Monday, October 15, 2012

BASIC LIFE SUPPORT (BLS) AND ADVANCED CARDIAC LIFE SUPPORT (ACLS) : WHAT'S NEW IN THE REVISED GUIDELINES?

http://www.maxhealthcare.in/newsletter/max-medical-journal/may-11/bls.html
Dr Ritesh Aggarwal, Dr Omender Singh, Dr Gurpreet Singh

INTRODUCTION:
The 2010 AHA Guidelines for CPR and ECC are based on the most current and comprehensive review of resuscitation literature ever published. The 2010 evidence evaluation process included 356 resuscitation experts from 29 countries who reviewed, analyzed, debated, and discussed 411 scientific evidence reviews on various topics in resuscitation and emergency cardiovascular care (1). The recommendations in the 2010 Guidelines confirm the safety and effectiveness of many approaches, acknowledge ineffectiveness of others, and introduce new treatments based on intensive evidence evaluation and consensus of experts (2). We discuss the highlights of 2010 guidelines, the key changes from the previous guidelines, and the rationale behind those changes.
CHANGES IN BASIC LIFE SUPPORT (BLS) GUIDELINES

I) The Change From "A-B-C" to "C-A-B"
The newest development in the 2010 AHA Guidelines for CPR and ECC is a change in the basic life support (BLS) sequence of steps from "A-B-C" (Airway, Breathing, Chest compressions) to "C-A-B" (Chest compressions, Airway, Breathing) for adults and pediatric patients (children and infants, excluding newborns).

There are multiple valid reasons for giving more emphasis to chest compressions. The highest survival rates from cardiac arrest are reported among patients of all ages with witnessed arrest and a rhythm of VF or pulseless ventricular tachycardia (VT). In these patients the critical initial elements of CPR are chest compressions and early defibrillation. Also, by changing the sequence to C-A-B, chest compressions will be initiated sooner and ventilation only minimally delayed until completion of the first cycle of chest compressions (30 compressions should be accomplished in about 18 seconds) (1,2). 

Having said that, a change in something as established as the A-B-C sequence would require re-education of everyone who has ever learned CPR.

II) Removal of "look - listen - feel"
The BLS algorithm has been simplified, and "Look, Listen and Feel" has been removed from the algorithm. Performance of these steps is inconsistent and time consuming. For this reason the revised guidelines stress immediate activation of the emergency response system and starting chest compressions for any unresponsive adult victim with no breathing or no normal breathing (ie, only gasps).

III) Chest compressions
In the revised guidelines, there is an increased focus on high-quality CPR. Adequate chest compressions require that compressions be provided at the appropriate depth and rate, allowing complete recoil of the chest after each compression and an emphasis on minimizing any pauses during compressions.

There is an emphasis on higher "chest compression rates". The recommendation has been changed from compression rate of "approximately 100/min" to compression rate of "at least 100/min". The number of chest compressions delivered per minute during CPR is an important determinant of return of spontaneous circulation (ROSC) and survival with good neurologic function. In most studies, delivery of more compressions during resuscitation was associated with better survival, when compared to fewer compressions (3).

The recommendation for chest compression depth has also been changed to "at least 2 inches (5cm)". Compressions generate critical blood flow and oxygen delivery to the heart and brain. Rescuers often do not push the chest hard enough. Studies have shown that increasing the depth of compressions is associated with increased blood flow.

IV) Cricoid pressure
Cricoid pressure can prevent gastric inflation and reduce the risk of regurgitation and aspiration during bag-mask ventilation, but it may also impede ventilation. Seven randomized studies showed that cricoid pressure can delay or prevent the placement of an advanced airway (e.g., endotracheal tube) and some aspiration can still occur despite application of cricoid pressure. In addition, it is difficult to appropriately train rescuers in use of the maneuver. Hence, revised guidelines do not recommend routine use of cricoid pressure in cardiac arrest.

V) New "circular" ACLS algorithm (Table 1)

Adult cardiac Arrest
The older 2005 "box and arrow" designed algorithm listed key actions performed during the resuscitation in a sequential fashion. The revised algorithm is simplified and streamlined, and is "circular".

Before 2005, ACLS courses focused mainly on added interventions, such as manual defibrillation, drug therapy, and advanced airway management, as well as alternative and management options for special situations. Although adjunctive drug therapy and advanced airway management are still part of ACLS 2010, but the emphasis is exclusively on high quality CPR - the only thing which has consistently shown to work and improve outcomes (3). There is no definitive clinical evidence that early intubation or drug therapy improves neurologically intact survival to hospital discharge.

VI) Capnography
2005 guidelines only recommended CO2 detector device to confirm endotracheal tube placement.

Continuous quantitative waveform capnography is now recommended for intubated patients throughout the peri-arrest period. Moreover, its applications now include recommendations for confirming tracheal tube placement and for monitoring CPR quality and detecting return of spontaneous circulation based on end-tidal carbon dioxide (EtCO2) values.

Continuous waveform capnography is the most reliable method of confirming and monitoring correct placement of an endotracheal tube. Because blood must circulate through the lungs for CO2 to be exhaled and measured, capnography can also serve as a monitor of the effectiveness of chest compressions and to detect return of spontaneous circulation. Ineffective chest compressions are associated with a low PetCO2. Falling cardiac output or re-arrest in the patient with return of spontaneous circulation also causes a decrease in PetCO2. In contrast, return of spontaneous circulation may cause an abrupt increase in PetCO2.

VII) Atropine is 'out'; Adenosine is 'in'
Atropine is no longer recommended for routine use in the management of pulseless electrical activity (PEA) and asystole. Evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (4). Adenosine is recommended in the initial diagnosis and treatment of stable, undifferentiated regular, monomorphic wide-complex tachycardia. This is on the basis of new available evidence of its safety and potential efficacy.

VIII) Post-cardiac arrest care
Post-Cardiac Arrest Care is a new section in the revised guidelines (5). To improve survival for victims of cardiac arrest who are admitted to a hospital after return of spontaneous circulation, a comprehensive, multidisciplinary system of post-cardiac arrest care should be implemented in a consistent manner. Treatments should include cardiopulmonary and neurologic support, as well as therapeutic hypothermia and percutaneous coronary interventions (PCIs), when indicated. An electroencephalogram (EEG) for the diagnosis of seizures should be performed with prompt interpretation as soon as possible and should be monitored frequently or continuously in comatose patients after return of spontaneous circulation (ROSC).

The benefits of therapeutic hypothermia have been re-emphasized, based on two recent large studies.

IX) Ethical issues
Until recent guidelines, no prognostic indicators had been established for patients undergoing therapeutic hypothermia. According to 2005 guidelines, there were 3 factors associated with poor outcomes:

  1. absence of papillary response on day 3
  2. absence of motor response on day 3
  3. bilateral absence of somato-sensory evoked potentials.
The revised guidelines discuss ethical and withdrawal of support decisions in more details (6). In adult post-cardiac arrest patients, it is recommended that clinical neurologic signs, electrophysiologic studies, biomarkers, and imaging be performed at 3 days after cardiac arrest. On the basis of the limited available evidence, potentially reliable prognosticators of poor outcome in patients treated with therapeutic hypothermia after cardiac arrest include bilateral absence of N20 peak on somato-sensory evoked potential > 24 hours after cardiac arrest and the absence of both corneal and pupillary reflexes = 3 days after cardiac arrest. Limited available evidence also suggests that a Glasgow Coma Scale Motor Score of 2 or less at day 3 after sustained return of spontaneous circulation and presence of status epilepticus are potentially unreliable prognosticators of poor outcome in post-cardiac arrest patients treated with therapeutic hypothermia. The reliability of serum biomarkers as prognostic indicators is also limited by the relatively few patients who have been studied. Currently, there is limited evidence to guide decisions regarding withdrawal of life support. The clinician should document all available prognostic testing 72 hours after cardiac arrest treated with therapeutic hypothermia and use best clinical judgment based on this testing to make a decision to withdraw life support when appropriate.

What's new in Electrical therapies?
The 1-shock protocol for VF/pulseless VT has not been changed.

Over the last decade biphasic waveforms have been shown to be more effective than monophasic waveforms in cardioversion and defibrillation. However, there are no clinical data comparing one specific biphasic waveform with another (7). Whether escalating or fixed subsequent doses of energy are superior has not been tested with different waveforms. However, if higher energy levels are available in the device at hand, they may be considered if initial shocks are unsuccessful in terminating the arrhythmia.

Transcutaneous pacing has also been the focus of several recent trials. Pacing is not generally recommended for patients in asystolic cardiac arrest. Three randomized controlled trials indicate no improvement in rate of admission to hospital or survival to hospital discharge when paramedics or physicians attempted pacing in patients with cardiac arrest due to asystole in the prehospital or hospital setting. However, it is reasonable for healthcare providers to be prepared to initiate pacing in patients with bradyarrhythmias in the event the heart rate does not respond to atropine or other chronotropic drugs.

What's new in CPR devices?
Several devices have been the focus of recent clinical trials. Use of the impedance threshold device (ITD) improved ROSC and short-term survival when used in adults with out-of-hospital cardiac arrest, but there was no significant improvement in either survival to hospital discharge or neurologically-intact survival to discharge (8).

To date, no adjunct has consistently been shown to be superior to standard conventional (manual) CPR.
Table 2: Key changes in revised  AHA guidelines for CPR & ECC

I
Change in BLS sequence of steps from “A-B-C” to “C-A-B” for adults and pediatric patients (except newborns)
II
“Look- Listen- Feel” removed from BLS algorithm.
III
Recommended chest compression rate changed from “approx 100/min” to “at least 100/min”
IV
Recommended compression depth changed from “1.5 – 2 inches” to “at least 2 inches”
V
Cricoid pressure no longer recommended.
VI
New circular ACLS algorithm replaces older box & arrows algorithm.
VII
Use of continuous quantitative capnography emphasized for intubated patients.
VIII
Atropine no longer recommended for PEA or asystole.
IX
Adenosine recommended for initial diagnosis & treatment of stable, monomorphic wide complex tachycardia.
X
Emphasis on post cardiac arrest care.
XI
Ethical issues: Prognostic indicators defined to assess poor outcomes and to guide decisions regarding withdrawal of support.

References

  1. Hazinski MF, Nolan JP, Billi JE, et al. 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2010;122:S250-S275.
  2. John M. Field, Mary Fran Hazinski, Michael R. Sayre, et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S640-S656.
  3. Rea TD, Cook AJ, Stiell IG, et al. Predicting survival after out-of-hospital cardiac arrest: role of the Utstein data elements. Ann Emerg Med. 2010;55:249-257.
  4. Stiell IG, Wells GA, Hebert PC, et al. Association of drug therapy with survival in cardiac arrest: limited role of advanced cardiac life support drugs. Acad Emerg Med. 1995;2:264-273.
  5. Mary Ann Peberdy, Clifton W. Callaway, Robert W. Neumar, et al. Post-Cardiac Arrest Care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S768-S786.
  6. Laurie J. Morrison, Gerald Kierzek, Douglas S. Diekema, et al. Ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S665-S675.
  7. Mark S. Link, Dianne L. Atkins, Rod S. Passman, et al. Electrical Therapies: Automated External Defibrillators, Defibrillation, Cardioversion, and Pacing: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S706-S719.
  8. Cabrini L, Beccaria P, Landoni G, et al. Impact of impedance threshold devices on cardiopulmonary resuscitation: a systematic review and meta-analysis of randomized controlled studies. Crit Care Med. 2008;36:1625-1632.
Authors :
Dr Ritesh Aggarwal, Attending Consultant, Dept. of Critical Care, Max Hospital, Gurgaon, Mobile: 9650923723, email: ritesh.icu@gmail.com,
Dr Omender Singh, Head of Department, Dept. of Critical Care, Max Hospital, Mobile: 9810734246, email:omender.singh@maxhealthcare.com,
Dr Gurpreet Singh, Consultant, Dept. of Critical Care, Max Hospital, Gurgaon, Mobile: 9810091823 email:gurpreet.singh@maxhealthcare.com

Eat more fruits and veggies in the pursuit of happiness

http://www.nydailynews.com/life-style/health/eat-fruits-veggies-pursuit-happiness-article-1.1181882?localLinksEnabled=false


That’s the conclusion of a study from the University of Warwick in the UK, which found that the more servings of fruits and vegetables people ate, the better their mental well-being.

Organic fruits and veggies can be more nutritious than non-organic varieties.



According to a new British study, finding happiness could be as easy as eating more fruits and vegetables.

That’s the conclusion of a study from the University of Warwick in the UK, which found that the more servings of fruits and vegetables people ate, the better their mental well-being.

For their research, scientists from Warwick and Dartmouth College in the US analyzed the eating habits of 80,000 people across Britain and found that well-being peaked at seven portions a day.

Meanwhile, the consumption of fruits and vegetables is dismal at best in the UK, as researchers point out that a quarter of the population eat just one portion or even less per day, while one-tenth of Britons are estimated to consume seven servings daily.

The full results of their research is to be published in an upcoming issue of Social Indicators Research.

Meanwhile, another study published in the British Medical Journal found that eating more green, leafy vegetables can significantly reduce the risk of developing the medical scourge of the 21st century, type 2 diabetes.


Friday, October 12, 2012

10 Manfaat Gelombang Theta yang Mungkin Tidak Anda Sadari

http://www.gelombangotak.com/gelombang_theta.htm


Gelombang theta berada pada rentang frekuensi antara 4 sampai 8 Hz, dan biasanya diproduksi selama tidur dengan mimpi serta pada kondisi deep trance dan dzikir kusuk.

Kemampuan untuk memasuki gelombang otak theta (yaitu di mana gelombang theta menjadi dominan pada otak) adalah salah satu yang berharga, karena sejumlah manfaat yang berhubungan dengan gelombang theta otak. Ini meliputi:

1. Peningkatan kemampuan belajar
Keadaan theta dikaitkan dengan kemampuan untuk belajar lebih mudah dan untuk menyimpan informasi lebih efektif. Untuk alasan ini, menggunakan Musik Terapi gelombang otak berfrekwensi theta mungkin akan bermanfaat bagi siswa/pelajar dan orang lain yang perlu untuk memproses sejumlah besar informasi.

2. Peningkatan kreativitas
Gelombang otak theta juga diproduksi dalam jumlah besar selama periode pemikiran kreatif yang intens. Hal ini berlaku bagi mereka yang meekuni karya kreatif tradisional, seperti musisi dan seniman, serta siapa saja yang terlibat dalam berpikir kreatif. Jadi jika Anda ingin belajar untuk berpikir lebih kreatif, meditasi gelombang otak dengan frekwensi theta dapat membantu.

3. Menghilangkan stress
Gelombang otak theta juga dihubungkan dengan penurunan stres secara fisik dan mental. Stres dapat menyebabkan banyak penyakit, jadi jelas bermanfaat untuk dapat melepaskannya sebelum menjadi masalah.

4. Komunikasi bawah sadar
Keadaan theta juga dikaitkan dengan kemampuan akses ke pikiran bawah sadar. Ini berarti bahwa pada kondissi theta menjadikan Anda lebih mudah untuk memprogram ulang keyakinan bawah sadar dan melepaskan pembatasan yang mungkin menahan Anda, serta mengadopsi keyakinan baru yang lebih meningkatkan kwalitas hidup.

5. Lebih banyak energi
Banyak dari mereka yang berlatih meditasi theta secara teratur melaporkan peningkatan energi. Contoh cara mudahmemasuki ke keadaan theta selama beberapa menit atau lebih adalah tidur siang. Tidur siang sangat membantu dalam hal memulihkan energi pada tubuh dan pikiran Anda.

6. Kemampuan penyembuhan diri yang lebih baik
Menggunakan Audio gelombang otak berfrekwensi theta theta juga dapat membantu tubuh Anda untuk tetap sehat. Tubuh Anda mempunyai kekuatan penyembuhan diri ketika Anda bebas dari stres dan sangat santai, dan kondisi theta sangat terkait dengan pelepasan stres dan relaksasi yang sangat mendalam.

7. Kemampuan untuk memiliki mimpi lebih nyata dan terkendali
Bayangkan bisa mengendalikan mimpi, Anda tidak hanya dapat menghentikan mimpi buruk di jalurnya, tapi Anda bisa mengalami skenario yang Anda inginkan! Nah, meditasi theta mungkin dapat membantu Anda melakukan hal itu, seperti bermimpi lebih nyata dan terkendali juga terkait dengan produksi gelombang otak theta. Belajar untuk masuk ke kondisi theta secara konsisten dapat membuat lebih mudah untuk menjadikan mimpi lebih nyata dan terkendali.

8. Kemampuan untuk memiliki pengalaman keluar dari tubuh (Out of ody Travel/Raga Sukma)
Perjalanan raga keluar tubuh dan kemampuan paranormal sangat berhubungan dengan produksi gelombang otak theta. Belajar untuk memiliki pengalaman raga keluar dari tubuh adalah usaha yang sangat bernilai, karena memberikan Anda kesempatan untuk menjelajahi luar realitas duniawi, dan merasakan pengalaman baru dari pemberdayaan diri. Mampu memasuki keadaan theta dengan mudah adalah bagian penting dari belajar untuk mampu meninggalkan tubuh Anda (raga sukma).

9. Pengembangan kekuatan psikis
Berbagai kemampuan psikis juga terkait dengan produksi gelombang theta, termasuk telepati, indra keenam,dan lain-lain. Jadi jika Anda ingin memulai untuk memasuki potensi sesungguhnya dari pikiran Anda, belajar untuk memasuki keadaan theta adalah hal terbaik untuk memulai.

10. Memori yang lebih baik
Tampaknya gelombang otak theta dikaitkan dengan kemampuan untuk mengambil kenangan juga. Hal ini terutama berlaku untuk memori jangka panjang, kondisi theta dikaitkan dengan akses yang lebih besar untuk pikiran bawah sadar, yang memainkan peran penting dalam penyimpanan memori.

Jadi seperti yang Anda lihat, ada banyak manfaat gelombang otak theta, dan daftar ini hanyalah sebagian. Di masa lalu, manfaat ini hanya bisa di rasakan bagi mereka yang berpengalaman dalam meditasi, atau yang hanya cukup beruntung untuk memiliki kemampuan alami untuk memasuki keadaan trance dengan mudah.

Untungnya bagi Anda yang masih awam, terapi gelombang otak mejadikan siapapun bisa memasuki pada kondisi theta relatif mudah, bahkan bagi mereka yang tidak memiliki pengalaman meditasi. Dengan memanfaatkan audio gelombang otak berfrekwensi theta yang menggunakan Binaural beats atau monaural beats/isochronic, Anda dapat belajar untuk meningkatkan produksi gelombang otak theta Anda.
Jika Anda memutuskan untuk menggunakan audio gelombang otak berfrekwensi theta, penting untuk memilih audio yang berkualitas tinggi, jika tidak, Anda tidak akan mendapatkan hasil yang Anda cari.

Gelombang Otak dan Hypnosis

http://www.hypnosis45.com/gelombang_otak.htm


Jaringan otak manusia hidup menghasilkan gelombang listrik yang berfluktuasi. Gelombang listrik inilah disebut brainwave atau gelombang otak. Dalam satu waktu, otak manusia menghasilkan berbagai gelombang otak secara bersamaan. Empat gelombang otak yang diproduksi oleh otak umumnya manusia yaitu beta, alpha, tetha, delta. Akan tetapi selalu ada jenis gelombang otak yang paling dominan, yang menandakan aktivitas otak saat itu. Gelombang otak menandakan aktifitas pikiran seseorang.

EEG Gelombang Otak
Gelombang otak diukur dengan alat yang dinamakan Electro Encephalograph (EEG). EEG ditemukan pada tahun 1929 oleh psikiater Jerman, Hans Berger. Sampai saat ini, EEG adalah alat yang sering diandalkan para peneliti yang ingin mengetahui aktivitas pikiran seseorang.

Beta, frekuensi 12 - 25 Hz.
Dominan pada saat kita dalam kondisi terjaga, menjalani aktifitas sehari-hari yang menuntut logika atau analisa tinggi, misalnya mengerjakan soal matematika, berdebat, olah raga, dan memikirkan hal-hal yang rumit. Gelombang beta memungkinkan seseorang memikirkan sampai 9 obyek secara bersamaan.

Alpha, frekuensi 8 - 12 Hz.
Dominan pada saat tubuh dan pikiran rileks dan tetap waspada. Misalnya ketika kita sedang membaca, menulis, berdoa dan ketika kita fokus pada suatu obyek. Gelombang alpha berfungsi sebagai penghubung pikiran sadar dan bawah sadar. Alfa juga menandakan bahwa seseorang dalam kondisi light trance atau kondisi hypnosis yang ringan.

Theta, frekuensi 4 - 8 Hz
Dominan saat kita dalam kondisi hypnosis, meditasi dalam, hampir tidur, atau tidur disertai mimpi. Frekuensi ini menandakan aktivitas pikiran bawah sadar.

Delta, frekuensi 0,1 - 4 Hz.
Dominan saat tidur lelap tanpa mimpi.
Penemuan alat untuk mengukur gelombang otak berpengaruh positif terhadap perkembangan hypnosis. Hypnosis yang semula dianggap sebagai hal yang misterius, menakutkan, dan dianggap fenomena supranatural, sekarang sudah diterima secara ilmiah sebagai kondisi alami manusia.

Telah dilakukan penelitian pada sejumlah subjek dan diperoleh hasil bahwa subyek yang sedang dalam kondisi hypnosis, gelombang otaknya antara alpha dan theta. Dalam kondisi terjaga, gelombang otak subyek umumnya adalah beta. Begitu dilakukan induksi, maka gelombang otak subyek secara cepat turun ke alpha, dan setelah dilakukan teknik deepening, otak subyek menunjukkan gelombang theta. Diyakini oleh para ilmuan bahwa apabila otak memproduksi gelombang otak theta yang dominan, maka sedang terjadi aktifitas pikiran bawah sadar.

Sekarang anda sudah tahu bahwa seorang dalam kondisi trance hypnosis gelombang otaknya adalah antara alpha dan theta. Pertanyaannya, apakah gelombang otak alpha dan theta hanya terjadi pada kondisi trance hypnosis saja?

Ternyata tidak. Secara alami anda memasuki kondisi alpha dan theta setiap akan tidur dan bangun tidur. Ketika anda sudah merasa sangat rileks, tenang, dan hampir tertidur, tapi anda masih menyadari keberadaan anda, maka seperti itulah kondisi hypnosis. Ketika anda terjaga dari tidur, dan masih malas untuk beranjak dari tempat tidur karena masih ingin melanjutkan tidur lagi, maka seperti itulah kondisi hypnosis.

Bedanya ketika anda akan tidur yaitu anda hanya mengalami kondisi alpha-theta dalam beberapa menit saja, kemudian gelombang otak anda turun ke delta (tanda bahwa tubuh dan pikiran anda beristirahat total). Sedangkan dalam kondisi hypnosis, anda bisa mengalami kondisi trance (gelombang otak alpha-theta) dalam waktu yang lama.

Orang yang bermeditasi, berdoa dengan khusyuk, terpana melihat sesuatu, terhanyut membaca novel atau suatu cerita, melamun dan semacamnya juga menghasilkan gelombang otak alpha sampai theta.

Dengan mengetahui bahwa kondisi hypnosis adalah kondisi yang alami bagi manusia, maka tidak perlu ada ketakutan lagi bahwa hypnosis itu berbahaya. Kecurigaan bahwa ada unsur magic/sihir/paranormal dalam hypnosis sudah lenyap sejak diketahui bahwa hypnosis itu fenomena mental yang alami.

Jika Anda ingin tahu lebih banyak tentang Gelombang Otak dan efeknya pada pikiran manusia, Anda bisa membaca di situs TerapiMusik.Com atau AktivasiOtak.Com