion and broadly based self directed learning 11 4 Evaluation Jill Morrison Evaluation is an essential part of the educational process. The focus of evaluation is on local quality improvement and is analogous to clinical audit. Medical schools require evaluation as part of their quality assurance procedures, but the value of Purpose of evaluation evaluation is much greater than the provision of simple audit information. It provides evidence of how well students’ learning x To ensure teaching is meeting students’ learning needs objectives are being achieved and whether teaching standards x To identify areas where teaching can be improved x To inform the allocation of faculty resources are being maintained. Importantly, it also enables the x To provide feedback and encouragement for teachers curriculum to evolve. A medical curriculum should constantly x To support applications for promotion by teachers develop in response to the needs of students, institutions, and x To identify and articulate what is valued by medical schools society.

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It is for this reason that some written reports contain the recommendation section at the beginning of the report generic kamagra 100mg overnight delivery. In this section is set out a list of clear recommendations which have been developed from your research discount kamagra 100mg overnight delivery. Further Research It is useful in both academic reports and work-related re- ports to include a section which shows how the research can be continued. Perhaps some results are inconclusive, HOW TO REPORT YOUR FINDINGS/ 137 or perhaps the research has thrown up many more research questions which need to be addressed. It is useful to include this section because it shows that you are aware of the wider picture and that you are not trying to cover up something which you feel may be lacking from your own work. This includes all the literature to which you have referred in your report. A popular method is the Har- vard system which lists the authors’ surnames alphabeti- cally, followed by their initials, date of publication, title of book in italics, place of publication and publisher. If the reference is a journal article, the title of the article appears in inverted commas and the name of the journal appears in italics, followed by the volume number and pages of the article. Figure 5 pro- vides a section of a bibliography from a PhD thesis to il- lustrate this method. Bibliography Larger dissertations or theses will require both a reference section and a bibliography. As discussed above, the refer- ence section will include all those publications to which you have referred to in your report. If, however, you have read other work in relation to your research but not actu- ally referred to them when writing up your report, you might wish to include them in a bibliography. However, make sure they are still relevant to your work – including books to make your bibliography look longer and more impressive is a tactic which won’t impress examiners. Example list of references Appendices If you have constructed a questionnaire for your research, or produced an interview schedule or a code of ethics, it may be useful to include them in your report as an appen- HOW TO REPORT YOUR FINDINGS/ 139 dix. In general, appendices do not count towards your to- tal amount of words so it is a useful way of including ma- terial without taking up space that can be used for other information. However, do not try filling up your report with irrelevant appendices as this will not impress exam- iners. When including material you must make sure that it is relevant – ask yourself whether the examiner will gain a deeper understanding of your work by reading the appen- dix. Other information which could be included as an appendix are recruitment leaflets or letters; practical details about each research participant; sample transcripts (if permission has been sought); list of inter- view dates; relevant tables and graphs or charts which are too bulky for the main report. X It is obvious that ideas and sentences have been ta- ken from other sources. Most academic journals do not pay for ar- ticles they publish, but many professional or trade publi- cations do pay for your contribution, if published. However, competition can be fierce and your article will have to stand out from the crowd if you want to be suc- cessful. The following steps will help you to do this: X Choose a topical, original piece of research. X Do your market research – find out which journal pub- lishes articles in your subject area. X Check on submission guidelines – produce an article in the correct style and format and of the right length. X Read several copies of the journal to get an idea about the preferences of editors. X If you are thinking about writing for a trade publica- tion, approach the editors by letter, asking if they might be interested in an article. X Produce a succinct, clear, interesting and well-written article – ask friends, tutors or colleagues to read it and provide comments. X Make sure there are no mistakes, remembering to check the bibliography. X If it is your first article, gain advice from someone who has had work published. Also you might find it easier to write an article with someone else – some tutors or HOW TO REPORT YOUR FINDINGS/ 141 supervisors will be willing to do this as it helps their publication record if their name appears on another article. You may find that you will do most of the work, but it is very useful to have someone read your article and change sections which do not work or read well.

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