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Establish an initial i.v. line in the antecubital fossa.
Give at least 20 mL of normal saline to flush any drugs administered, that are given after the third DC shock.
Elevate the limb for 10–20 s to facilitate drug delivery to the central circulation. Establish a second i.v. line unless the cardiac resuscitation is rapidly successful ideally this line should be inserted into a central vein, either the external or internal jugular or the subclavian a central line should only be inserted by a skilled doctor, as inadvertent arterial puncture, haemothorax or pneumothorax may invalidate further resuscitation attempts also, the central venous route poses additional serious hazards should thrombolytic therapy be indicated all drugs are then given via this central line.
Endotracheal intubation
A skilled doctor with airway training may insert a cuffed endotracheal tube. This maintains airway patency, prevents regurgitation with inhalation of vomit or blood from the mouth or stomach, and allows lung ventilation without interrupting chest compressions. Confirm correct endotracheal tube placement by seeing the tube pass between the vocal cords, and by observing bilateral chest expansion, and auscultating the lung fields and over the epigastrium. Immediately connect an exhaled carbon dioxide detection device such as a waveform capnograph, and look for a tracing, as the signs above are not completely reliable never delay CPR to intubate the airway except for a brief pause in chest compressions of not more than 10 s, as the tube is passed between the vocal cords. Once the airway has been secured, continue cardiac compressions uninterrupted at a rate of at least 100/min, and ventilate the lungs at 10 breaths/min (without any need now to pause for the chest compressions) take care not to hyperventilate the patient at too fast a rate. Subsequent management depends on the cardiac rhythm and the patient’s condition. Keep the ECG monitor attached to the patient at all times.