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Hi guys, thank you for joining. Um, I hope you guys hear me. All right. Um, can you let me know maybe time into the chat if you can hear me? Ok. Um, I think we are going to it for, um, a few more minutes because they even actually start at 630. So just a few more minutes to see if, um, anyone, um, else going to join and then we will start. Ok. So just go grab your drinks. Um, yeah, then we'll start in a few minutes. Ok. Right. I think we'll make a start. Um, so we don't delay decision any further. So, hi, my name is Pat. I'm one of the fy one, at Saint James Hospital in Leeds. Uh, I'm doing, um, psychiatry at the moment, but I've done my first and the second rotation in gastroenterology and also general surgery. So, um, but as you can see, I'm trying, I'm hoping to cover, um, like the basics, um, of cardiac arrest, including how do you manage the situation. Um, what do you need to know, um, and what you can do during this, um, cardiac arrest situations. So, um, I just wanted to know um a little bit about the back of you guys. Are you guys um medical students or you guys also a validation training doctor? So, um if you would like to share your back and you can type into the um checkbox or you can um just unmute yourself. Ok. So I'm not sure if any of you guys uh um uh do need a doctor or an if one but uh so as you might know, some of us would need to carry like a crash beat um during our own calls and then that, that's when we will be called to any cardiac arrest or any crash call in the hospital. So it's important to have some basic understanding about um cardiac arrest um and what you can do to help in that situations. So, um I will try to base this um teaching on my um experience. So I'll use the, I'll start with AC which is actually based on um the um situation that I have faced during my own call and then we'll discuss about what we want to do. Um what we think would be useful um If we are a doctor, um basically, if we are facing that situations, ok. So the thing is that it's a, it's um 6 a.m. in the morning and you were on night shift, you were about to finish, but then you got a crash, a crash bleed. Um It went off and then you need to go and see um a, a gentleman in a different ward, in an on quality ward. You do not know about this patient. And when you got there, you were um the first few person who arrived and the patient was unresponsive. So the nurse um in charge told you that he um has a backup metastatic prostate cancer um and also anemic. So he was admitted because he um was confused and was quite unwell. He's then being treated with the IV antibiotics for UTI. So throughout the night, he was quite unwell with fever. And then the nurse actually found out that um he has become unresponsive this morning. So you, you saw the other two doctors who was, who were, who were there and one of them um uh fy two and another one is fy one doctors, you know, that more help is on the way because that's how it is when the crash bleed went off. So, in this case, um what can you do? What would you start doing first? Would you just, would you start um um dumping up on this pa patient's chest right away? Ok. Right. So, um I think, well, jumping starting CPR right away is probably um not uh probably not a, it's probably not a bad decision, but I think there is a few steps that we need to do to start before we starting CPR. And I think one of the most important thing is that you need to confirm that this patient um have cardiac arrest. So if you start um CPR right away and if the patient is not in c arrest, you will be able to tell because the patient will probably just push you away or because it's quite painful and invasive for them. So before you start doing that, you should check for the response, he can approach the patient and then ask uh how is he feeling? Um So it's likely that he will not respond to you and then you will start to assess for sigh of life with the look fee. Look, listen and feel. So you will look for any chest um movement, any listen for any breathing and then feel for the carotid ps. All of this will help you to con confirm um whether the patient has any signs of life, but you should not take longer than 10 seconds to do this because you want to basically start CPR as soon as possible. So if you can't find, if you don't see um any normal breathing pattern, you can't feel for carotic ps, you should confirm cardiac arrest right away. Ok? So after you confirm cardiac arrest and you know that the nurses are calling out for help, then um the next thing that you sorry. Ok. Then the next thing that you should do is you should confirm um the respect form whether they are in place. And um also the DNA CPR form, whether this patient is um DN ACP or not before starting the CPR. But this should not take too long. I think it, most of the time it, it is quite easily accessible and the nurse in charge should be able to tell you about this. So, if the patient, unfortunately, this patient did not have DNA CPR. So um we start, we start that CPR right away. Ok. So um have you done a CPR before? Have any of you done a CPR before or do you guys know how to do it? I think if you have done um before, you would know that it's basically not um it's basically an unpleasant experience to um the patient and also to us as well. Um So this is how you do CPR, right? You form the hand movement like this and then you basically press, use the palm of your hand to press on the at the center of the patient chest around um 5 to 6 centimeter depth. Oops, yeah, five centimeter depth and then at the rate of 100 to 120 compression per minute, right? Um And you should minimize any interruption to chest compression as much as possible because this is um the only way to um facilitate the high quality of the um chest compression. Ok? I can see in the response that um some of you have done and some of you have not, if you have done it. You probably would know that this is really un present for the person who's performing it. Um, for me, when I was doing it, I could feel it. I have cracks, um, some ribs and, um, it's really feel unpleasant to be doing that. Um, but yeah, you should, like I said before, the part just to keep, continue, just continue doing it. Um, do you know how long you should be doing the CPR before another person should swab with you? Any ideas? Has anyone done it for quite a long time? If you have done it, if you have done it, you would know that it's actually quite tiring. Um, although it's probably quite, um, you're probably quite under a lot of stress and you probably have a lot of adrenaline but to, to, to do like, um CPR for like five minutes straight is actually very, very tiring. So how we are supposed to do is it actually we're supposed to do two cycle of CPR? So, meaning 3030 compression and then two breath, another 30 compression and two, and then you should change to a different person to ensure that that person take a break and then ensure that patient continue to continuously have the high quality CPR. Ok. So, um, now one of the person in the team have arrived has gone to do the CPR. What do you think is the next thing we should do at this point? I think we probably would need to check the airway, aren't we? So, um, the thing, the reasons for us to check the airway is because, um, patient might have any obstruction. Um, do you, do you know any size of airway obstruction? What do you think? How would you tell that this patient might have airway obstruction? It might be compromising his breathing. Yeah, I think that would be um, some size that you can definitely um tell that this patient is in um that's this patient is having a obstruction. So this include um Stridor. So Stridor is a really high pit. Yeah, choking noises. Yep. Um So Stridor is basically um like a high ptch voice. That's um basically indicate that patient have an upper airway obstruction. Uh You can also hear wheeze some patient has a really, um quite obvious wheeze that you can hear this, this indicate of more like a lower airway obstruction. Gurgling is um, can tell that this patient probably have some kind of liquid um at the um blocking the airway. Yeah. Yeah, it's very stable and um another, another one is snoring. So snoring is um basically um indicated that might be something blocking the lulling is most commonly is the, is the tongue which cause the airways to, to be obstructed and compromise the breathing. Ok. So now that you, let's, if, now you have access for this side um, airway obstruction. So if you see that there's anything that could block the airway. What do you think you could do? How, how can you remove all this um, thing that might be blocking the airway? Ok. So you can do a suction. So what you can do is um basically that will be a suction um, equipment in the trash uh sorry, in the crash um trolley. Yeah. So, um how you need, you would need to do this ideally is to shine a torch light down the amount and then insert the suction if you can see the suction device um until the back of the throat and try and try to suck, basically suck all the liquids at the um upper airway. Um be careful. The reasons why I said use to tosh light is because you should not put the suction way too dull. If you put it way too dull and um it, which is on the tech here, then it could basically cause the airway collapse or could cause the broncho spasm. And then patient could actually go to respiratory arrest, which you would not want that in the patient who is already um ha not having any signs of life and and of life and probably have um um compromised breathing. So just make sure that you have suck uh all the liquid or any content that's probably blocking the airway. Ok. So now you have to remove any liquid that might be blocking the airway. How would you maintain the airway? How would you protect the airway to keep it pa patent? Is that an easy maneuver? I'm sure you guys heard about this maneuver before the maneuver that you can easily do to keep the airway open. Have you guys heard about her two and chin lift? Yep. So this is basically how to do her tooth and she is. Yeah, feel safe. Thank you. So, head tilt, she left. Yeah. So how you do it is basically you can put one of your hand onto the patient for head and then lift up the shin. So how it is if you can see in the pictures um in these pictures, the tongue, it's basically blocking the airway. So how to, oh sorry. So how you remove the tongue is basically you tilt the forehead and then lift up the shin in this way, you kind of um pull the tongue back and um prevent it from blocking the airway. Ok. Another matter what you can do is also um jaw thrush ru. So how you do this is basically um just applying some force to put, to basically push the jaw upwards to keep the airway open and keep the tongue away from the airway. So you would choose to do this in a patient who have a hi who have high risk of um cervical spine injury. So how, how would you tell? Do you have any idea how you can tell whether this patient has um cervical spine injury. So ideally, I think it would be quite difficult. We can't really always tell. But um obviously, if you think that patient basically become have cardiac arrest after having a fall or you've, or like having some trauma injury. Yes. Um tha right. So if that, if patient basically have any involvement of falls or trauma or um if you can see that there's a bleeding from the head or somewhere that could indicate that patient has fall, um that would um raise your suspicion that this patient probably have um cervical spine injury and you might want to choose to do Tetras instead of the head to and you lift. Ok. So what else can you do to protect the airway? I don't think you want to um keep this, I don't think you want to keep this um position throughout your whole resuscitation. Am I right? There's always um some uh equipment you can use to maintain the airway. It is probably more effective than you doing than you're doing the um head tilting to live or as well. So, um, right. Have you guys seen this one or have you guys used this one before? It's one of the airway a advances to help to protect the airway. So, um this is called Goodell, I think you probably have heard of that or it is uh oral pharyngeal airway. Have you guys seen it in the hospital or maybe in uni Yes, thank you to safe airways is and basically all it, all this device that you can use to keep the airway open. So good. That is one of them, how you basically use it is that it's come in different size from a small to um, a bigger one. You can actually just um, tell the size by just seeing it. Like if it's a small person. Um, you can use the green one. If it's like a big person, you can probably go to orange or eight. OK. So how you basically inserted? This is that you insert it in the way in ups upside down manner. So this is how it is inserted. So when this is in, then you can twist, twist it back so that it's basically um hover over the tongue and push the tongue out of the airway like in this pictus. OK. And then um do you guys know any other type of airway advance the one that we see quite often? Have you guys seen the nasal phalangeal tube? So, yeah, this is um nasopharyngeal tube or NP. How it work is that um you, it's a plastic tube that's quite flexible. And then you put the daily at the jelly at the tip of the, the tube and then insert it um um into the nostril all the way down this airway. This um the basically this tube will help to keep um the airway part in and then push the tongue away. So um when do you think you used the NPA or when you used the Goodell, what is the difference? You can imagine that it's probably would be, would not be very nice to use to have a good L inserted, isn't it? It's probably going to cause somebody to gag. Um So, yes, how we use it is basically we use the Goodell in an un unconscious patient. So um because if you use this in a patient who might be semiconscious, like, let's say if they just have confusion or they still respond to pain or respond to voices, um then you can use um then you shouldn't, you should not use the gel because you might trigger the gap reflex and then causing the vomit to come up and then that would basically compromise the airway and blocking the airway, isn't it? So, in the patient who is still having some sort of um consciousness um or responding to any stimulus, then I think we would need to use the NASO GS, the nasogastric tube uh sorry, the nasal functional airway. Um And in the unconscious patient, we can proceed and use oral f airway. OK. So just have a question. Can we insert NPA in any nostril? Um So basically, we recommend to use the right nose because the right nostril is um is bigger than the left in mo in like most of the people. But to be honest, it's, it's not a rule and it's actually doesn't affect um patient care. So um just use whichever no nostril that is um easier to be inserted. However, just remember that um having those nasal fall into airway inserted into the nostril can actually cause bleeding, especially in patient with nasal polyps. So if even though it's like a really flexible soft tube, it can um kind of scratch the nasal polyp or even um take it off. So if it could basically cause the bleeding from the nasal polyp, and that would not be ideal because we're trying to protect the airway. So if you notice that you basically need to do suction and then we probably need to change um the airway management. Ok. Right. Um So now we know the difference when we should use um NPA when we should use good. Now, so after we inserted all these airway at to in, we need to, we have protected the airway. So now we need to keep patient oxygen, make sure that he has um ventilation, effective ventilation. So we can use one of the type of the um mask to put, to give the oxygen. This type is called bile mask. I'm not sure if you have seen it in the hospital. This type of mask is actually quite common. So how you actually give the oxygen is basically you found a TCU um like you can see in this pictus, you use the mask to form a tie shoes to the face. Um So a lot of time we recommend people to use two hand technique. So um you would basically use both of your hand to grab hold of the mask and the face to make sure that it format you and then there's no air leaking. However, um but this procedure, you would need two people to do it. So if you are confident that you can just use one hand um to Pharma, you, you can go for that or if you don't have enough people to help, you can go with um just one hand to Pharma you as well. Ok. So, um yeah, so instead of this back wall mask, um ventilation, that's another way that we can form. Um, we can basically use the effective ventilation by inserting the s glottic airway. And I think you might have seen this in the hospital before. Um The one that's commonly seen is green, it's like a green yell green jelly at the tip instead of yellow in this pictures. Um So how it work is that you inserted it through the mouth and then um this this green bit or yellow bit. Uh the jelly will basically sit in front of the L link and then keep the airway patent. So, um then you connect it to the oxygen and then we just um ventilate the lung. I think this is one of the very effective way um to um ventilate the patient. That's another way that you can do as well is by intubation. However, for um to do the um track care in intubation, you would need um to have the skills to do it. Basically, you need to train and you need to, you need to be trained. Um and a lot of time it is quite difficult if the if um the patient is undergoing CPR and you need to insert the, the um intubation tube. So um in this way, slo the airway is a lot easier to be inserted while patient is um having CPR consta continuously. OK. Any question at this point? OK. I think that's no questions, then we're gonna move on. Um So now we have um started CPR, we have protected the airway. What what should we do next? Should we shock the patient? Have you guys seen like in Grey's anatomy or like in all those medical movie where you shock the patient? Should we do that? We'll probably can't do that do that until we um assess the cardiac rhythm and we not all the cardiac arrest rhythm is shockable. So you need to basically assess the cardiac rhythm first before you decide whether you want to um keep a patient a shock or not. So this can be done by using the defibrillator. This is the automated um external defibrillator. If you can see the yellow machine, yellow green machine here it is very easy to use. Um It would tell you where to attach the patch. But basically, um it's at the anterior chest ball on the right. And another one at the um mid axillary, right on the left, that is um the way to attach the patch. And there's another way so that you can do if the patient, let's say, have a pacemaker inserted and you don't want to give a patient a shock right at the pacemaker, because this can um damage the device, then you can put both uh um you can put um both patch at the literal size of the patient. Um Another one is you can put on the left anterior chest wall and one at the back. OK. So, um yeah, this when once you attach this patch on onto the patient, then the defibrillator would um assess the cardiac rhythm. So this is when we will be able to tell whether we should check this patient or not. So, yeah, there are two type of cardiac rhythm. The machine will be able to tell you that this is a shockable rhythm or unshockable rhythm. So far shockable rhythm. Um The two type that's a v fibrillation is the first one and another one is pulseless ventricular tachycardia. I would go to um each of one e each of this and then tell you how it looked like in a bit. OK. So another type is a non shockable rhythm. So it is powerless electrical activity. It's one of them and another one is a assist. Ok. So, um let's see how the, how each of them look like, right? So this is ventricular fibrillation, as I said, it's a shockable rhythm. So what happened in this um this uh this um kind of rhythm is that the, the ventricle, the ventricular muscle is depolarizing randomly, meaning that it's basically pumping at the random um pace. So, ho how, how um the ECG would look like in this um uh cardiac rhythm is that it would be quite bizarre. You would not be able to make out the rate. Um And it's it as it will look quite irregular. Um And then the amli the amplitude, so like the high of the, of the rhythm and also the frequency would be quite V as well. So if this case happened, you would be able to tell that, oh, this is the patient is in VF and this is a shockable rhythm. So the machine would go on and tell you it, it will go on and tell you that um advised shock. That's when you know that you would, this patient will probably need a shock. Ok. So another type of um cable rhythm that we have talked about is ventricular tachycardia. So what happened in this situation is that the ventricle depolarized at a really quick um speed. So it's depolarized, meaning that it's contract um regularly, but in very, very quick speed. So it does not allow um enough time for blood to be filled into the heart before it's pump out blood again. So this can cause basically a loss in cardiac output and would put patient into cardiac arrest. So how ecg um would show in patient who have ventricular tachycardia is that um you will see a really broad complex and then patient will ha um and then is um basically, and then patient will be in tachycardia. So you can see that um the heart rate is quite quick. It's really quick here, isn't it? Yeah. So that's when you can tell the patient had has ventricular tachycardia and um this is um shockable rhythm. So the machine would advise you to shock the patient. Ok. So now we have talked about a shockable rhythm and we'll move on to the non shockable rhythm. So, do you guys remember what is in the non shockable rhythm? Ok. So one of them is oops, yeah, is um a cysto, right? This is looking like a flat line, which is essentially a flat line. Um because um in patients who have a cysto, the patient heart is basically not pumping. So um there is no yeah assist though. Thank you, Joseph. Um So in um in basically, in this case, it's that um patient atrium and wino are not pumping, there's no electrical activity at all. So that's why the ECT machine does not detect any electrical activity and it would show a flat line. Um Right. Another one is the other one that we talk about is the pulseless electrical activity. So you guys are wondering why I do not have a picture for this. Um uh for this um, d it's not because I'm, I'm lazy and I just can't be bothered to show you guys the pictures. But it's because um, in pu in p less um electrical activity, um we do not use it to refer to like a specific card rhythm. Um patient might still have a cardiac rhythm but we just can't feel any pulse. So basically, it's defined as um a clinical absence of cardiac output despite having an electrical activity. So the heart might be pumping but it is too weak to cause any cardiac output. Um So there's no um ec D like basically, sorry. So there's no pulse even though patient is having um electrical activity. So this is when we classify patient as having pless electrical activity. Um And this is a non um a nonshockable rhythm. So um the machine would tell, will tell you to continue CPR and would not advise shock. OK. So um now we basically have we have gone through um different type of cardiac rhythm. I just wanted to show you guys um this algorithm from um the um UK I feel like this is a very useful um algorithm has basically summarize everything we are talking about um in this diagram. So what we have ha what have happened to us be um so far is that we went in, we saw a patient who was unresponsive, no breathing, um no signs of life. Um You, one of us have started CPR um and uh we also have attach d defibrillator. It has assessed the rhythm. If the patient is in shockable rhythm, then we would, the machine would say advised shock, then you would ask everyone to stay away and then we would deliver shock. After that, we would continue our second um cycle of CPR for two minutes. After each cycle of CPR, we would need to um stop and then assess the cardiac rhythm using the, using the defibrillator. So um if the second time the in the after the second cycle, if the rhythm is still um remain shockable, meaning that it's still either VF or PVT, we would give a shock and then continue the third um cycle of CPR like two minutes. CPR. In the third cycle, we would normally also give um IV Adeline for um 1 mg. So um then we would, if it's still remaining shockable um written and then we could give um IV adrenaline again um every 3 to 5 minutes so that it's around every alternative um two minutes CPR cycle. So you would give it in the third cycle and then again, around the fifth cycle if patient remain in the shockable rhythm. However, um patient can always um flop from the shockable rhythm to the non shockable rhythm at any point. So you need that is, that's why it's important to assess the rhythm after every two minutes cycle of CPR. Because if the patient turn from VF, which is a shockable rhythm to the assist, though, which is a nonshockable rhythm, the machine would not advise to shock and you would just need to continue with CPR. So in the case that the patient started off with um uh nonshockable rhythm or um let's say, um pe you would manage patient by um continue CPR for two minutes. And then um you would give IV adrenaline 1 mg as soon as um you have the IV access and then again, you can give another IV um adrenaline every 3 to 5 minutes or every alternative cycle. Um And then you need to continue assessing the cardiac rhythm. When do you guys think we would stop? Um the CPR, we would stop the whole resuscitation process. You guys have any ideas if you guys have been to the cardiac arrest um before uh do you know when did they stop the, the resuscitation process? So, ideally, I don't think that is like a specific time that they stop the resuscitation process. Um The medical team would need to assess the situation, assess patient back down and then um decide to make a decision to stop the resuscitation process. However, um from um what it was told in the I in the um research UK um website is that you can, if the patient remain in the shockable rhythm or you can identify any reversible cause of the cardiac arrest, then it's worthwhile doing the, continue doing the CPR. Ok. So, right, so now should we go on and then um see what could be this reversible cause of the cardiac arrest? Do you guys have, do you guys have a clue about this? Do, do you know what could be the cause of the um could be a reversible cause of cardiac arrest? Do you guys have, have you guys heard about thing called 4h and four tea? That is basically how we um remember the irreversible, oh, sorry, this is just um a slide that talk about what I um ha what I told you before about when to check um the when to keep the a adrenaline in the shockable rhythm and um what to do in the non shockable rhythm where you can um shock the patient? Ok. So, right, I just wanted to remind you the priority of basically continuing to continue um CPR with and minimize any hand of time as much as possible. This is the main priority that you need to um mm basically make sure that it happened during the cardiac arrest. Just continue doing CPAP. Make sure that um that um patient has the high quality CPR because this really increase the chance of um patients surviving cardiac arrest. Ok. So um let's come back to um this basically this is the picture I inserted this wanted you guys to um uh basically have an idea about how it looked like during the cardiac arrest arrest call. So, um for those of you guys who have been to the um crash call, you would know how chaotic it is. Um But the idea basically the, the, the structure of this cardiac um for for this crash call is that you would need to have one person who is the leader of the team. So this person will not do anything, they will not um put their hand on the patient. Um He, they, he would just um observe um the overall situations and then um basically just have the, the overall pictures of what's going on and then provide the guidance to whoever that is um having the hands on the patient. So you can see this is, this guy is likely to be a leader. Mm I have uh a situation I've heard about a situation where if one has become a leader of the cardiac um of the crash car before which um is understandable because in a lot of time, uh junior doctors including if one would um be the first few person who arrive at the scene because um with the seniors, the consultant, other registrar, um they are, they can be, they probably are more busy and obviously they would try to leave right away to come to the crash hall, but it would probably be um easier and quicker for the F one to get to the scene. So in that time, you could leave um the resuscitation process until um you feel that that is someone who is probably have more experience or probably are more confident to take over. Or you, if you are confident enough, you can actually just continue with you. If you feel like you're doing well, you can just continue leading the resuscitation process. OK? So um yeah, you need to also have one person mana managing the airway. So you can see this guy is basically managing the airway. Another um person is doing a CPR, another person is trying to get um IV access and also blocks and um one person could get all the equipment. Um what she is holding in this picture is the um IV adrenaline to be given. OK? In, in this picture, I assume that this lady is probably there to observe and then scribe. So um in the category ever um uh situation, you would need to have one person to um scribe about um what happened at what time. And then um after the cardiac arrest arrest call, we normally have a debrief. So that's when we will um discuss about what happened. Um What, how can we improve in the next um cardiac arrest. Ok. So, yep, we have um done the CPR, we have managed the airway, we have assessed the rhythm and we, we have um identify and we need to now identify and treat the reversible causes. So, um like TAA has put into the chart that um the way to remember the um reversible cause is H and T. So that's right. Um The easy way to remember all these the causes is 4h and four Ts. So um 4h you can see in this picture stands for hypoxia, hypothermia, hyperkalemia or electrolytes, imbalance and hypovolemia. And for 40 there's a cardiac temp, not um pulmonary or Coron coronary, thrombosis, tension, pneumothorax, and then toxin. Ok. Shall we go through each of these in a bit more detail? So, hypoxia is basically um obviously, when you, when the patient don't have enough oxygen. So during the resuscitation, you just need to ensure that patient has effective airway management and ventilation. Um And then you could identify the cause of hypoxia, which could be um could be anything, could be COPD, could be um chest infection, um could be our way obstruction and then you can treat the cause if possible. Ok. The next one is hypovolemia. So the one, the one of the very common cause of hypovolemia is basically severe bleeding. It could be from the trauma. So the patient might basically um get be involved in the trauma and then has lost a lot of blood causing the BP to go really low. Another one is gi bleed, which is also quite common and also in the aortic aneurysm. So, in this patient who have cardiac arrest from having hypovolemia. Um you can treat it by um giving the IV fluids and trying to um Reuss the patient and increase the blood pressures. Ok. Another one is the um hypokalemia, hypo hypo hypokalemia, hypokalemia and also hypocalcemia. So, basically, it's um any source of electrolyte imbalance really. So as you know, ec electrolyte imbalance can um increase the risks of patient um having arrhythmia and that could lead to patient um end up in cardiac arrest. So, um you can tell this by having a look at the recent blood um or you can run a quick ABD. And another thing you can do is if you can tell from the past medical history. So let's say like, for example, if the patient um has renal failure, you could probably um raise your suspicion that um you um basically electrolyte inland is the cause of the cardiac arrest. OK. And the last one of the fourish is hypo hypothermia. So you can check patient temperature. And then um you can basically, if you found that patient is in hypotonia, then you can treat the patient, you know, by trying to um increase the body temperature slowly. OK. So let's move on to 40. So, um yeah, um like we discussed, so um the first t is thrombosis. So it can be coronary, thrombosis or pulmonary thrombosis or pe. So in cor coronary thrombosis, I understand it would be quite hard to manage in the cardiac oration. That is because um because of the facility that we have basically. So if you are in the hospital that um PC or um cardiac surgery is feasible, then you probably could do coronary, um could basically could treat the coronary thrombosis um during ongoing CPR um for um pulmonary embolism. Um you basically could give the patient thrombolytic agent immediately to dissolve all that clot in the lungs. Ok. Another one is tension pneumothorax. So tension pneumo is basically where there is at um inside of the lung. And that's basically pushed um the lung all the way to the other side is um compress um the lung. So that basically lung can, can't really be filled up with air. So the way to treat it is that you can um insert the um you can aspirate the lung to get the air out and then um using the needles, a long needle to insert into um the lung to remove the air. And another type that you can do is you can insert the chest strain and keep the drain in to remove the lung. Ok. Um Yeah, the next cause is cardiac TPO not. So this would be um you would basically think about this cause if patient, if there is anything that you think could cause um bleeding from the heart. So basically, if the patient has been to cardiac surgery or have any trauma, so it was, this would basically um raise your suspicion that patient might be in cardiac tympanal. And you, if the patient is in cardiac tym, not, then you can um use the needle um to insert into the pa pericardium space to get ba basically to aspirate all the bloods out. Um and allow the heart to remove the pressure from the heart and then allow the heart to breathe again. It will pump again. Ok? And the last one it's toxin. So, um this can be anything, it can be um from the allergic reaction to all the drugs or patient can be taking overdose. So, um if you sus if you suspect that a patient might um develop cardiac arrest from toxin, then you should also review patient drug chart for any allergy and the history of overdose. Ok. Do you guys have any questions at this point? I think we have gone to through um the basics of um um what would you do? How would you approach the patient? How you confirm the cardiac arrest? Um How would you start? Um CPR, how can you perform CPR, how do we protect the airway and ventilate the patient effectively? And then um how do we assess the cardiac rhythm? And also um how do we um when do we sh give the patient a shock? And when uh when do we not? Um and how do we identify the reversible cause of um cardiac arrest? So, shall we go back to our scenario. So back to um the C you guys have started the CPR, you have put in the ideal or the supraglottic airway in if you remember is the, the yellow, the one that has the yellow bit at the tip and then you connected to it to the oxygen and you have ventilated the patient. Um You put in the defibrillator and analyze the cardiac rhythm and it show that patient is in a system. Can you shock a patient if the patient is in a system? You guys remember what are the shockable and non shockable rhythm? So, unshockable rhythm is VF and um powerless VT, right? So, ventricular fibrillation and pless ventricular tachycardia, sh um nonshockable rhythm is assist and pe ap electrical activity. So, um in this case, because this patient um remain in assist, we were not able to shock the patient. So what we do is that we just continue CPR and then continue to um and give IV ANA and just continue to assess the rhythm. This patient remained in a CTO two out. So we went to um four and 4h, but unfortunately, we could not find any reversible cause of cardiac arrest and then we continue the CPAP for five cycles. And then the medical team decided to stop resuscitation for this patient. So this patient basically um did not um survive the resuscitation. So, unfortunately, this is what happened quite a lot in um patient who have CPR. You can see that the success rate is quite low. So, um I've been to quite a few uh crash call now. Um the one that is a, actually is a true cardiac arrest, um that is not peri arrest. Um Most of them end up not. So I think, but this doesn't mean that you should not do CPR or you. Um Basically, I also have seen quite a few patient who told me that um they have cardiac arrest two months ago and they look quite well now or some of the patient basically had like survived two episodes of cardiac arrest. So um although the rate is quite low, some of the patient do survive it. So that's why um it is important to um have the effective um high quality CPR and airway management. OK. Right. Enough of the um depressing talk, I I would just wanted to remind you guys about this um guideline. Again, it is very useful to summa summarize um the basic uh information about what you need to do in cardiac arrest. So I heard that some of the cardiac, like some of the trolley, if you can, if you know what it is, it's like the red to tolerate with like um four draws with ABCD that thing. So um I was told that some of in some, that's these guidelines in some of it. But um uh if not, then I think you should, you should basically um remember this guideline cause I think it would be very handy um in the cataract risk. Ok. So have you guys um been to any cardiac arrest called that you think that, that you've, you has a different outcome or do you guys, have you guys done any cardiac arrest? I'm not sure in medical school. Do you get to see cardiac arrest? I got to see one true cardiac arrest in my, in my fifth year I think. Yeah, that was the first true cardiac arrest that I've seen. Um and the outcome was the same as this case, this patient did not um did did not survive the the resuscitation process. Um But what I saw at that time is that they do have the automatic CPR machine. I don't know if you guys seen this, but it's basically, it's a machine that you put on patients here and is provide a really effective and also quite um intense CPR. Um so that the spot does not need to do it. OK. So um this is just the reference that uh I've used um in decisions, I've also recently done my um I OS um training as well. So if you guys want to know more about cardiac arrest, which I think is important because you would definitely have one, you would definitely have been called to the, to the cardiac arrest and you probably need to do um some of the maneuver um during the, the the resuscitation process. So it would be very handy if you basically have some training if you um or you have a read about, about it. So, um yeah, I would recommend to do to basically sign up for the um I OS training. If you guys are one of the medics or you guys are about to be um an F one soon, it will be very useful. Ok. Um Do you guys have any questions? Anything you guys want to share about any traumatic or not traumatic, maybe maybe any kind of um crash call you have been to. Well, if not, then thank you very much. Um I appreciate you guys time for attending these sessions um and also answering some of the question as well. Um I hope that is that um decision is useful. Um And it's probably give you some of the ideas about what you need to do if you um if you basically are being called to a crash or you have a patient on the ward who um go into the crash. Um Yeah. So um thank you for your time. Please complete the feedback form. I think it's on the feedback tab. Um If you complete that, uh we will send you a certificate of attendance um afterwards and this session I think would be reco it is recorded and it would be uploaded on our website. So if you guys wanna revisit or wanna check out a slide, then um you can always um revisit this um I'm doing another teaching um probably next week about common A to e situations. So, um I will use it mostly based on my own experience about the ale and real patient. I've seen um in my f one year and uh how did I perform a and um what happened during that situations? So, if you guys are interested then um it would be around the same time on Wednesday, 630 to 730. Um So just feel free to joy. It will be on mid all again. Ok. So thank you very much you guys. I hope you enjoy decision and have a good evening. Bye.