RC (UK)

RESUSCITATION COUNCIL (UK) RESUSCITATION COUNCIL

(QAT)

ADVANCED LIFE SUPPORT

2/15/2003 , 1

INTRODUCTION

Dr.Montaser IsmailMRCP, Arab Board of Cardiology

RC (UK)

Cardiovascular Disease

• In Europe cardiovascular disease accounts for 40% of all deaths < 75 yrs

• In QAT cardiovascular disease accounts for 29% of all deaths all ages.

• One third of all people developing an MI die before reaching hospital

• Presenting rhythm in most of these cases is VF/VT

• In-hospital cardiac arrest more likely non-VF/VT

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Chain of Survival

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CAUSES AND PREVENTION OF CARDIORESPIRATORY

ARREST

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Causes of cardiorespiratory arrest 1. Airway obstruction

• CNS depression • Blood, vomit, foreign body• Trauma• Infection, inflammation• Laryngospasm• Bronchospasm

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Causes of cardiorespiratory arrest 2. Breathing inadequacy

• Decreased respiratory drive– CNS depression

• Decreased respiratory effort– neurological lesion– muscle weakness– restrictive chest defect

• Pulmonary disorders– pneumothorax, lung pathology

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Causes of cardiorespiratory arrest 3. Cardiac abnormalities

Primary• Ischaemia• Myocardial infarction• Hypertensive heart disease• Valve disease• Drugs• Electrolyte abnormalities

Secondary• Asphyxia• Hypoxaemia• Blood loss• Septic shock

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Recognition of patients at risk

• History, examination, investigations• Clinical indicators of deterioration before in-hospital cardiac arrest in

80%–tachypnoea–tachycardia–hypotension–reduced conscious level

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Medical Emergency Team (MET) Calling Criteria

• Airway -threatened• Breathing

– Respiratory arrest– RR < 5 or RR >36

• Circulation– cardiac arrest– PR < 40 or PR >140– Systolic BP < 90

• Neurology

– sudden fall in GCS > 2

• Any other worries

RR = respiratory rate

PR = pulse rate

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Airway obstruction

Symptoms and signs• Difficulty breathing,

distressed, choking• Shortness of breath• Stridor, wheeze, gurgling • See-saw respiratory pattern

Actions• Suction, positioning• BLS manoeuvres• Advanced airway

intervention

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Breathing inadequacy

Symptoms and signs• Short of breath, anxious,

irritable• Decrease in conscious level• Tachypnoea• Cyanosis

Action

• Oxygen

• Ventilatory support

• Treat underlying cause where possible

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Cardiac abnormalities:Acute Coronary Syndromes

Clinical syndromes form spectrum of the same disease process:

Unstable angina

Non-Q wave myocardial infarction

Q wave myocardial infarction12

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Immediate treatment in all acute coronary syndromes

• “MONA”

–Morphine (or diamorphine)

–Oxygen

–Nitroglycerine (GTN spray or tablet)

–Aspirin 300 mg orally (crushed/chewed)

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Patients with ST segment elevation MI or MI with LBBB

Early coronary reperfusion therapy:• Thrombolytic therapy

– streptokinase

– alteplase

• Percutaneous transluminal coronary angioplasty (PTCA)• Coronary artery bypass surgery (CABG)

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CARDIAC MONITORING &

RHYTHM RECOGNITION

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Which patients?• Cardiac arrest or other important

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

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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

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How to monitor the ECG (2):Defibrillator paddles

• Suitable for “quick-look”

• Movement artefact

• Risk of spurious asystole

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

• “Hands-free” monitoring and defibrillation

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12-lead ECG

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12-lead ECG

• 3D electrical activity from heart

• More sophisticated ECG interpretation

• ST segment analysis

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• Depolarisation initiated in SA node

• Slow conduction through AV node

• Rapid conduction through Purkinje fibres

Basic electrocardiography (1)

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Basic electrocardiography (2)

• P wave = atrial depolarisation

• QRS = ventricular depolarisation (< 0.12 s)

• T wave = ventricular repolarisation

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How to read a rhythm strip

1. 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?

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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

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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

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Is the QRS rhythm regular or irregular?

• Unclear at rapid heart rates

• Compare R-R intervals

• Irregularly irregular = AF

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Is the QRS width normal or prolonged?

• Normal QRS:

–< 0.12 s (< 3 small squares)

–originates from above bifurcation of bundle of His

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• Prolonged QRS (> 0.12 s) arises from:

–ventricular myocardium, or

–supraventricular with aberrant conduction

Is the QRS width normal or prolonged?

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A broad complex tachycardia should be assumed to be

ventricular in origin unless there is a very good reason to suspect

otherwise.

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Is atrial activity present?

• P waves (leads II and V1)

• Rate, regularity, morphology

• Flutter waves

• Atrial activity may be revealed by slowing QRS rate with adenosine

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How is atrial activity related to ventricular activity?

• Consistent, fixed PR interval

• Variable, but recognisable pattern

• No relationship - atrioventricular dissociation

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Heart Block: First Degree

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Heart Block: Second DegreeMöbitz Type I (Wenckebach) Block

Möbitz Type II Block

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Heart Block: Third Degree

• Site of pacemaker:– AV node 40 - 50 min-1

– Ventricular myocardium 30 - 40 min-1

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DEFIBRILLATION

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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

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Defibrillation

Success depends on delivery of current to the myocardium

Current flow depends upon:

• Electrode position

• Transthoracic impedance

• Energy delivered

• Body size

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Transthoracic Impedance

Dependent upon:

• Electrode size

• Electrode/skin interface

• Contact pressure

• Phase of respiration

• Sequential shocks

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Manual Defibrillation

Relies upon:

• Operator recognition of ECG rhythm

• Operator charging machine and delivering shock

• Can be used for synchronised cardioversion

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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

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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

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Automated external defibrillators• Analyse cardiac

rhythm• Prepare for shock

delivery• Specificity for

recognition of shockable rhythm close to 100%

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Automated external defibrillators

Advantages:

• Less training required

–no need for ECG interpretation

• Suitable for “first-responder” defibrillation

• Public access defibrillation (PAD) programs

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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

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AIRWAY MANAGEMENT

AND VENTILATION

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Common causes of airway obstruction

• Upper Airway–tongue–soft tissue oedema, foreign material–blood, vomit

• Larynx–laryngospasm, foreign material

• Lower Airway–secretions, oedema, blood–bronchospasm–aspiration of gastric contents52

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Recognition of airway obstruction

• LOOK for chest/abdominal movement

• LISTEN at mouth and nose for breath sounds, snoring, gurgling

• FEEL at mouth and nose for expired air

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Opening the airway

• Head tilt

• Chin lift

• Jaw thrust

• CAUTION! – cervical spine injury

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Head Tilt and Chin Lift

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Jaw Thrust

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Suction

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Simple airway adjuncts

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Oropharyngeal Airway

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Nasopharyngeal Airway

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Mouth to mask ventilation

Advantages:• Avoids direct person to

person contact• Decreases potential for cross

infection• Allows oxygen enrichment

Limitations:• Maintenance of airtight seal• Gastric inflation

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Bag-valve-mask, 2-person ventilation

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Ventilation using self inflating bag

Advantages

• Avoids direct person to person contact

• Allows oxygen supplementation – up to 85%

• Can be used with facemask, LMA, Combitube, tracheal tube

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Ventilation using self inflating bag

LimitationsWhen used with a facemask:

• Risk of inadequate ventilation• Risk of gastric inflation • Need two persons for optimal use

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Advanced Airway Management

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The Laryngeal Mask Airway

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The Laryngeal Mask Airway

Advantages• Rapidly and easily inserted• Variety of sizes• More efficient ventilation than

facemask• Avoids the need for laryngoscopy

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The Laryngeal Mask Airway

Limitations• No absolute guarantee against

aspiration• Not suitable if very high inflation

pressures needed• Unable to aspirate airway

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The Laryngeal Mask Airway

Fig 1

Fig 2 Fig 3

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The Laryngeal Mask Airway

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Tracheal Intubation

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Tracheal Intubation

Advantages

• Allows ventilation with up to 100% O2

• Isolates airway, preventing aspiration

• Allows aspiration of the airway

• Alternative route for drug administration

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Limitations

• Training and experience essential

• Failed insertion, oesophageal placement

• Potential to worsen cervical cord or head injury

Tracheal Intubation

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Needle Cricothyroidotomy

Indication• Failure to provide an airway by any

other means

Complications• Malposition of cannula

– Emphysema– Haemorrhage– Oesophageal perforation

• Hypoventilation• Barotrauma

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Cardiac Arrest Rhythms and ALS Universal

Treatment Algorithm

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

– movement– electrical interference

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Pulseless ventricular tachycardia

• Monomorphic VT

–Broad complex rhythm

–Rapid rate

–Constant QRS morphology

• Polymorphic VT

–Torsade de pointes

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Asystole

• Absent ventricular (QRS) activity

• Atrial activity (P waves) may persist

• Rarely a straight line trace

• Consider fine VF

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Pulseless Electrical Activity

• Clinical features of cardiac arrest

• ECG normally associated with an output

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Cardiac Arrest

Precordial Thump if appropriate

BLS Algorithm if appropriate

Attach Defib-Monitor

AssessRhythm

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

Defibrillate X 1

CPR 2 min CPR 2 min

During CPRCorrect reversible causesIf not already:•check electrodes, paddle position and contact•attempt / verify airway & O2

i.v. access•give epinephrine every 3 minConsider:amiodarone, atropine / pacing buffers

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

Universal ALSAlgorithm

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Precordial thump

• Indication:

–witnessed or monitored cardiac arrest

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Cardiac Arrest

Precordial Thump if appropriate

BLS Algorithm if appropriate

Attach Defib-Monitor

AssessRhythm

+/- Check Pulse

VF/VT Non-VF/VT

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Look Listen & FeelX 10 seconds

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30 : 2

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AssessRhythm

+/- Check Pulse

VF/VT

Defibrillate X 1

CPR 2 min

Ventricular Fibrillation/Pulseless Ventricular Tachycardia

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• Deliver 1 shocks in < 30 seconds

• Continue CPR for 2 minutes regardless.

VF / VT

SHOCK maximum (200 – 360) joules

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During CPRCorrect reversible causes

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

i.v. access• give epinephrine every 3-5 min (every other cycle of CPR)

Consider:amiodarone, atropine / pacing, buffers

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Chest compressions, airway and ventilation

• Secure airway:–tracheal tube–LMA–Combitube

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

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Intravenous access and drugs VF/VT

• Central veins versus peripheral• Epinephrine 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

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VF/VT (continued)

• Epinephrine every 3-5 minutes

• Consider bicarbonate 50 mmol if pH < 7.1

• Consider paddle positions

Shock maximum (200 – 360) J

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Non-VF/VT

CPR 2 min

AssessRhythm

+/- Check Pulse

Asystole

Pulseless Electrical Activity

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

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Asystole

• Confirm:

– check leads - view via leads I and II

– check gain

• Epinephrine 1 mg every 3-5 minutes

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

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Pulseless electrical activity

• Exclude/treat reversible causes

• Epinephrine 1 mg every 3-5 minutes

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

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POST RESUSCITATION CARE

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The return of spontaneous circulation

is the first step in the continuum of resuscitation

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Post Resuscitation Care

The goal:

• Normal cerebral function

• Stable cardiac rhythm

• Adequate organ perfusion

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Continued resuscitation:airway and breathing

Aim: to ensure a clear airway, adequate oxygenation and ventilation

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Aim: the maintenance of normal sinus rhythm and a cardiac output

adequate for perfusion of vital organs

Continued resuscitation:circulation

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Continued resuscitation:neurological assessment

• Glasgow Coma Scale

• Pupils

• Limb tone and movement

• Posture

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Further assessmentMonitoring

• History

• ECG

• Pulse oximetry

• Blood pressure

• End tidal carbon dioxide

• Urine output

• Temperature

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Further assessmentInvestigations

• Full blood count• Biochemistry • 12-lead ECG • Chest X-ray• Arterial blood gases

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Post Resuscitation CareChest X-ray

• Fractured ribs, pneumothorax, aspiration, sub-diaphragmatic gas

• Tracheal tube• CVP line• Chest drain• Nasogastric tube• Pacing wire

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Transfer of the patient

Aim: to facilitate a safe transfer of the patient between the site of resuscitation

and an appropriate place of definitive care (critical care area)

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Supporting relatives

• Clear explanation of what they will see

• Clear explanation of the events leading to the arrest

• Direct not to interfere• Use simple language• Ensure they are supported by a

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Dealing with the recently bereaved

• Early contact with one person, usually a nurse

• Provision of a suitable room• Recognising the grief response• Encouraging and arranging

viewing of the body• Establishing religious

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Dealing with the recently bereaved

Possible responses to grief:• Acute emotional distress• Anger• Denial• Guilt• Catatony

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لــكـــم شكــــرًا�Thank You