Download The Author`s Manuscript

Information for AHA ECC Writers and Editors
F. G. Stoddard, PhD
Editor in Chief
Mary Fran Hazinski, RN, MSN
Senior Science Editor
© 2004 American Heart Association
Contents [flush left, cap and lowercase]
Introduction................................................................................................… 2
The Approach to Writing...........................................................................…. 2
Elementary Principles..........................................................................…. 3
Some Amplification..............................................................................…. 6
Basic Manuscript Preparation..................................................................….. 9
Contents...............................................................................................…. 9
Formatting Text....................................................................................…. 9
Numbering Pages....................................................................................12
Chapter Titles and Subheads.............................................................…..12
Notes and References.............................................................................12
Tables and Figures..................................................................................13
Checking and Cross-checking......................................................................14
Proofread………………………………………………………………………14
Check Spelling.........................................................................................14
Check Quotations.............................................................................…....15
Check for Completeness...................................................................…...15
Check Cross-references....................................................................…...15
Cross-check the Manuscript for Consistency.....................................…...16
Parts of the Manuscript to Cross-check.............................................. ...17
Additional Materials to Cross-check for Instructor Manual Manuscripts...17
Additional Materials to Cross-check for Written Examination Questions..18
Pearls and Perils............................................................................................18
Checklist for All Manuscripts..........................................................................22
Additional Checklist for Instructor Manuals....................................................23
Some Matters of Style....................................................................................24
Lists...........................................................................................................24
Numbers....................................................................................................26
Punctuation............................................................................................…27
Spelling and Capitalization....................................................................….31
Usage........................................................................................................34
How to Import Reference Data From the PubMed Website in EndNote……..38
Basic Reference Works..................................................................................39
Glossary……………………………………………………………………………..40
1
Introduction
I
n the past 4 years the number, diversity, and complexity of ECC products has grown
substantially. From 1999 through 2003, ECC writers, editors, and staff produced
scores of different educational products—targeting instructors in BLS, ACLS, and PALS
and targeting family members, school-age rescuers, workplace rescuers, and
prehospital and hospital healthcare providers with information about resuscitation of
victims of all ages.
The goal of ECC product development is to teach potential rescuers the skills needed to
increase survival and functional outcome of victims of cardiovascular emergencies. To
support this goal we must produce high-quality guidelines and educational materials in a
timely and cost-efficient manner. Quality and efficiency have their roots in manuscript
development and preparation. If a manuscript is clean, clear, appropriate for the target
audience, and complete when it is submitted for publication, the ultimate quality of the
publication will be high and the product will require less editorial time and be less
expensive to produce.
This document identifies our expectations of authors and editors in the physical
preparation of manuscripts. It provides examples of practices that facilitate efficient
development of excellent products, and it also contains examples of practices that
reduce efficiency or quality.
The Approach to Writing
All writers and final editors should be knowledgeable about the content, breadth, and
depth of all components (eg, video, text, posters) that will be part of the final product. Be
sure that all information is consistent in all components.
Before you begin writing, familiarize yourself with existing AHA/ILCOR publications and
identify any content from those publications that you can use. All writers and editors
should be familiar with the relevant content in the most recent versions of the following:
•
ECC Handbook
2
•
International Guidelines 2000 or the ILCOR Consensus on Science and
Treatment Recommendations
•
American Heart Association Guidelines for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care
In addition, subspecialty (BLS, ACLS, and PALS) writers and editors must be familiar
with AHA publications in their subspecialty. BLS writers and editors should be familiar
with the content of all BLS lay rescuer and healthcare provider publications and training
materials. ACLS providers must be familiar with the content of the ACLS Provider
Manual and the ACLS Reference Text and training materials. PALS writers and editors
must be familiar with the PALS text and training materials.
Write the text to the appropriate reading level and likely knowledge base of the target
audience. The target reading level is established during the product development
process. The Microsoft Word program will provide a Flesch-Kincaid reading level and an
indication of readability. The program will also note the percentage of sentences that are
written in the passive voice. To obtain these readability statistics in the Word program,
click on the Tools menu, select Options, and then select the Spelling & Grammar tab. If
you check the option “Show readability statistics,” the information about reading level
and readability will be displayed at the end of each spellcheck. The active voice is the
preferred writing style for medical publications, so the manuscript should contain few
sentences written in the passive voice (see below).
Elementary Principles
1. Prefer the simple and direct.
2. Use the active voice.
Less desirable (passive voice): When chest compressions are performed, the
chest must be compressed approximately one hundred times per minute.
Better (active voice): When you perform chest compressions, compress the
chest at a rate of about 100/minute.
3. When appropriate, use the imperative. Don’t hesitate to say you.
Acceptable (occasionally preferable): The participant should check for a pulse.
Often better: Check for a pulse.
3
4. Keep the student and the instructor uppermost in mind.
• Will a bulleted list make the prose easier on the mind or the eye?
• Will the instructor or student find the text easier to use if two items are adjacent
rather than apart?
• Will it be useful to get a particular item onto a single page?
• Is all essential wording consistent—eg, in the algorithm, lists, and tables?
• Simple repetition of a term may be valuable. If you use synonyms—eg, aim,
purpose, goal—you may confuse the reader. In the example above, the reader
may not know if the aim, the purpose, and the goal are one thing or three things.
• Are the steps in the same order? Are all the steps there? And so on.
The careful editor will be alert to many details, large and small, that can help the
student or instructor. Emphasize consistency as an aid to understanding.
5. Be flexible. Break any rule rather than do something barbaric.
6. Omit needless words.
Effective writing is concise. Make every word count. Many expressions in
common use violate this principle.
Wordy: Be sure to use effective breaths to make the chest rise in the
recuscitation situation.
Better: During resuscitation use effective breaths to make the chest rise.
7. Be clear.
Clarity is not the prize in writing, nor is it always the principal mark of a good
style. . . . But since writing is communication, clarity can only be a virtue. And
although there is no substitute for merit in writing, clarity comes closest to being
one.
— E. B. White
8. Be precise in describing recommendations and choice of therapies.
The word recommended has special meaning for AHA publications: it suggests a
guideline that results from evidence evaluation and consensus of a
subcommittee or task force. If the AHA science volunteers have not made an
official recommendation but you want to list actions that are appropriate, you can
note that “many researchers recommend” or simply describe the action without
qualifiers to avoid suggesting an official position.
4
Do not use the phrase “of choice” (as in “drug of choice” or “treatment of choice”)
unless a subcommittee or task force has used this precise phrase in a published
guideline or statement or has specifically approved the use of this phrase in a
specific context. Very few resuscitation therapies earn such a designation for any
length of time.
5
Some Amplification
Use active voice and positive statements whenever possible. Avoid phrasing instructions
in a negative. Tell readers what they should do rather than what they shouldn’t do—
unless the caution is necessary to prevent common mistakes.
Prefer: If adjuncts are unavailable, use your fingers. [Positive; active voice.]
Avoid: If adjuncts are not available, fingers should be used. [Negative; passive
voice.]
Prefer: Give each rescue breath slowly, over about 2 seconds. [Active voice;
positive; simple and direct.]
Avoid: Breaths should not be delivered over less than 2 seconds. [Passive voice;
negative.]
Prefer: Avoid rapid, forceful delivery of rescue breaths because it may contribute
to gastric inflation and its complications. [Active voice; positive.]
Avoid: Gastric inflation can be prevented by avoiding rapid and forceful
delivery of breaths. [Passive voice.]
Prefer: If you find an unresponsive victim, begin the steps of CPR immediately.
[Brief; direct; vigorous.]
Avoid: When a victim becomes unresponsive, it is important for the steps of CPR
to begin immediately. [Wordy; lax, less forceful.]
Prefer: If the patient has maxillofacial trauma or if basilar skull fracture is
suspected, insert an orogastric rather than a nasogastric tube because a
tube inserted nasally can enter the brain.
Avoid: Maxillofacial trauma or suspicion of a basilar skull fracture are indications
for orogastric tube insertion because intracranial tube migration may
result from a nasal approach. [The verb to be (are) is generally weak.
Here the action verb insert is much stronger than are. Also compare can
enter with migration may result. Write with nouns and precise verbs.]
6
Prefer: If the victim is not breathing normally, give rescue breaths.
Avoid: In the absence of normal breathing, it will be necessary to deliver rescue
breaths. [Prefer subject-verb (victim is not breathing) to the noun phrase
(the absence of normal breathing). Prefer the active, the direct, the brief.
The shorter sentence is more vigorous.]
Eliminate unnecessary words and include only essential details. Keep in mind that
unnecessary detail will distract the reader and may create inconsistencies across
publications.
Prefer: Place one hand on the victim’s forehead and tilt the head back. Use the
fingers of your other hand to lift the bony part of the chin. Do not press on
the soft tissues of the neck because this can obstruct the airway.
Avoid: Place the palm of one hand on the victim’s forehead. Place the index and
middle (second and third) fingers of the other hand on the underside of
the jaw, being careful to lift the bony part of the jaw, rather than on the
soft tissues of the neck, which may obstruct the airway.
If appropriate content already exists in other AHA publications, use it. The content in
published material has already been copyedited, reviewed for scientific accuracy, and
scrutinized by many readers. Use of published material will probably save you time, and
it is a tried and true presentation of the information.
Be sure that borrowed content is appropriate in reading level and detail for the target
audience. We are trying to simplify material, so you may want to make the excerpted
material even more concise. If you simplify, be sure that the new text retains the same
concept as the old material.
The International Consensus on Science and Treatment Recommendations, the AHA
Guidelines, and any interim AHA science statements provide the scientific foundation for
all training materials. The ECC Handbook is updated every 1 or 2 years, so it will contain
any recent revisions of drug doses or algorithms. All ECC materials must be consistent
with these sources and with other publications in a product line. ACLS recommendations
7
for prehospital management of acute coronary syndromes, arrhythmias, and stroke
cannot differ substantially from guidelines for treatment of these conditions published by
the AHA and ACC or the American Stroke Association. All ECC materials must be
consistent with these sources.
8
Basic Manuscript Preparation
Contents
The author is responsible for providing
•
Title page
•
List of contributors with their professional designation (eg, EMT-P) or highest
academic degree(s). Undergraduate degrees are not listed. Do not list authors’
affiliations (eg, FAAC).
•
Table of contents (the page is titled “Contents” and is set flush left)
•
Any other preliminaries (preface, epigraph, etc)
•
Text with EndNote references called out
•
Tables, if any, numbered and on separate pages
•
List of illustrations, specifying those owned by AHA (and the specific page and
AHA publication where they can be found) and any that are to be copied with
permission from other sources. ECC Product Development staff will obtain
permissions, but include any permissions you have in writing and all information
needed to obtain permissions.
•
Legend copy for illustrations, on separate pages from the text
•
Footnotes, in a separate section
•
All end matter (appendixes etc) except the index
Assemble the manuscript in this order: text, figure legends, tables, figures.
Formatting Text
Consistency is essential.
Keep formatting to a minimum. Use the ECC heading template and indicate heading
levels in braces:
9
Ethical Issues—Part 1: Basic Principles{H1}
Introduction{h2}
Complex and Difficult Decisions{h3}
Cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) have the same
goals as other medical interventions: preserve life, restore health, relieve suffering, and limit disability.
CPR attempts to reverse clinical death, an outcome achieved in only a minority of patients. This
attempt to reverse death, however, may conflict with the patient’s own choices or may not be in his or
1
her best interest. Decisions to start or not start, or to stop or not stop, CPR are complex and difficult.
Ethically such decisions should always involve as a minimum the patient, the family, the physician,
and for patients with such beliefs, the clergy. The very nature of resuscitation, however, almost
always prevents this ethical ideal.
The Two Big Decisions{h3}
This chapter attempts to guide ECC healthcare professionals in making the two most difficult . . . .
Do not use color to designate heading levels because it makes the type more difficult to
read on the computer screen and the color is lost when the document is printed in black
and white. If it is necessary to fax the document, colored type or shaded background
may render sections of the page illegible.
Software. All files should be submitted in Microsoft Word format and in the same font.
The font for body text should usually be Arial (Helvetica) 11 point.
Word spacing. It is now standard publishing style to leave a single character space, not
two spaces, after colons and after periods at the end of sentences. No extra character
space should be left after the final punctuation at the end of a paragraph.
Line spacing. No copy should be single-spaced. Set the line spacing at 1.5 and insert an
extra line between paragraphs (as in this document) and before and after quotations.
Space all copy at 1.5, including notes, quotations, and references. Do not use single
spacing.
Capitalization. Capitalize the first letter of each head and all words except prepositions of
3 letters or fewer, articles (a, an, the), and coordinating conjunctions (and, but, or, nor,
for). ECC style is to capitalize all words of 4 letters or more when used in a head even if
10
they’re prepositions, such as into, down, from, with. Do cap verbs of 2 letters, such as Is
and Be. Do not type heads in all caps. No period follows a head typed on a line by itself.
See ECC style for capping certain words, pages 31-32.
Hyphenation. Turn off the hyphenation function of your word processor. The only
hyphens that appear in the manuscript should be hard hyphens, ie, hyphens in
compound forms, such as compression-relaxation ratio or first-degree block.
Margins. Do not use justified margins.
Dashes. For an em dash—one like this that indicates a break in a sentence—use the em
dash character on your word processor (Ctrl + Alt + -). Leave no space on either side of
the dash.
Em dash: —
En dash: –
Hyphen: Italics, underlining, and boldface. Use italics, not underlining, for words that are to be
italicized in the printed version. Use boldface only for words that are to appear in
boldface in the printed version. If you intend underlining to appear in the published
version, say so: {{{To Ed: Retain underlining.}}}. If something requires special emphasis
and you don’t know what to do, say so: {{{To Ed: Sentence needs special emphasis.}}}.
Do not use ALL CAPS to indicate emphasis. In general, clear writing should have
sufficient impact without the need for italics or other changes in typeface.
{{{Place author’s notes—ie, notes to the editor—in curved braces, as in this example.}}}
Do not use parentheses or square brackets, because parentheses will not stand out
from the text and anything in square brackets is treated as a reference by the EndNote
program. If you insert notes into a manuscript that will be reviewed by several people,
clearly identify the recipient or the author of the note. For example, “FGS: Check this”
could be interpreted as either a note to FGS or from FGS. It would be better to label as
follows: {{{“To FGS: Please check this,” or “From FGS: Please check this.”}}}
11
Numbering Pages
Number the pages. In a book that contains short chapters or no chapters, number
consecutively from page 1 through the end of the book. In books that contain longer
chapters, such as BLS for Healthcare Providers, you can number manuscript pages by
chapter. Although centering the number at the top of the page has long been standard,
some writers and editors (including FGS) find it easier if the page numbers are flush
right.
Chapter Titles and Subheads
Chapter titles. “Chapter 1,” “Chapter 2,” and so on should be typed flush left above the
title. The chapter title should be typed in roman type (rather than italic or bold), starting
flush left, and with initial capitals only. Do not use all caps. The title should not be
followed by a period.
Subheads. A subhead should begin on a line by itself with one or two lines of space
above, flush left. Indicate level of all heads according to the template provided by
Product Development. Use the headings and template to create the Table of Contents
for each chapter, and then check the headings for order and consistency. If similar topics
(eg, antiarrhythmic drugs or chest compression in infants, children, and adults) are
presented, ensure that heading levels are used consistently.
Notes and References
Note numbers and reference numbers in the text are typed above the lineLike this with no
parentheses, periods, or slash marks. Reference numbers follow commas and
Periods.4—like this There is no space between the punctuation mark and the number.
Reference numbers precede colons and semicolons, again with no space inserted. Two
references are done like this16,17; here’s how to handle another situation.5,17-20
Notes. Footnotes are rarely used in ECC materials. Type them spaced at 1.5 lines, in the
same size font as the main text (body copy), not in a smaller font. During copyediting it is
12
often easier if the notes are embedded in the text, ie, typed in the body copy.*
{{{Footnote: *Keeping the notes embedded is especially important if the text will be
edited online.}}} The preceding note is embedded in the body copy. The typesetter will
place it at the bottom of the page.
Notes should never be in a separate file. Each note should end with a period (or other
terminal mark of punctuation). For footnotes in the body copy or in tables, the following
symbols are used in the order shown:
* (asterisk)
† (dagger)
‡ (double dagger)
§ (section mark)
¶ (paragraph symbol)
# (number sign)
** (asterisk repeated)
References. Use the Circulation style in EndNote. Make certain that you cite the correct
references and that all references are called out.
Tables and Figures
Tables. Type tables on pages separate from the text. Type the word Table and the table
number (eg, Table 1, Table 2, Table 3) on a line above the table. Do not type table titles
in all caps; capitalize as in heads. No period follows the table title. Table footnotes are
typed below the table and are indicated by superscript symbols: *
† ‡
and so on.
Indicate in body copy where tables are to be placed. Example: {{{Insert Table 2.}}} In
your manuscript place the tables at the end of the chapter. The typesetter will insert
them where they are called out in the body copy.
Figures and Legends. Do not insert the figures or legends in the body of the manuscript.
Include notes in the text to indicate the approximate location of each figure: {{{Insert
Figure 1.}}} Then place the figures and legends at the end of the manuscript. In calling
out figures in body copy, it is usually superfluous to say “see” Figure 1; just “Figure 1”
will do.
13
•
List all figures at the end of the document and indicate the source or location of
these figures.
•
If you are using existing figures from other AHA publications, be sure that the
borrowed illustrations depict the appropriate rescuer (eg, lay rescuer,
workplace rescuer, EMS rescuer, in-hospital healthcare provider), with
appropriate equipment (eg, gloves versus no gloves, masks with one-way
valves versus face shields), with the appropriate victim (family member, infant,
child, adult, school-age child, workplace colleague). Indicate all parts of the
figure.
•
When you want figures reproduced from non-AHA sources, provide complete
information about the source of the figure.
•
Type figure legends on a separate sheet, spaced at 1.5. End legends with a
period. Typing legends on a separate sheet will reduce the cost of typesetting.
Checking and Cross-checking
Proofread
Proofread a printed copy of the text in final form. This will facilitate side-by-side
comparison of headings, objectives, and steps that appear several times or in several
forms in the same document. Be sure you have included all parts. If the manuscript has
been edited several times with “track changes,” proofread the final version with all
changes accepted or without the changes visible on the printed version. Save the
version with all changes accepted under a different file name so that you can refer to the
version with the track changes indicated if necessary. This will allow you to verify that all
changes have been made correctly and completely.
Check Spelling
Use spellcheck before submitting the manuscript.
14
Check Quotations
Check all quoted matter against the original source, for both content and citation. Unless
the manuscript editor is certain to have the original source at hand (ECC Guidelines
2000, for example), enclose a copy of the quoted material with the manuscript. Doing so
will often save time in copyediting.
Check for Completeness
1. Make sure that all references are complete.
2. Make sure that all references are called out (cited) in the text and in consecutive
order.
3. Make sure that all figures and tables are called out (cited) in consecutive order, with
placement indicated in the text. Be sure that you include all legends and all parts of all
figures.
4. Be sure that you have correctly included all citations for figures, tables, and
quotations.
Check Cross-references
All cross-references should be verified—whether to a chapter, a section, an appendix, or
even a sentence of text. A chapter title or number may have been changed after the
original draft, or a passage may have been deleted. Cross-references are best made to
chapter or section numbers, not to page numbers. If absolutely necessary (eg, listing of
the page on which a reader can find the correct answer for a review question), a page
number should be indicated by 3 bullets (Example: see page •••). After final typeset, the
editor will insert the number.
If telephone numbers or web addresses are to be published, check them. Phone the
numbers; check the web addresses online. If the manuscript is to be published
electronically and contains links, check them carefully online.
15
Cross-check the Manuscript for Consistency
1. Titles and headings. See that the chapter titles and the headings match the table of
contents (TOC) word for word. See that all appropriate headings are included in the TOC
and that their relation to each other is correct. That is, the TOC should clearly
differentiate between level 1 and level 2 heads, and so on. Often only level 1 and level 2
heads are included in the final, but it is helpful to the manuscript editors to have a TOC
that lists all heads and indicates their relative level. If in doubt about the number of
headings to include in a TOC, err on the side of too many. It’s less expensive for an
editor to delete heads than to add them. Print out the TOC and review the headings to
be sure they are parallel when appropriate (see Consistency of Text, below), and similar
in format and tense. If you use the ECC template, the TOC can be created automatically
from the headings, but be sure that you create the TOC from the latest draft of the
document.
2. Consistency of Text. Repeated text usually should be identical. If, for example,
“Objectives” are listed at the start of a chapter and in the summary and in a poster and in
a performance checklist, the objectives should be identical everywhere. This is also true
for major skill steps. For example, the list of major steps of AED operation should not
include 4 steps in one place and 6 steps in another. It is acceptable to provide more
detail in one list than in another. You can list additional details as sub-parts but keep the
major steps identical in number and wording.
Present similar material in the same form. This is particularly important when describing
the same rescue steps for victims of different ages. You should use wording and
headings that help the reader grasp the common elements. For example, if you title a
heading “Breathing” for a child, also use the heading “Breathing” for an infant—don’t call
it “Breathing: Child” and then “Breathing and Airway: Infant” unless there is a real need
for difference in content. If “Breathing: Child” is organized ABC, don’t organize
“Breathing: Infant” ACB unless there is a good scientific or pedagogic reason for the
difference.
3. Consistency in Numbers. Numbers should be the same—in drug doses, number of
compressions, and so on. Use the “search” tool to check for such consistency before
16
you submit the manuscript. If different numbers or drug doses are appropriate for
different groups, use the group name (eg, infant or child or adult) to search for
consistency. Then perform a second search using the name of the drug or factor (eg,
epinephrine or chest compressions) to verify consistency and accuracy.
4. Consistency in Terms. As a general rule, use the same terms throughout. Examples:
• Not written evaluation and written examination referring to the same thing.
• Not module, part, section, and so on referring to the same thing.
• Not textbook, provider manual, student manual referring to the same thing.
• Not objectives, goals, purpose referring to the same thing.
Check the glossary, if available, to verify meanings of common terms.
5. Verify references. Be sure that the correct reference is called out to document the
appropriate statement. Print the numbered reference list and check it as you read
through the manuscript.
Parts of the Manuscript to Cross-check
• All titles and subtitles against table of contents
• Subheads against table of contents
• Tables against their text references and callouts
• Figures against their titles, legends, text references, and callouts
• All cross-references
• Drug doses—be sure to check decimal points and units (eg, mg versus µg; mg/kg
versus mg; µg/kg per minute versus µg/min or mg/min
• All numbers—number of compressions, number of shocks, percentages, ratios, etc
• References
Additional Materials to Cross-check for Instructor Manual Manuscripts
• All lists (including objectives, skill steps, checklists) against student manual
• All lists, descriptions, and actions against supplementary material, including manuals,
17
posters, videos, reminder cards, algorithms, scenario cards, and skill checklists
• All numbers and all drug doses against student manual, posters, videos,
reminder cards, algorithms, scenario cards, and skill checklists
• All course sections and times against the sections and times of the course video
Additional Materials to Cross-check for Written Exam Questions
• All wording of lists, descriptions of emergency conditions, and actions against the
student manual, video, reminder cards, algorithms, and scenario cards
• All incorrect answers against wording of all student materials including video
Pearls and Perils
This section lists things that can sabotage manuscript quality, increase preparation and
editing time, and delay publication.
1. The template will provide consistent heading sizes and fonts. When you format a table
of contents, check to be sure that headings are concise and are parallel when
appropriate. Eliminate inconsistencies in wording and level of heading. For example, if a
chapter presents use of drugs for arrhythmias, the drug names should usually be in the
same level of heading, and subheadings should usually be consistent in number,
subject, and wording. For example:
Epinephrine
Indications
Dose
Precautions and Contraindications
Lidocaine
Indications
Dosage [Wrong! Should be dose, as above]
Precautions and Contraindications
OR
18
Vasopressors
Epinephrine
Indications
Dose
Precautions and Contraindications
Vasopressin
Indications
Dose
Precautions and Contraindications
Amiodarone {{{No! A parallel head to Vasopressors would be
Antiarrhythmics, with Amiodarone and Lidocaine as subheads parallel to
Epinephrine and Vasopressin. The Indications, Dose, and Precautions headings
should ideally be in the same heading size throughout the chapter.}}}
Indications
Dose
Precautions and Contraindications
2. Check the glossary, guidelines, recent scientific statements, and other training
materials to be sure your definitions and explanations are consistent with existing
materials.
3. During manuscript development, keep track of all people who contribute to the
document and the level of their contribution. All contributors must sign a conflict of
interest statement before their names are listed as contributors to the document. Too
often, when the document is ready to go to press, the editorial team has to scramble to
assemble a list of contributors and their credentials, and the editors may not be able to
locate one or more contributors. If more than one level of contribution will be listed (eg,
contributors and reviewers), be sure you and all contributors have a clear understanding
of the requirements for listing in each category.
19
4. Carefully review each figure and be sure that each figure correctly depicts the specific
skill or scenario called out in the text and that it includes the appropriate characteristics:
•
Level of rescuer (family member versus workplace rescuer versus EMS
versus in-hospital healthcare provider)
•
Rescuer equipment (especially personal protective equipment)
•
Age of victim (infant, child, adult)
Do not rely on your memory of figure details. Figures may not be inserted until late in the
typesetting process, when it is costly in both dollars and time to make changes. If figures
depict rescuers without gloves when gloves are needed or if they depict rescuers in
scrubs when the publication is for workplace rescuers, the illustrations will be
inconsistent with the text and inappropriate for the target audience. Substitution of a
different figure at this stage may require a costly change in layout of one or more pages.
Figures cannot be redrawn at the last minute, so if new figures are needed, they will
delay publication.
5. When lists or other text appears more than once in a document, you can ensure
consistency in wording if you copy the text from the first use and paste that text when it
should appear again. But this “cut and paste” approach can introduce errors. To avoid
them:
a. If any wording is changed in later revisions, you must be sure to make changes
every place the text appears.
b. If you cut and paste steps of skills for victims of different ages, you must be sure
to enter the appropriate victim age and make appropriate changes in numbers
and ratios. For example, it is a good idea to copy the steps of rescue breathing
from the infant section and paste it into the child section so that the steps are
perfectly consistent. For the pasted section to be accurate for the child section,
you must be sure to change the word infant to child and be sure to modify the
technique where appropriate (eg, change the description of mouth-to–mouthand-nose breathing for an infant to a description of mouth-to-mouth breathing for
a child).
c. If you cut and paste actions for conditions such as toxicities or drug therapies, be
sure you indicate differences where they should be noted.
20
6. To be sure that you have correctly designated appropriate victims for each skill and
each indication, search the document for key terms such as infant, child, and adult to be
sure these terms are appropriately placed. In ACLS materials use types of arrhythmias
and drugs as search terms to verify that everything is correct as submitted. Search the
document for each drug dose to be sure that the correct dose and correct unit of dose
(mg/kg versus µg/kg versus µg/kg per minute) is listed every time the dose is noted.
In an effort to reduce errors in medications, OSHA encourages the use of mcg
instead of µg in handwritten medical documents. AHA will decide whether and how to
apply this recommendation to printed material.
7. Double-check and triple-check lists and objectives and skill steps to be sure they are
absolutely consistent at the beginning and end of all chapters and in all course materials.
8. When you proofread the document on the computer, display the document at 150%
size. At this size extra spaces and inappropriate punctuation will be easier to spot. Print
the document and proofread a hard copy from beginning to end. You will see errors and
inconsistencies more easily when reading a printed document.
Emerson noted, “A foolish consistency is the hobgoblin of little minds, adored by little
statesmen and philosophers and divines.” However, his next sentence, less often
quoted, is, “With consistency a great soul has simply nothing to do”—a worthy goal when
deadlines are pressing.
21
Checklist for All Manuscripts
Initial and date each part of this checklist and submit it with the manuscript.
_______ I have included all parts of the document needed for production
_______ All front matter is complete, including preface and complete list of contributors
and their credentials
_______ I have checked with contributors about their preferred name
_______ The manuscript is spaced at 1.5 lines, including references
_______ Figure legends are typed on a separate page from text (body copy)
_______ All figures are complete and contain appropriate rescuer level, victim, and
equipment
_______ Level of all heads is indicated
_______ Pages are numbered
_______ Note numbers and reference numbers are typed as superscript
_______ I have used spellcheck
_______ All references are complete
_______ All references are called out in the text and in order
_______ All figures and tables are called out and in order
_______ The TOC matches the chapter titles and headings word for word
_______ Headings are parallel and consistent in form when appropriate
_______ Repeated text is the same everywhere—in summaries, tables, posters, etc
_______ I have checked drug doses and other numbers for consistency and accuracy
_______ I have used terms consistently throughout
_______ I have included any recent changes in science or AHA recommendations in the
document
_______ I have used the EndNote master library for all citations.
22
Additional Checklist for Instructor Manuals
Initial and date each part of this checklist and submit it with the manuscript.
______ I have checked all lists and objectives against the following:
_____ manuals
_____ posters
_____ videos
_____ reminder cards
_____ algorithms
_____ scenario cards
_____ skill checklists
______ I have checked all numbers, drug doses, and descriptions of skills against
the following:
_____ manuals
_____ posters
_____ videos
_____ CD-ROM material
_____ reminder cards
_____ algorithms
_____ scenario cards
_____ skill checklists
______ I have checked all course outlines and agendas and ensured consistency in
headings and time allotments with the video
______ I have checked to ensure that all skill checklists, equipment lists, and other
instructor reference materials are included in the document
______ I have included any recent changes in science or AHA changes in
recommendations in the instructor and student material
23
Some Matters of Style
This section is intended primarily for copyeditors and proofreaders.
Lists
A colon is commonly used to introduce a list or a series, especially after anticipatory
phrasing such as the following or as follows.
Do not use a colon to introduce a list or enumeration immediately preceded by a verb or
preposition. A colon should not separate a verb from its complement or a preposition
from its object. The following examples correctly illustrate these principles:
Check the following:
• Number of acres in pasture
• Total number of goats
• Number of female goats
That irksome teenager wants me to
• Do his laundry
• Pick up after him
• Pay for his mistakes
The signs are
• Hesitation
• Staring blankly
• Feigning indifference
Capitalize the first word of each item in a vertical list, as above.
Do not use a period after an item in a list unless the item is a complete sentence. If the
vertical list completes a sentence begun in an introductory element, the final period is
omitted. If some items in a vertical list are complete sentences and some are not, use
periods for all the bullets.
Each course must have the following personnel:
• An ACLS-EP course director.
• If the course director is not a physician, an ACLS-EP physician instructor must be
present for the learning stations.
24
Do not use a comma or semicolon after each item in a list.
The major events were
1. Toasting the honorees
2. Dancing the carioca
3. Planning another shindig
The following general suggestions are presented for instructors:
1. Preregistration is a must.
2. Phone registration is usually more efficient than mail registration.
3. Establish a central control center for each training site.
25
Numbers
Generally follow AMA style guidelines.
Do not use the number symbol (#) with titles or labels:
Case 1, not Case # 1
Avoid unnecessary numbering. Bullets are often more appropriate than numbers.
Numbering suggests a specific order or priority and should be used to emphasize
sequence. If actions or steps or items are not ordered or prioritized, use bullets rather
than numbers.
Mixed fractions
Precise measurements require decimals: A loading dose of 1.5 mg/kg is acceptable.
Less precise measurements use mixed fractions: Compress the chest about 1½ inches.
Common fractions
Common fractions are expressed with words:
Nearly three fourths of the counselors are whimsical.
A half-second pause preceded the drumroll.
26
Punctuation
Punctuation should be governed by its function:
• To make the author’s meaning clear
• To promote ease of reading
• In varying degrees to contribute to the author’s style
There is inevitably a certain amount of subjectivity in punctuation.
The tendency to use all the punctuation that the grammatical structure of the material
suggests is referred to as close (klos) punctuation. Although close punctuation may be
helpful when the writing is elaborate, chunks of it can make the prose slow-going and
choppy. Only the rare sentence in ECC materials should require close punctuation.
Close punctuation was more common in the past. The tendency today is to punctuate
only when necessary to prevent misreading. Most contemporary writers and editors lean
toward this open style of punctuation yet preserve a measure of subjectivity and
discretion.
Too closely punctuated: The soil, which, in places, overlies the hard rock of this
plateau, is, for the most part, thin and poor.
Better: The soil, which in places overlies the hard rock of this plateau, is for the
most part thin and poor.
ECC style is moderate, open punctuation.
Comma
Adverbs and commas. "The modern tendency is to use fewer commas . . . . It is
especially noticeable in the trend away from setting off adverbial modifiers . . . .[Setting
off most introductory adverbs with commas is] unnecessary and somewhat oldfashioned." —Copperud, p.78.
Usually do not insert a comma after such introductory adverbs as usually, recently,
sometimes, occasionally, frequently. Some contemporary editors display their ignorance
by automatically inserting a comma after every such word. See “Intolerable Commas,”
below.
27
A common problem. A dependent clause that follows the conjunction between two
coordinate clauses of a compound sentence is usually followed, but not preceded, by a
comma:
Brighton examined the documents for over an hour, and had not Smedley intervened, he
would undoubtedly have discovered the forgery. [No comma before had]
In very open punctuation both commas might be omitted. But ECC style includes both
commas.
Quotation marks with other punctuation marks. Commas and periods go inside final
quotation marks; colons and semicolons go outside.
ECC style is to use the serial comma.
Stay me with flagons, comfort me with apples, and bear my heart away.
28
Intolerable Commas
Automatic punctuation, according to the rules or not, betrays an uncultivated mind. The
discriminating editor eschews the automatic comma.
The commas in the following sentences are as pointless as a swimsuit on a cat.
Suddenly, it’s summer!
Yesterday, love was such an easy game to play.
In 1996, the only stock newsletter named to the Forbes Honor Roll was Michael
Murphy’s California Technology Stock Letter.
Hopefully, Rowena rapped at the gate. [Here hopefully is used correctly.]
After breakfast, the stable boy took the mare for a trot.
On Tuesday, she said, “Cash your dreams before they slip away.”
But, you don’t need a weatherman to know which way the wind blows!
In the doorway, stood a siren in a red cape.
Actually, I measure time by how a body moves.
Unfortunately, the market fell.
Usually, he’s late.
During the meeting, Eleanor snored.
En dash
Except in tables, join mixed and decimal fractions by the word to, not by an en dash.
1½ to 2 inches, not 1½–2
2.5 to 3.8 cm
29
Parentheses
Use double parentheses (like this) to enclose numerals or letters marking divisions or
enumerations run into the text.
Professors are interested in (1) committee meetings, (2) lunch, and
(3) students—in that order.
Use a period without parentheses after numerals or letters used to enumerate items in a
vertical list.
Do the following, in order:
1. Hatch your chickens.
2. Count your chickens.
30
Spelling and Capitalization
Avoid excessive capitals. ECC, like Chicago (see “Basic Reference Works”), generally
prefers a “down” style, defined by Chicago as “the parsimonious use of capitals.”
Although proper names are capitalized, many words derived from or associated with
proper names (board of regents, hungarian goulash), as well as the names of significant
offices (presidency, papacy) may be lowercased with no loss of clarity or respect. Thus
course director, instructor, learning station are acceptable, but Learning Station 1:
Electrolytes is appropriate when used as a title.
Style for a number of terms encountered in ECC manuscripts is indicated below.
Ambu bag
AV, not A-V
β-blocker, β-blocking agent. In heads cap the b, eg: β-Blockers in Action
bundle branch block
cardioprotective
caregiver
Chain of Survival
closed-chest compression, CPR, etc.
communitywide
compression-relaxation cycle
compression-ventilation ratio
defibrillator/monitor
distention
email
Emergency Department
first-degree type II atrioventricular block
first responder
first-response team
the 1992 Guidelines
31
head tilt−chin lift
high-degree (adj)
high-density lipoprotein
high energy density (of batteries)
i.d. (internal diameter)
instructor candidate
the instructor station, Instructor Station A
instructor trainer
main stem (noun)
main-stem (adj) N.B.: Right main bronchus is correct; right main-stem bronchus is
jargon.
Megacode
Mega-VF
mid-chest
nonrebreathing
online
Osborne wave
pharmacologic
physiologic
positive-pressure ventilation
pre-excitation
pro-life
pro-smoking
quick-look paddles
recordkeeping
suction-tip catheter
32
torsades de pointes
tPA
33
Usage
and/or. Try to avoid this. Often or will suffice. Or try or both: Use A or B or both.
Arrhythmias:
Use:
atrial fibrillation waves
Avoid: atrial fibrillatory waves [outdated term]
Use:
preserved ventricular function
Avoid: normal ventricular function
Use:
Avoid:
depressed or decreased ventricular function
depressed heart or depressed cardiac function
pre-excitation is the preferred spelling
Avoid non- with pre-excitation (no non–pre-excitation, nonpre-excitation, etc)
Reentrant: Refers to the arrhythmia
Reentry: Refers to the mechanism that creates the arrhythmia
In the treatment of atrial fibrillation and atrial flutter, the distinction in duration is
48 hours or less or
more than 48 hours
atrial fibrillation waves. Not fibrillatory
Brand names of drugs. The generic or nonproprietary name is the established, official
name of a drug. The generic name is in the public domain. It is not capitalized. The
manufacturer’s name for a drug (or other product) is called a proprietary name or brand
name. Proprietary names use initial capitals. AMA publications do not use the trademark
symbol ™ because capitalization indicates the proprietary nature of the name. ECC
publications usually use only generic names, but there are exceptions. For example, for
the sake of clarity someone might write “Administer reteplase (Retavase).”
D5W
34
data. As an abstract mass noun (like information), data is singular. More than 20 years
before the publication of Paradise Lost (1667), data was standard in English. How it was
declined by the great Cicero may be important to a good education, but it is irrelevant to
modern English. Might as well argue that it is incorrect to say the earth’s crust because
earth is an Anglo-Saxon word whose possessive is eorthan. In ECC publications data is
far more often singular than plural.
The data on humility among operatic tenors is scarce. So is the humility.
The information is convincing. The data [collection of material] is convincing.
The pieces of information are contradictory. The data [pieces of information] are
contradictory.
depressed or decreased ventricular function. Not depressed heart or depressed
cardiac function
eg. Means for example [Latin exempli gratia]. Do not use periods. Compare ie.
Jo thinks some 20th-century composers difficult, eg, Berg, Schoenberg.
foot. 12 x 12 ft [no period]. See inch.
he or she, his or her. This locution is awkward and clumsy. Sometimes we use it to
avoid sexism. If the sentence cannot be recast, generally use he or she and his or her,
not he/she. Sometimes it may be feasible to alternate he and she or his and her. But do
not use he or she (or his or her) when doing so would make the writing clunky. Prefer
felicity of expression to this season’s political correctness:
The 1992 Guidelines recommend that one rescuer be on his knees and the other
on his feet. (Here his or her would be ludicrous, clunky.)
In formal writing we use a singular pronoun (he, she, it) with an indefinite pronoun like
anybody, everybody, each, none, and so forth. We say
Everybody carried his stethoscope.
None of the actresses received her paycheck.
Each of the cats extended its paw.
We do not say
Everybody carried their stethoscope.
None of the actresses received their paycheck.
Each of the cats extended their paw.
35
This is a rule of formal writing although we often bend it in informal speech. To avoid his
as sexist, or to avoid his or her as awkward, in informal speech we sometimes use the
incorrect their. Do not use this bad grammar in ECC publications. Perhaps it is best, if
possible, to avoid gender entirely.
Everyone carried a stethoscope.
None of the actresses received a paycheck.
Each of the cats extended a paw.
Caution: Pronouns should correspond with figures: do not use he or his
referring to a figure that pictures a female!
however. Generally avoid starting a sentence with however when the meaning is
“nevertheless.” The word usually serves better when not in first position. (EBW)
The streets were narrow and menacing. However, we at last reached home.
The streets were narrow and menacing. At last, however, we reached home.
But: However you advise him, he will still play the fool.
Frequently however can be deleted with no loss in meaning. Often however can be
replaced with but to the advantage of the prose. Lots of however’s and therefore’s signal
that the prose is critically ill and requires doctoring.
ie. Means that is [Latin id est]. Used without periods, ie, as in this sentence.
inch. 2 x 2 in [no period]. 6-inch needle. 6-inch (3.6 cm) needle. Sit 5 inches away.
Nouns as adjectives. Be wary of nouns used as adjectives:
No: making the ventricular tachycardia management decision
Yes: making the decision about management of ventricular tachycardia
No: Safety requires following infectious disease precautions
Yes: Safety requires following precautions for infectious disease
No: Blix fears Iraq weapons reports distortion
Yes: Blix fears that his reports on Iraq weapons will be distorted
only. The word only is often misplaced. Prefer precise placement. That is, usually place
only before the element it modifies. Copperud quotes a sentence from Word Study that
illustrates the importance of placement: I hit him in the eye yesterday. Try placing only in
the eight possible positions in that sentence and see how the meaning is changed.
preserved ventricular function. Not normal ventricular function.
prior to. Often simply medicalese for before.
36
regarding. Often simply medicalese for about.
sign/signal. Use sign as much as possible, in preference to signal, in BLS materials.
(Loring Flint, in reviewing BLS exams F1 and F2)
signals and actions. One term. No comma after signals in series.
times/minute. Do not use: the first item in such a virgule (ie, slash) construction must be
a unit of measure.
Trailing zero. In drug doses do not use a trailing zero after a decimal point: 1 mg, not
1.0 mg. But OSHA recommends retaining the zero before a decimal number that is less
than 1, eg, 0.01 mg and 0.5 mL, not .01 mg and .5 mL.
Units of measure. Usually spelled out in running text except in drug dosages.
utilize. “Lame substitute for use.” —Wired Style: Principles of English Usage in the
Digital Age. Often signals pretention and ignorance.
Allow utilize when it means “find a profitable or practical use for,” as in this sentence
from Robert Frost: I’m a great person for utilizing waste power.
Another example of correct usage: The teachers could use the computers, but they
could not utilize them.
Do not allow such uses (not utilizations) as this: Every student should be taught to utilize the
mnemonic.
Or this: Utilize your head!
VF, VT. Do not allow terms such as V-tach, Vfib.
Z79, not Z-79
37
How to Import Reference Data From the PubMed Website in
EndNote-Friendly Format
Unless you are provided with different instructions, you should use the AHA master
EndNote library as the EndNote library for AHA ECC manuscript preparation. When the
master library is used, it is not necessary to send that library with the manuscript. If a
separate and unique library is used for a manuscript, you will be notified of the need for
a separate library before work on the project begins. In that case you will submit the
unique library with the manuscript.
1. Consult the Output Formats & Corresponding Import Options table so that you know
the best download format:
Information Provider
Recommended Download Format
Import Option
2. Go to <http://www.pubmed.gov/> www.PubMed.gov.
3. Conduct the search.
4. Choose Medline format from the drop-down list next to the Display button.
5. Choose File in the drop-down list next to the Send button, and then click the Send
button.
6. Save file on the Desktop, changing the extension from .fcgi to .txt because that will
make it easier to find when browsing for this file.
7. Open your EndNote library.
8. Go to File/Import.
9. Click the Choose File button and find the text file you’ve just saved.
10. Choose PubMed (NLM) as the Import Option in the drop-down list. If PubMed does
not appear as a selection in this list, choose Other Filters and select PubMed (NLM).
11. Press Import.
Important: For other data providers, consult the EndNote7 Manual in
Start/Programs/EndNote/EndNote Manual or locate the .pdf file in the EndNote folder on
your C:\ drive—Output Formats and Corresponding Import Options table, pp. 150-154. If
you are using EndNote 7, you need to download a patch from www.endnote.com to
correct an import error in PubMed. The NLM changed its format in early 2004, so the
import function does not work properly without updating the import filter. The information
is one the main web page at the site PubMed News Alert.
38
Basic Reference Works
The style manual for ECC publications is the American Medical Association.
Manual of Style: A Guide for Authors and Editors. Baltimore: Williams & Wilkins;
1998.
The AMA Manual of Style is supplemented by two definitive publications:
The Chicago Manual of Style. 15th ed. Chicago: The University of Chicago
Press; 2003. Referred to in the trade as “Chicago.”
Words into Type. 3rd ed. Englewood Cliffs, New Jersey: Prentice Hall;
1974.
These two works provide essential discussions of copyediting style (including
grammar, punctuation, usage) and typographical style. Words into Type has the
more detailed discussion of punctuation.
The dictionary of reference for the sake of consistency is Merriam-Webster’s
Collegiate Dictionary. 11th ed. Every editor should be familiar with other
dictionaries, especially the American Heritage Dictionary of the English
Language. The 4th edition, 2000, is available online. Copyeditors should have
available the current American Heritage collegiate dictionary. In regard to usage,
many experts consider the American Heritage Dictionary superior to the MerriamWebster collegiate.
The indispensable standard on writing is William Strunk Jr. and E. B. White. The
Elements of Style. 4th ed. Boston: Allyn and Bacon; 2000. Every copyeditor is
expected to be thoroughly familiar with this text and to edit according to its
principles.
Copperud refers to Roy H. Copperud. American Usage and Style: The
Consensus. New York: Van Nostrand Reinhold, 1980. Alas, OOP.
39
Glossary for ECC Writers and Editors
Abbreviations used in this glossary: ACLS RT = ACLS—The Reference
Textbook. ACLS RT is in two volumes: ACLS: Principles and Practice (short title ACLS
P&P) and ACLS for Experienced Providers (short title ACLS-EP), GL= Guidelines; 2000
GL = 2000 International Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care.
Abdominal thrust: A thrust applied to the abdomen just above the navel and
well below the xiphoid to expel a foreign-body causing airway obstruction. Also called
the Heimlich maneuver.
Active compression-decompression CPR (ACD-CPR): An alternative form of
CPR using a hand-held mechanical device to augment chest relaxation between
compressions. The device uses a type of suction cup attached to the chest. The device
is used to provide positive pressure to the chest on the compression downstroke and
negative pressure to lift the anterior chest on the upstroke. Use of this device appears to
augment venous return to the heart during CPR. This form of CPR is recommended in
the 2000 Guidelines as an alternative to CPR by healthcare providers “when rescuers
adequately trained in use of the device are available” (Class IIb, 2000 GL, page 106).
Acute coronary syndromes (ACS): A term that encompasses symptomatic
conditions resulting in an inadequate blood supply to the heart, including angina and
acute myocardial infarction. The pathophysiology of ACS is summarized in the Updated
2004 Handbook, page 28, and ACLS P&P, page 380. ACS are typically initiated by
rupture of the thin fibrous cap over a lipid-laden intracoronary plaque. Inflammation is
thought to contribute to the rupture. The coagulation cascade is activated when arterial
blood comes into contact with the exposed core of the plaque, and platelet adhesion,
activation, and aggregation contribute to formation of a coronary thrombus. See ACLS
P&P, pages 384-385, for definitions. Note that the signs of ACS (chest pressure,
discomfort, pain) must be consistent with other AHA publications. See chest
discomfort. If the thrombus occludes the coronary vessel, an infarction develops. An
ST-elevation MI is characterized by ST elevation of ≥1 mm in 2 or more contiguous
leads. A non–ST-elevation MI is characterized by ST depression >0.5 mm in 2 or more
contiguous leads, T-wave inversion, dynamic ST changes with pain, or elevation of
cardiac markers. See myocardial infarction. {{Note to writers: please be careful to use
≥ (ie, “greater than or equal to”) sign as indicated for ST elevation and depression.
Anyone writing about ACS should be familiar with the AHA ECC Guidelines as well as
40
recommendations published by the American College of Cardiology and the AHA in
2002 and 2004 that are cited in the Handbook.}}
Adhesive electrode pads: Pads that adhere directly to the skin of the patient’s
chest. These electrodes can be used to capture the surface ECG, and they can be used
as a contact medium for conducting electric current from an automated external
defibrillator (AED) or transcutaneous pacer to the patient. In AHA materials for lay
rescuers we use the term pads, but in healthcare provider materials we use adhesive
electrode pads or even electrodes or electrode pads.
Advance directive: A medical order written by a physician in response to the
expressed wishes of the patient. The advance directive should state the level of care the
patient desires at the end of life. An advance directive may name a surrogate decision
maker to make those choices if the patient is unable to do so. In common usage this
term includes living wills, but it is preferable that these terms are not interchanged. A
living will contains an expression of the patient’s wishes. An advance directive, in
contrast, is a physician order that is based on the patient’s wishes.
Advanced cardiovascular life support (ACLS): A group of interventions used
to treat and stabilize adult victims of life-threatening cardiorespiratory emergencies and
to resuscitate victims of cardiac arrest. These interventions include CPR, basic and
advanced airway management, tracheal intubation, medications, electrical therapy, and
intravenous (IV) access. ACLS also refers to a training course sponsored by the
American Heart Association that instructs healthcare providers in the basic and
advanced techniques of resuscitation.
Agonal electrical cardiac activity: A cardiac arrest rhythm characterized by
occasional wide complexes on the electrocardiogram (ECG).
Agonal respirations: Ineffective, reflex, gasping respiratory efforts that may
occur at the moment of cardiac arrest and may persist during the first few moments after
cardiac arrest. Writing for AHA Guidelines and texts should avoid any suggestion that
agonal respirations are effective respirations. Victims demonstrating agonal respirations
require support of breathing (delivery of rescue breaths). The lay rescuer is taught to
look for “normal” respirations; the HCP is taught to look for “effective” respirations, and if
these are not present, the rescuer should give rescue breaths.
Aneurysm: An abnormal localized dilation of a blood vessel wall, which weakens
it, often causing sudden rupture and bleeding.
41
Angina: Transient pain, pressure, or discomfort resulting from a temporary lack
of adequate blood supply to the heart muscle. Angina is referred to as “unstable angina”
if it is associated with ST-segment depression >0.5 mm in 2 or more contiguous leads,
dynamic T-wave inversion, dynamic ST-T changes with pain, or release of cardiac
markers. Note that when writing about the signs of ACS we must be consistent with
other AHA publications. See Chest discomfort.
Antiplatelet agents: Platelets are small disc-shaped structures in the blood that
adhere together or aggregate to form clots. Platelet aggregate activity serves an
important function by stopping bleeding (hemostasis), but it also may contribute to the
formation of harmful blood clots (thrombosis) in the coronary arteries or brain.
Antiplatelet agents block this action. Aspirin is a well-known and effective antiplatelet
agent.
Apneic: May refer to either a pause (of 20 seconds or longer) in breathing or
complete cessation of breathing.
Arrhythmia: Abnormal heart rhythm. Some medical publications use
dysrhythmias, but arrhythmia is the term used in AHA ECC materials.
Arteries: Muscular blood vessels that carry blood away from the heart.
Arterioles: Very small muscular blood vessels located throughout the body that
regulate blood pressure.
Arteriosclerosis: Commonly called “hardening of the arteries,” arteriosclerosis
includes a variety of conditions that cause the artery walls to thicken and lose elasticity.
Asphyxia: A life-threatening condition caused by a lack of oxygen (eg,
suffocation).
Asymptomatic coronary artery disease (CAD): The phase of CAD in which the
patient has not yet experienced symptoms.
Asystole: Cardiac standstill or an absence of any electrical cardiac rhythm; also
called flat line.
Atherosclerosis: A process that leads to a group of diseases characterized by a
thickening of artery walls. Atherosclerosis is a leading cause of death from heart attack
and stroke.
Atrial fibrillation: An abnormal, irregular heart rhythm that results in quivering of
the atria so that they no longer contract. This arrhythmia can lead to stasis of blood in
the atria and formation of clots. These clots can embolize to other parts of the body.
42
Automated external defibrillator (AED): An external computerized defibrillator
designed for use by lay rescuers and healthcare providers for treatment of sudden
cardiac arrest (signs are unresponsiveness, no breathing, and no signs of circulation,
including no pulse). The AED detects the victim’s heart rhythm through adhesive
electrodes placed on the victim’s chest, analyzes the rhythm, and identifies shockable
rhythms (ventricular fibrillation or rapid ventricular tachycardia). Once a shockable
rhythm is identified, the AED automatically charges to a preset energy level and provides
voice prompts for the operator. When activated by the rescuer, the AED will deliver a
shock through the adhesive electrodes.
Automaticity: The ability of cardiac tissue to reproducibly generate its own
electrical impulse.
Bag-mask (device): A mechanical aid used to deliver positive-pressure
ventilation. The device consists of a bag with an oxygen inlet and a mask. Many bags
contain a unidirectional valve to deliver air flow from the bag (and oxygen source if
oxygen is attached) to the victim when the bag is squeezed and to divert the patient’s
exhaled air into the atmosphere between delivered breaths. A bag, unidirectional valve,
and mask can be referred to as a bag-valve-mask system, and this was the term used in
pre-2000 Guidelines. Because some bags do not contain valves, the process of
delivering rescue breaths with a bag and mask is now referred to as “bag-mask
ventilation (BMV)” rather than ‘bag-valve-mask (BVM) ventilation.”
Barrier device: Any number of devices used in rescue breathing (including face
shields and masks) that create a physical barrier between a rescuer and a victim to
decrease the small chance of disease transmission.
Basic life support (BLS): A group of actions and interventions used to treat,
stabilize, and resuscitate victims of cardiac or respiratory arrest. These BLS actions and
interventions include recognition of a cardiac or respiratory emergency or stroke,
activation of the emergency response system, cardiopulmonary resuscitation (CPR), use
of an AED, and relief of foreign-body airway obstruction. BLS also refers to a training
course sponsored by the American Heart Association that instructs healthcare providers
in the basic techniques of resuscitation.
Biphasic: Having 2 phases or variations.
Biphasic waveform defibrillator: A defibrillator that delivers a current that flows
in one direction for a specified duration of time and then reverses direction for the
remaining milliseconds of electrical discharge. A biphasic defibrillator can often
43
defibrillate the heart with lower peak current than a monophasic defibrillator. Use of
lower peak current is thought to be associated with less myocardial damage.
Bradycardia: Slow heart rate (usually less than 60 beats per minute in an adult).
Capillaries: Minute, thin-walled blood vessels in which there is an interchange of
various substances between the blood and tissue, including gases.
Cardiac arrest: The cessation of cardiac mechanical activity. Victims of cardiac
arrest are unresponsive, with no normal breathing and no signs of circulation, including a
pulse. When cardiac arrest is sudden and unexpected and is caused by a cardiac
problem (rather than secondary to respiratory arrest), it is referred to as sudden cardiac
arrest. Four cardiac arrest rhythms are recognized in AHA ECC materials: asystole,
pulseless electrical activity (PEA), ventricular fibrillation (VF), and pulseless ventricular
tachycardia (VT).
Cardiopulmonary resuscitation: In the broadest sense, attempting any
maneuvers or techniques designed to restore circulation to a victim of cardiopulmonary
arrest. A rescuer begins the steps of CPR when finding an unresponsive victim. Note
that these steps may include opening the airway and rescue breathing or may require
rescue breaths and chest compressions. We would not refer to opening of the airway as
CPR but would say that the rescuer is performing some of the steps of CPR. Some use
the term to refer to a combination of artificial ventilation and chest compressions, but we
prefer the broad use of the term when possible. We do not want to say that if the rescuer
finds an unresponsive victim, opens the airway, and gives 2 rescue breaths and finds no
signs of circulation, the rescuer then begins CPR. At that point the rescuer is already
performing CPR—the rescuer begins compressions and continues compressions and
ventilations and attaches an AED when available.
Cardiovascular: Pertaining to the heart and blood vessels.
Cardioversion: Typically referred to as synchronized cardioversion. This is the
delivery of a shock to the heart in an attempt to terminate a rapid supraventricular or
ventricular arrhythmia. Cardioversion uses lower energy than defibrillation. Unlike
defibrillation, the shock used for cardioversion is timed to coincide with the patient’s R
wave.
Cerebral: A term referring to the cerebrum, the main portion of the brain
occupying the upper part of the cranial cavity.
Cerebral thrombosis: Formation of a blood clot in an artery in the brain. This is
a common cause of an ischemic stroke.
44
Cerebrovascular: A term referring to the brain and the vessels that supply the
brain with blood.
Chain of Survival: An American Heart Association metaphor that uses the links
in a chain to describe the actions needed to save a victim of sudden cardiac arrest. The
links in the adult Chain of Survival are early access to 911, early CPR, early
defibrillation, and early advanced care. The links in the pediatric Chain of Survival are
prevention of injury and arrest, early CPR, early access to 911, and early advanced
care.
Chest discomfort, pain, pressure with ACS: Please check on the AHA website
for any recent updates in descriptive terms. If you find any new information, please share
with your writing colleagues in ECC. In early 2004 the description of chest discomfort
was reworded as follows:
•
Chest discomfort: Most heart attacks involve discomfort in the center of the chest
that lasts more than a few minutes or that goes away and comes back. It can feel
like uncomfortable pressure, squeezing, fullness, or pain.
•
Discomfort in other areas of the upper body: Symptoms can include pain or
discomfort in one or both arms, the back, neck, jaw, or stomach.
•
Shortness of breath: May occur with or without chest discomfort. {{Note to
writers: This “or without chest discomfort” is new as of 2004.}}
•
Other signs: These may include breaking out in a cold sweat, nausea, or
lightheadedness.
Cholesterol: A fatlike substance in the blood that contributes to the formation of
atherosclerosis.
Cincinnati Stroke Scale: A focused physical exam designed to rapidly detect
patients with stroke without the need for blood sampling or use of equipment. This scale
is designed to detect facial droop, arm drift (the patient’s eyes are closed and the arms
held out), and abnormal speech. If any one of the findings is abnormal, the probability of
stroke is 75%. This scale can be accurately used in the prehospital setting. See also Los
Angeles Prehospital Stroke Screen (LAPSS).
Computed tomography (CT) scan: A series of x-rays (radiographs) that are
analyzed and reconstructed by a computer into a pictorial image of a part of the body.
CT scans can be used to visualize a variety of disorders, including tumors,
hemorrhages, and abscesses, and they may reveal areas of abnormal blood flow or
45
injury. A CT scan of the brain is required to rule out the presence of hemorrhagic stroke
before administration of fibrinolytics.
Coronary artery disease (CAD): A group of diseases, including angina and
myocardial infarction, caused by the development of arteriosclerotic plaques that narrow
the artery walls and obstruct distal blood flow to part of the heart.
Coronary artery spasm: Severe, usually localized constriction of a coronary
artery resulting in a lack of blood supply to the heart. This can be an uncommon cause
of angina, called Prinzmetal’s variant angina. In cocaine toxicity, coronary spasm—with
or without intracoronary artery plaque—can be an inciting cause of infarction.
Coronary care unit: A specialized intensive care unit in a hospital that treats
victims of heart disease during the critical or unstable phase of their illness.
Coronary reperfusion: Restoration of some blood flow to an area of the heart.
This may be accomplished by administration of fibrinolytics, angioplasty with or without
stent placement, or coronary revascularization (coronary artery bypass grafting).
Coronary revascularization: The restoration of blood flow to the heart by
means of blood vessel grafting.
Cricothyrotomy: A surgical procedure opening the cricothyroid membrane (in
the windpipe of the neck) to provide an airway. This procedure may be performed by
insertion of a needle through the cricothyroid membrane. A needle cricothyrotomy
enables emergency delivery of oxygen but is unlikely to provide effective ventilation
(elimination of carbon dioxide).
Critical incident stress debriefing (CISD): A group meeting of rescuers
involved in a resuscitation attempt designed to educate and to ease the psychological
and emotional impact of the incident.
Cyanosis: Bluish discoloration of the skin (most often around the lips and nail
beds) often caused by a severe lack of oxygen in the blood.
Deciliter: One tenth of a liter.
Defibrillation: The untimed (asynchronous) depolarization of the myocardium
that successfully terminates ventricular fibrillation (VF) or pulseless ventricular
tachycardia (VT). In defibrillation and defibrillation attempts, a shock is delivered to the
myocardium, most often through the chest wall (although internal defibrillation may be
accomplished if the chest is open). The goal of defibrillation is to enable resumption of a
perfusing rhythm, but the shock may convert the rhythm to asystole. In common usage
the term defibrillation is used interchangeably with the term shock. However, the shock
46
is used to attempt defibrillation, and the term defibrillation should be reserved for the
successful termination of VF/VT.
Defibrillator: A device used to deliver a shock to the heart. A defibrillation shock
depolarizes the heart in an effort to terminate ventricular fibrillation (VF) or pulseless
ventricular tachycardia (VT) and allow a perfusing rhythm to return. Defibrillators may be
manual or automated (see Automated external defibrillator). Manual defibrillators
often have the capacity to perform synchronized cardioversion (see Cardioversion).
DNR (No CPR, DNAR): The terms DNR (“do not resuscitate”), No CPR, and
DNAR (“do not attempt resuscitation”) are used to indicate that in the event of a cardiac
arrest, no cardiopulmonary resuscitative measures should be instituted.
Electrical therapy: Interventions used to convert, terminate, or stabilize a
cardiac rhythm, including defibrillation, cardioversion, and pacing.
Embolic stroke: A stroke caused by an embolism.
Embolism: The sudden blockage of an artery by a clot or other material that has
traveled through the bloodstream from another location.
Emergency cardiovascular care (ECC): A system including all interventions to
manage emergencies related to the heart, blood vessels, and brain. These interventions
include BLS, PALS, and ACLS assessments and interventions performed by bystanders,
trained responders, healthcare professionals, and allied health personnel.
Emergency medical dispatchers (EMDs): EMS personnel who answer 911
calls and dispatch EMS responders to the scene of an emergency. EMDs also provide
telephone instructions to bystanders at the scene while the responders are en route.
Emergency medical services (EMS): The planned configuration of community
resources and personnel designed to respond to medical emergencies and provide
immediate care to persons who have suffered an unexpected illness or injury. The EMS
system includes EMS dispatchers and EMS responders.
Emergency medical technicians (EMTs): Prehospital emergency care
providers trained in a program using the structure and guidelines set forth by the
Department of Transportation (DOT).
EMS responders: A group of EMTs-basic, EMTs-intermediate, and EMTsparamedic who respond with specialized equipment and resources to emergencies in
the community.
Enhanced 911: An emergency medical dispatch system (911) that allows the
dispatcher to identify the location and telephone number of incoming telephone calls.
47
This system allows the dispatcher to send responders to the scene of an emergency
even if the caller cannot provide the address or other information.
Evidence-based: The conscientious, explicit, and judicious use of current best
medical and scientific evidence in determining recommendations for medical care or
policy or decisions about patient care.
Exsanguination: Drainage or massive loss of blood from the body.
Face shield: A barrier device placed over the mouth and nose of a cardiac arrest
victim (or manikin) during rescue breathing.
Fibrinolytic: A term referring to “clot-busting” medications administered to heart
attack and stroke victims. If given within the recommended time, these drugs dissolve
the blood clot that is causing the heart attack or stroke. The benefit of these medications
is time-dependent. Note that this term has replaced the term thrombolytic in most uses.
First responders: A group including police officers and firefighters trained in a
nationally recognized program to respond to emergencies with resources such as
oxygen and an AED.
Focal neurologic dysfunction: Loss of function of part of the body caused by
localized damage to the brain controlling that area.
Foreign-body airway obstruction (FBAO): An obstruction of the airway in any
location from the mouth to the bronchioles, caused by food, toys, or other external
objects.
Glasgow Coma Scale: A scale used to quickly assess the severity of neurologic
dysfunction in patients with altered consciousness. The scale is based on the best
responses for eye opening (1 to 4), verbal responses (1 to 5), and movement (1 to 6).
The total score ranges from 3 to 15.
Good Samaritan laws: Laws or regulations (which vary from state to state) that
generally protect a person who renders emergency aid from civil damages if the person
acts in good faith and not for remuneration. Good Samaritan laws and regulations
typically provide limited immunity, ie, immunity for all but gross negligence. “Limited
immunity” means that if the person acts reasonably and prudently, the person has
immunity from prosecution.
HDL: High-density lipoprotein (“good” cholesterol).
Heimlich maneuver: An abdominal thrust performed in children or adults (not
infants) to relieve FBAO.
48
Hemorrhagic stroke: Localized brain damage caused by bleeding resulting from
the rupture of a blood vessel in the brain.
Hemothorax: Bleeding within the pleural cavity (the space between the lung and
chest wall).
Hypercholesterolemia: High levels of cholesterol in the bloodstream.
Hypertension: High blood pressure. Systolic pressure, diastolic pressure, or
both may be elevated.
Hypertriglyceridemia: High levels of triglycerides (fats) in the bloodstream.
Hypoglycemia: Low blood sugar. Significant hypoglycemia is symptomatic.
Hypothermia: An abnormally low body temperature. It may be caused by
exposure to environmental extremes or physiological factors that affect mechanisms of
heat production and heat loss. Hypothermia can be used therapeutically to reduce
oxygen demand in a victim of cardiopulmonary arrest or head trauma.
Hypothermic: Referring to a low body temperature.
Hypovolemia: Low blood volume, which may be caused by hemorrhage, burns,
metabolic disorders, or other causes of loss of body fluid. Hypovolemia may be absolute
(caused by intravascular volume loss) or relative (caused by expansion of the vascular
space).
Hypoxemia. A low partial pressure of oxygen in arterial blood. Hypoxemia is
present if a patient has a PaO2 less than 80 mm Hg while breathing room air at sea level.
Hypoxia: Inadequate oxygen supply (delivery) to the body’s tissues. When
hypoxia is present, anaerobic metabolism occurs and lactic acid is generated (lactic
acidosis).
Implanted cardioverter defibrillator (ICD): A biomedical device (slightly larger
than a pacemaker) implanted under the skin of the chest or upper abdomen and joined
to the heart by wire electrodes. An ICD detects abnormal (“shockable”) heart rhythms
(ventricular tachycardia or fibrillation) and automatically defibrillates the heart if required.
Interposed abdominal compression CPR (IAC-CPR): A 2- or 3-person CPR
technique that includes manual compression of the abdomen during the relaxation
phase of chest compression. This alternative form of in-hospital CPR requires an
additional rescuer to press on the abdomen in the midline, halfway between the xiphoid
process and the umbilicus. IAC-CPR is an acceptable alternative form of CPR for inhospital resuscitation whenever sufficient personnel trained in the technique are
available (Class IIb, Guidelines 2000, page 105).
49
Intracerebral hemorrhage: Bleeding into brain tissue caused by rupture of a
blood vessel. Hypertension is the most common cause of intracerebral hemorrhage.
Intravascular: Within the blood vessels.
Ischemia: Inadequate blood supply to an organ such as the heart or brain.
Ischemic stroke: Localized brain damage caused by blockage of a blood vessel
supplying the brain. A blood clot is the most common cause of blood vessel blockage.
The blood clot may form at the site of the blockage (thrombotic stroke) or originate
elsewhere in the body (usually the heart) and travel to the blood vessel in the brain
(embolic stroke).
Laryngeal edema: Swelling of the larynx and surrounding tissues. This swelling
can result in airway obstruction.
Laryngospasm: Severe constriction of the larynx.
Larynx: The structure in the neck formed by rings of cartilage guarding the
entrance to the trachea and functioning secondarily as the organ of voice. Commonly
called the voice box.
LDL: Low-density lipoprotein (“bad” cholesterol).
Living will: An expression of an individual’s wishes regarding healthcare issues
at the end of life. It should be enforced by a formal advance directive that comes from a
physician.
Los Angeles Prehospital Stroke Screen (LAPSS): A focused physical exam
designed to quickly identify patients with stroke. The LAPSS considers age (>45 years),
absent history of seizures or epilepsy, symptom duration <24 hours, patient not
wheelchair-bound or debilitated, and blood glucose between 60 and 400 mg/dL. Then
the screen looks for asymmetry in facial smile/grimace, grip and arm strength.
Mobile life support unit: An intensive care transport vehicle that treats victims
of a wide variety of illnesses and injuries using specialized equipment and personnel.
Monomorphic: Existing in only 1 form.
Monophasic: Exhibiting only 1 phase or variation. This term is used to describe
defibrillators that deliver current of one polarity, ie, one current direction or flow. These
devices have largely been replaced by biphasic defibrillators. See biphasic.
Morphology: Form and structure.
Mouth-to-nose ventilation: An alternative form of rescue breathing in which the
rescuer provides positive-pressure ventilation through the victim’s nose. This technique
50
is recommended when it is impossible to ventilate through the victim’s mouth, when the
mouth cannot be opened, or when a tight mouth-to-mouth seal is difficult to achieve.
Myocardial infarction (MI): Death of heart tissue commonly caused by a blockage
of a coronary artery owing to an arteriosclerotic plaque, thrombus, embolus, or spasm.
When myocardial necrosis (cell death) occurs, cardiac-specific biochemical markers,
such as troponin T or I, are detectable in the blood. See also Acute coronary
syndromes (ACS) and ACLS P&P, pages 384-855, and ACLS-EP, Chapter 2, Part 2.
Myocardial infarctions are characterized by the coronary artery occlusion produced and
the characteristic ECG changes that result, as follows:
•
ST-elevation MI: If the thrombus occludes a coronary vessel for a prolonged
period, ST-elevation myocardial infarction (STEMI) develops. It is characterized
by ST elevation and rise of cardiac markers. STEMI is treated with early/prompt
fibrinolysis or percutaneous coronary intervention.
•
Non–ST-elevation MI: A partially or intermittently occluding thrombus produces
symptoms of ischemia. This phase is characterized by a rise of cardiac markers
and ST depression or dynamic T-wave changes but no persistent ST elevations,
so the term non–ST-elevation MI (NSTEMI) applies. At this stage the thrombus is
platelet-rich, and treatment with anti-platelet agents and glycoprotein IIb/IIIa
inhibitors is most effective. This process was formerly named non–Q-wave
infarction, but this term is now outdated.
Myocardial ischemia: Inadequate delivery of oxygen to the heart muscle. This
ischemia may create pain, called angina. See angina.
Neurologic dysfunction: Abnormal function caused by neurologic insult or
injury.
Normothermic: Normal core body temperature.
Percutaneous coronary interventions (PCIs): A variety of cardiac procedures
using a catheter in combination with other devices to open a blocked coronary artery and
maintain patency. PCIs include angioplasty and stent placement.
Percutaneous transluminal coronary angioplasty (PTCA): The process of
clearing a blocked coronary artery with a balloon that dilates and compresses an
arteriosclerotic plaque against the artery wall.
51
Pericardial tamponade: A collection of blood or fluid in the pericardial sac
around the heart, which can impair cardiac function and obstruct venous return to the
heart.
Peripartum: Pertaining to the period immediately before, during, and after the
birth of a baby.
Pharynx: The musculomembranous area between the mouth and nares and the
esophagus. It communicates with the esophagus, the larynx, the mouth, the nasal
passages, and the auditory tubes.
Platelets: Disc-shaped structures in the blood that aggregate (stick together or
adhere) to stop bleeding. Platelets can exert a protective effect because they protect
from bleeding (hemostasis), but they can also contribute to clot formation (thrombosis)
that can lead to myocardial infarction or ischemic stroke.
Pneumatic antishock garment (PASG): Pneumatic trousers used to control
hemorrhage in the legs and pelvis, thereby increasing peripheral vascular resistance.
Pneumatic vest CPR: An alternative form of CPR using an inflatable vest that
fits completely around the patient’s chest. The vest cyclically inflates and deflates,
producing an increase in intrathoracic pressure. Vest CPR is considered an alternative
to standard CPR in-hospital or during ambulance transport when there are an adequate
number of well-trained personnel to properly provide CPR (Class IIb, Guidelines 2000,
page 106). This is also presented in ACLS P&P, page 191.
Pocket mask: A device that consists of a mask and 1-way valve used to give
rescue breaths and provide a physical barrier between the rescuer and the victim.
Polymorphic: Existing in more than 1 form.
Positive-pressure ventilation: The act of delivering air into the lungs under
pressure, ie, bag-mask ventilation.
Prearrival instructions: Instructions given by a dispatcher to a layperson at the
scene of an emergency before the arrival of EMS. Instructions may include how to
perform chest compressions and rescue breathing, how to assist with childbirth, etc.
Primary hypertension (essential hypertension): High blood pressure of
unknown cause.
Primary prevention: A number of changes in behavior or lifestyle designed to
prevent disease or injury.
Psychomotor: Pertaining to physical actions, which are the end result of mental
activity.
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Public access defibrillation (PAD): A healthcare initiative sponsored by the
American Heart Association and other organizations. This initiative, also called lay
rescuer defibrillation, places AEDs throughout the community in structured programs
with lay rescuers who are trained to recognize sudden cardiac arrest, phone 911,
provide CPR, and use an AED. The goal of PAD programs is to shorten the interval
between collapse due to sudden cardiac arrest and bystander CPR and defibrillation.
These programs should improve survival from sudden cardiac arrest. The 2004 NEJM
publication of the multicenter NHLBI study of PAD programs (Hallstrom et al)
documented improved survival when lay rescuers recognized sudden cardiac arrest,
phoned 911 and provided immediate bystander CPR and even greater increase in
survival when use of AEDs was added to the lay rescuer CPR programs.
Pulseless electrical activity (PEA): A cardiac arrest rhythm characterized by
organized electrical activity of the heart but without a palpable pulse. This term is used to
replace the outdated term electromechanical dissociation.
Rapid sequence intubation: The use of deep sedation and paralysis to facilitate
tracheal intubation and to minimize potential adverse effects. RSI incorporates actions to
prevent pain, anxiety, and distress; to blunt multiple adverse physiologic responses to
laryngoscopy and tracheal intubation; and to reduce the risk of aspiration of gastric
contents.
Recurrent VF: Ventricular fibrillation that occurs again.
Refibrillation: The reoccurrence of VF after conversion to an organized rhythm.
Regurgitation: To vomit gastric contents. This term can also be used to indicate
backward flow of blood, such as occurs from the left ventricle to the left atrium through
an incompetent mitral valve.
Reperfusion: The process of restoring blood flow to a tissue bed. Coronary
reperfusion can involve techniques such as fibrinolysis (use of “clot-busters”) or
angioplasty. Reperfusion can also occur when circulation is restored (eg, to the brain)
following cardiac arrest.
Respiratory arrest: The absence of respirations, ie, apnea. Cessation of
effective breathing requires intervention to prevent progression to cardiorespiratory
arrest. Note: In BLS courses lay rescuers are taught to provide rescue breaths if an
unresponsive victim is not breathing “normally”; healthcare providers are taught to give
rescue breaths if an unresponsive victim is not breathing “effectively.”
53
Respiratory failure: The state that exists when the respiratory system can no
longer support life. If an intervention is not provided, the victim will become progressively
more hypoxic or hypercarbic, or both, and will ultimately die.
Respiratory insufficiency: Respiratory function that is inadequate to maintain
normal levels of oxygen and carbon dioxide in the blood.
Secondary hypertension: High blood pressure caused by a condition such as
kidney disease.
Secondary prevention: Actions taken to prevent further complications after an
injury or illness.
Sedation: Sedation is administration of drugs to reduce the state of awareness.
A number of different terms are used to describe potential levels of sedation. The
American Society of Anesthesiologists (ASA) has defined 4 levels of sedation: minimal
sedation (anxiolysis), moderate sedation/analgesia (formerly called conscious sedation),
deep sedation/analgesia, and general anesthesia. Note that the term conscious sedation
is outdated and no longer used.
Shock: A clinical condition in which perfusion of the vital organs is inadequate to
meet organ tissue metabolic demand. It is characterized by a sustained and significant
reduction in blood flow and oxygen delivery to some organs and tissues. Shock may be
characterized by etiology or according to its effect on blood pressure. In PALS shock is
classified as compensated when the systolic blood pressure is in the normal range and
as uncompensated when the systolic blood pressure is less than the 5th percentile for
age. See PALS Provider Manual, pp. 30-32, and ACLS-EP, p. 35.
Silent ischemia: An instance in which a patient experiences an ischemic event
in the absence of chest pain, making diagnosis of acute MI more difficult. Women,
persons with diabetes, and the elderly are more prone to silent ischemia than others.
Stroke: A disruption in blood supply to a region of the brain that causes acute
neurologic impairment.
Stroke Chain of Survival and Recovery: The term used to describe the actions
for survival and recovery from stroke, which are (1) rapid recognition and reaction to
stroke warning signs, (2) rapid start of prehospital care, (3) rapid transport by the EMS
system and hospital prenotification, and (4) rapid diagnosis and treatment in the
hospital. The AHA ECC materials also note that there are 7 D’s of stroke care, which
correspond to 7 potential linked actions that must be efficient to prevent delays of stroke
care. These 7 D’s should not be confused with the 4-link stroke Chain of Survival. See
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ACLS P&P, page 446, and check with the AHA website for any recent changes in these
terms.
Subarachnoid hemorrhage: Bleeding between the arachnoid membrane and
the surface of the brain caused by rupture of a blood vessel. The most common cause of
a subarachnoid hemorrhage is rupture of a cerebral aneurysm.
Subdiaphragmatic: A term indicating the area below the diaphragm (the
muscular partition separating the abdominal and thoracic cavities).
Sudden cardiac arrest: Sudden or unexpected cessation of heart function, most
often caused by a sudden arrhythmia, such as VF or pulseless VT. Sudden cardiac
arrest is not a cause of death that is reported to the CDC, so it is difficult to determine
the precise incidence of SCA. In 2004 we are using the following numbers based on
CDC data:
•
340,000 deaths from CHD outside of the hospital and in hospital outpatient areas
and EDs
•
250,000 as an approximation of out-of-hospital sudden cardiac arrest deaths,
based on the 262,380 CHD deaths that are left after you eliminate the outpatient
and ED deaths
AHA will likely update these numbers in the 2005 Statistical Update, available before the
2005 Guidelines conference.
Supraventricular tachycardia (SVT): An abnormally rapid cardiac rhythm
generated from an electrical focus in the heart that is above the ventricles. SVT typically
produces a heart rate greater than 140 beats per minute in the adult and greater than
180 to 220 beats per minute in the infant or child.
Syncope: A temporary loss of consciousness due to cerebral ischemia.
Tension pneumothorax: Air trapped in the pleural space (the space between
the lung and the chest wall) caused by a 1-way valve effect. A tension pneumothorax
results in increased intrathoracic pressure, respiratory failure, decreased blood return to
the heart, and shock.
Tidal volume: Volume of air inspired during 1 respiratory cycle.
Tracheobronchial: Pertaining to the trachea (windpipe) or bronchi within the
lung.
Tracheostomy: The surgical creation of an opening into the trachea through the
neck.
55
Transient ischemic attack (TIA): A reversible episode of focal neurologic
dysfunction. {{Note to writers: Since 2003 TIA is used to refer to the onset of any focal
neurologic deficit that spontaneously and completely resolves in 1 hour.}} Most TIAs last
only 5 to 10 minute and then resolve. TIAs are “red flags” for stroke: 25% of patients with
a documented stroke report a previous TIA, and 10% of patients presenting to an ED
with TIA will experience completed stroke within 3 months (most within 2 days). For
further information see Chapter 18: Acute Stroke in ACLS P&P.
Transthoracic impedance: The resistance to transmission of electrical current
represented by the skin, fat, muscle, and lung of a patient’s chest.
Universal choking sign: The sign in which a victim clutches his neck with both
hands, indicating a foreign-body airway obstruction.
Universal precautions: Steps taken to prevent potential contact with body
substances that may carry the human immunodeficiency virus (HIV) or hepatitis B virus
(HBV). This approach is designed to prevent the transmission of disease by using
gloves, goggles, masks, and gowns.
Utstein style: A method of data collection that includes a uniform definition of
terms and time intervals related to the discovery, assessment, and management of
prehospital and in-hospital cardiac arrest. The Utstein guidelines were developed to
guide collection, publication, and comparison of data in human and laboratory
resuscitation research.
Vasoactive agents. Drugs used to support cardiovascular function.
• Inotropes increase cardiac function and often increase heart rate as well.
• Vasopressors increase systemic and pulmonary vascular resistance. If
myocardial function is adequate, vasopressors will typically increase systemic and
pulmonary artery pressure.
• Vasodilators are designed to reduce systemic and pulmonary vascular
resistance. Although vasodilators do not directly increase myocardial contractility, they
reduce ventricular afterload, which often improves stroke volume and cardiac output.
Vasodilators are the only class of agents that can increase cardiac output and
simultaneously reduce myocardial oxygen demand.
• Inodilators improve cardiac contractility and reduce afterload.
See ACLS-EP, Chapter 11 and PALS, page 136.
Veins: Blood vessels that return blood to the heart.
56
Vena cava: The largest veins the body, which returns blood to the right side of
the heart.
Ventricular fibrillation (VF): A chaotic and disorganized heart rhythm that
results in cardiac arrest. When VF is present, the heart quivers and cannot pump blood
effectively.
Ventricular tachycardia (VT): An abnormally rapid heart rhythm generated
within the ventricles. Ventricular tachycardia with pulses is treated pharmacologically if
the patient is stable and with emergency cardioversion if the patient is unstable. Rapid
VT is likely to be associated with loss of pulses (cardiac arrest). Pulseless VT is treated
as VF, with attempted defibrillation. Any VT can deteriorate to VF.
Waveform: The form and structure of an electrically conducted impulse.
Xiphoid process: The bony protuberance at the base of the sternum.
57