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Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. The duration of cardiopulmonary resuscitation in emergency departments after out-of-hospital cardiac arrest is associated with the outcome: A nationwide observational study. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. Duration of prehospital cardiopulmonary resuscitation and favorable neurological outcomes for pediatric out-of-hospital cardiac arrests: a nationwide, population-based cohort study. Chest compression fraction in ambulance while transporting patients with out-of-hospital cardiac arrest to the hospital in rural Taiwan. Impact of cardiopulmonary resuscitation duration on neurologically favourable outcome after out-of-hospital cardiac arrest: a population-based study in japan. Validation of a universal prehospital termination of resuscitation clinical prediction rule for advanced and basic life support providers. The association between duration of resuscitation and favorable outcome after out-of-hospital cardiac arrest: implications for prolonging or terminating resuscitation. Choose proper destination for patient transport Patient Presentation Inclusion Criteria 1. History of circumstances and symptoms before, during, and after the event, including duration, interventions done, and patient color, tone, breathing, feeding, position, location, activity, level of consciousness b. Other concurrent symptoms (fever, congestion, cough, rhinorrhea, vomiting, diarrhea, rash, labored breathing, fussy, less active, poor sleep, poor feeding) c. Past medical history (prematurity, prenatal/birth complications, gastric reflux, congenital heart disease, developmental delay, airway abnormalities, breathing problems, prior hospitalizations, surgeries, or injuries). Family history of sudden unexplained death or cardiac arrhythmia in other children or young adults f. Social history: who lives at home, recent household stressors, exposure to toxins/drugs, sick contacts) g. Give supplemental oxygen for signs of respiratory distress or hypoxemia - Escalate from a nasal cannula to a simple face mask to a non-rebreather mask as needed [see Airway Management guideline] b. Suction the nose and/or mouth (via bulb, suction catheter) if excessive secretions are present 3. Consider transport to a facility with pediatric critical care capability for patients with high risk criteria present: i. History of prematurity (less than or equal to 32 weeks gestation or corrected gestational age less than or equal to 45 weeks) iii. All patients should be transported to facilities with baseline readiness to care for children Notes/Educational Pearls Key Considerations 1. Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants: a systematic review. Risk factors for extreme events in infant hospitalized for apparent life-threatening events. American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Committee, Emergency Nurses Association Pediatric Committee. Death, child abuse, and adverse neurologic outcome of infants after an apparent life-threatening event. Abusive head trauma in children presenting with an apparent life-threatening event. Apparent life-threatening event: multicenter prospective cohort study to develop a clinical decision rule for admission to the hospital. Do infants less than 12 months of age with an apparent life-threatening event need transport to a pediatric critical care center Availability of pediatric services and equipment in emergency departments: United States, 2002-03. A clinical decision rule to identify infants with apparent lifethreatening event who can be discharged from the emergency department. Mortality and child abuse in children presenting with apparent lifethreatening events.

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Patients in arrest due to traumatic etiology [see General Trauma Management guideline] Patient Management Assessment 1. The patient in cardiac arrest requires a prompt balance of treatment and assessment 2. In cases of cardiac arrest, assessments should be focused and limited to obtaining enough information to reveal the patient is pulseless 3. Once pulselessness is discovered, treatment should be initiated immediately and any further history must be obtained by bystanders while treatment is ongoing Treatment and Interventions the most important therapies for patients suffering from cardiac arrest are prompt cardiac defibrillation and minimally interrupted effective chest compressions 1. High flow oxygen is applied via a non-rebreather mask with an oropharyngeal airway 2. Pediatric Consideration: For neonates, 3:1 is the recommended compression to ventilation ratio. Either a supraglottic airway or an endotracheal tube may be placed without interruption of compressions 2. Ventilations are provided at 10 breaths/minute for adults 106 Updated November 23, 2020 7. Pediatric Consideration: for children, 1 breath every 3-5 seconds is recommended (12-20 breaths/minute) c. There is insufficient evidence to recommend for or against the routine administration during cardiac arrest Consider reversible causes of cardiac arrest which include the following: a. Performing manual chest compressions in a moving vehicle may pose a provider safety concern 2. In addition, manual chest compressions during patient movement are less effective in regards to hands on time, depth, recoil and rate 3. Ideally, patients should be resuscitated as close to the scene as operationally possible 4. Risks and benefits should be considered before patient movement in cardiac arrest situations. Effective chest compressions and defibrillation are the most important therapies to the patient in cardiac arrest. If an advanced airway is placed, ventilations should not exceed 10 breaths/minute (1 breath every 6 seconds or 1 breath every 10 compressions) in adults. Pediatric Consideration: For children with an advanced airway, 1 breath every 3-5 seconds is recommended (equivalent to 12-20 breaths/minute) 3. Consider additional monitoring with biometric feedback which may improve compliance with suggested Resuscitation section guidelines 4. Chest compressions are usually the most rapidly applied therapy for the patient in cardiac arrest and should be applied as soon as the patient is noted to be pulseless. If the patient is being monitored with pads in place at the time of arrest, immediate defibrillation should take precedence over all other therapies, however, if there is any delay in defibrillation (for instance, in order to place pads), chest compressions should be initiated while the defibrillator is being applied. There is no guidance on how long these initial compressions should be applied; however, it is reasonable to either complete between 30 seconds and 2 minutes of chest compressions in cases of no bystander chest compressions or to perform Updated November 23, 2020 108 5. Patients should therefore be resuscitated as close to the point at which they are first encountered and should only be moved if the conditions on scene are unsafe or do not operationally allow for resuscitation b. There is uncertainty regarding the proper goals for oxygenation during resuscitation i. This should not be continued into the post-resuscitation phase in which the goal should be an oxygen saturation of 94-98%. Pediatric Considerations: Special attention should be applied to the pediatric population and airway management/respiratory support.

Plant Alkaloids are cell-cycle specific which means they attack the cells during various phases of division. Antitumor antibiotics are also cell-cycle specific and act during multiple phases of the cell cycle. They are made from natural products and were first produced by the soil fungus Streptomyces. Targeted cancer therapies are sometimes called "molecularly targeted drugs," "molecularly targeted therapies," "precision medicines," or similar names. Examples of molecularly targeted therapy are imatinib (Gleevec), lapatinib (Tykerb), erlotinib (Tarceva), sunitinib (Sutent). Agents in this type of therapy are vastly different from the traditional chemotherapeutic agents. These new drugs are designed to target unique or abnormally-expressed molecules within cancer cells while sparing normal cells. Radioembolization: Embolization combined with the injection of small radioactive beads or coils into an organ or tumor. Use codes 01, 02, 03 as specific information regarding the agent(s) is documented. From a procedure report: Under x-ray guidance, a small catheter is inserted into an artery in the groin. Chemotherapy is injected through the catheter into the tumor and mixed with particles that embolize or block the flow of blood to the tumor. Do not code pre-surgical (pre-operative) embolization of hypervascular tumors with particles, coils or alcohol as a treatment. Pre-surgical embolization is typically performed to prevent excess bleeding during the resection of the primary tumor. Chemotherapy administered as first course of therapy, but the type and number of agents is not documented in the patient record. Chemotherapy was not recommended/administered because it was contraindicated due to patient risk factors i. Chemotherapy was not administered because the patient died prior to planned or recommended therapy. Record code 01 and document the information in the treatment documentation text field. Code the fluorouracil as a single agent and the levamisole as an immunotherapeutic agent. Record code 02 and document the information in the treatment documentation data field. The medical record indicated a combination regimen containing doxorubicin is to be administered. Record code 03 and document the information in the treatment documentation data field. Following surgical resection of an ovarian mass the physician recommends chemotherapy. The medical record states chemotherapy was not delivered and the reason is not documented. Record code 86 and document that the medical record states chemo not delivered but no reason given. A chemotherapy agent is injected through the catheter into the tumor and mixed with particles that embolize or block the flow of blood to the diseased tissue. Document all first course therapy chemotherapy information regardless of where it was done, in date order. Document if no chemotherapy was given, or if it cannot be determined if intended chemotherapy was given. Note: See the Text Documentation section of the 2018-2019 Handbook (page 245) for further explanation and examples. Record the first or earliest date on which hormone therapy was administered by any facility.

The upsides of these are that R has infinite flexibility, and total replicability, so that we get exactly the right figure, and the same figure, every time we run the same code. Here set up a new graph without plotting points, add text at each point, then more points, a line and some text. We are going to use an alternate coloring system, designed with human perception in mind (hcl). We scale the colors so that the hue varies between 30 and 300, depending on the height of the tree; I allow the symbols to be transparent (90% opaque) overlapping. Argument Meaning type Determines the type of X-Y plot, for example p, l, s, for points, lines, stair-step, and none, respectively. Useful if you want more control over each axis by using the axis function separately (see below). This can be a single value for an entire plot, or take on a unique value for each point, or anything in between. To add text more than one character in length, for instance a species name, we can easily add text to a plot at each point (see the next section). We frequently want to add a second y-axis to a graph that has a different scale. The trick we use here is that we plot a graph, but then tell R we want to do the next command ". Note we also specify extra margin space room on the right hand side, preparing for the second Y axis. For instance, to open a "graphics device" on a Mac computer that is 5 inches wide and 3 inches tall, we write > quartz(width = 5, height = 3) To do the same thing on a computer running Windows, we type > windows(width = 5, height = 3) To control the par ameters of the graph, that is, what it looks like, aside from data, we use arguments to the par function. We can build each side of the graph separately by initiating a graph but not plotting axes plot(. Last, we can use layout to make graph with several smaller subgraphs (see also (mfrow and mfcol arguments to par and the function split. The 378 B Programming in R function layout takes a matrix as its argument, the matrix contains a sequence of numbers that tells R how to fill the regions Graphs can fit in more than one of these regions if indicated by the same number. The first graph will be the upper left, the second the upper right, and the third will fill the third and fourth spots in the second. One way to get graphics out of R and into something else (presentation software, a manuscript), is to create a graphics device, and then save it with dev. You will have to find your own way to make graphics files that suits your operating system, your preferred applications, and your personality. For kicks, we put them into a single compound figure, in a "layout" composed of a matrix of graphs. The first named component is a vector of eigenvalues and the second named component is a matrix of corresponding eigenvectors. These will be numeric if possible, or complex, if any of the elements are complex numbers. In one sense, they have similar meanings - they both describe the asymptotic (long-term) properties of a system, either population size (demographic matrix) or a perturbation at an equilibrium. In the case of the stage (or age) structured demographic model, the elements of the demographic matrix are discrete per capita increments of change over a B. This is directly analogous to the finite rate of increase, in discrete unstructured models. Therefore, the eigenvalues of a demographic matrix will have the same units - a per capita increment of change. As differential equations, they describe the instantanteous rates of change, analogous to r. Therefore, values greater than zero indicate increases, and values less than zero indicate decreases. Because these rates are evaluated at an equilibrium, the equilibrium acts like a new zero - positive values indicate growth away from the equilibrium, and negative values indicate shrinkage back toward the equilibrium. When we evaluate these elements at the equilibrium, the numbers we get are in the same units as r, where values greater than zero indicate increase, and values less than zero indicate decrease.