RESUSCITATION

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Ventricular fibrillation at the earliest possible opportunity. Basic life support should be started if the defibrillator is not available immediately, but it should not delay delivery of the shock. If the arrest was witnessed, particularly in patients who are already monitored, and a defibrillator is not immediately available, a precordial thump should be given. In the presence of VF (or pulseless ventricular tachycardia) the left-hand side of the universal algorithm should be followed. Up to three shocks are given initially. In machines that deliver a monophasic waveform, energy levels of 200 J, 200 J, and 360 J should be used. Shocks of equivalent energy should be used with defibrillators that administer biphasic shocks. If more than one shock is required, the paddles or adhesive electrodes should be left in position on the patient’s chest while the defibrillator is recharged, and the monitor observed for any change in rhythm. When all three shocks are required, the objective should be to deliver these within one minute. This sequence should not normally need to be interrupted by basic life support, but if a delay occurs, because the equipment available does not permit rapid recharging between shocks, it is appropriate to consider providing basic life support between shocks. The carotid pulse should be checked only if the ECG changes to a rhythm compatible with a cardiac output. However, it is important to remember that after a shock is given a delay of a few seconds often occurs before the ECG display is again of diagnostic quality. In addition, successful defibrillation is often followed by a period of apparent asystole before a coordinated rhythm is established. Even if a rhythm that is normally compatible with a cardiac output is obtained, a period of impaired myocardial contractility often occurs, resulting in a weak or impalpable carotid pulse. It is important not to make a spurious diagnosis of pulseless electrical activity under these circumstances; for this reason the algorithm recommends only one minute of cardiopulmonary resuscitation (CPR) before reassessment of the rhythm and a further pulse check. After tracheal intubation chest compressions should continue uninterrupted at a rate of 100 per minute (except for defibrillation, pulse checks, or other procedures), while ventilation is continued at a rate of about 12 ventilations per minute. Continuous chest compressions may be possible with a laryngeal mask airway (LMA), but the seal around the larynx must prevent gas leaking and permit adequate ventilation of the lungs. If this is not possible, chest compressions should be interrupted to allow the usual 15 : 2 compression : ventilation ratio. Intravenous access should be established at an early stage in the management of cardiac arrest. Although cannulation of the central veins allows drugs to be delivered rapidly into the circulation, more complications can occur, some of which are serious. In most circumstances peripheral venous cannulation is quicker, easier, and safer. The choice will be determined by the skills of those present and the equipment available. In recent recommendations on the treatment of patients with VF refractory to initial attempts at defibrillation, anti-arrhythmic drugs have achieved less prominence. Amiodarone is currently recommended in the United Kingdom as the agent most likely to be successful in this situation. Lidocaine (lignocaine) may be considered as an alternative if amiodarone is not available but should not be given if the patient has previously received amiodarone. Procainamide is another alternative, although it is not widely employed in the United Kingdom. Further information about vasoconstrictor drugs and anti-arrhythmic agents is given in Chapter 16. If the patient remains in VF after one minute of CPR, then up to three further shocks should be given, each at 360 J (or the equivalent with a biphasic defibrillator), and the VF/VT Defibrillate x 3, as necessary CPR 1 minute Cardiac arrest Precordial thump, if appropriate Basic life support algorithm, if appropriate Attach defibrillator/monitor Assess rhythm ± Check pulse During CPR, correct reversible causes If not done already: • Check electrode/paddle positions and contact • Attempt/verify: Airway and O 2 , intravenous access • Give adrenaline (epinephrine) every 3 minutes • Consider: Amiodarone, atropine/ pacing, buffers Potentially reversible causes • Hypoxia • Hypovolaemia • Hyper- or hypokalaemia and metabolic disorders • Hypothermia • Tension pneumothrax • Tamponade • Toxic/therapeutic disturbances • Thromboembolic or mechanical obstruction Non-VF/VT CPR 3 minutes (1 minute if immediately after defibrillation) The advanced life support algorithm for the management of cardiac arrest in adults. Adapted from Resuscitation Guidelines 2000, London: Resuscitation Council (UK), 2000 The patient’s airway should be secured. Tracheal intubation is the preferred method, but this depends on the experience of the rescuer; the LMA or Combi-tube are acceptable alternatives. Once the airway is secure, ventilation is performed with as high a concentration of oxygen as possible With each loop of the algorithm 1 mg of adrenaline (epinephrine) should be administered. Vasopressin in a single intravenous dose of 40 units has recently been proposed as an alternative pending the outcome of further assessment of its role 9
ABC of Resuscitation 13:10:46 Combo Pads Shock 3200 J 13:10:53 Combo Pads Postshock Segment 1 Analysis 7 Motion 13:11:01 Combo Pads Medtronic Physio-Control Nonshockable Segment 1 Nonshockable No shock advised monitor must be checked between each shock. The interval between batches of shocks should not exceed one minute, even if the airway has not been secured or intravenous access obtained, because the best chance of successful resuscitation still rests with defibrillation. The loop on the left-hand side of the algorithm is continued with each sequence of three shocks (assuming successful defibrillation does not occur), which is followed by one minute of CPR. Further attempts to secure the airway or gain intravenous access may be attempted if necessary. Adrenaline (epinephrine) should be given with each loop or about every three minutes. The use of alkalising or buffering agents has achieved less prominence in resuscitation guidelines in recent years. The use of bicarbonate may be considered if the arterial pH is less than 7.1 (or [H] 0.80 mol/l), if cardiac arrest is associated with overdose of tricyclic drugs or in the presence of hyperkalaemia. An initial dose of 50 mmol is used, with further doses determined by the results of blood gas analysis. If VF persists, the position of the paddles may be changed or a different defibrillator, or paddles, or both, may be tried. Drugs given intravenously may take several minutes to exert their full effect, and drugs given by the endobronchial route may take even longer. Nothing is gained, however, by delaying further shocks because defibrillation remains the only intervention capable of restoring a spontaneous circulation. The algorithms are not intended to preclude the use of agents such as calcium, magnesium, or potassium salts whether for the treatment of known deficiencies in a particular patient, on clinical suspicion (for example, magnesium deficiency in patients on long-term diuretics), or on an empirical basis. Safety Care is needed to ensure that use of the defibrillator does not pose a risk to any of the staff participating in the resuscitation attempt. When defibrillation is carried out, it is essential that no part of any member of the team is in direct contact with the patient. The operator must shout “stand clear” and check that all those present have done so before giving the shock. There are traps for the unwary: wet surroundings or clothing are dangerous; intravenous infusion equipment must not be held Continuous ECG recording showing VF successfully treated by a countershock Defibrillation—points to note ● The number of “loops” completed during any particular cardiac arrest is a matter of judgment based on the clinical state of the patient and the prospects for a successful outcome ● Resuscitation that was started appropriately should not be abandoned while the rhythm is still recognisable VF; the development of persistent asystole is an indication that the prospects of success are poor ● Few situations call for resuscitation efforts continuing for more than one hour, exceptions being cardiac arrest in children, after drowning, or in the presence of hypothermia or drug overdose Epidemiology of ventricular fibrillation ● 70 000 deaths per annum in the United Kingdom are sudden cardiac deaths ● Most sudden deaths are due to coronary disease ● Most coronary deaths occur outside hospital ● 50% of those who die of acute myocardial infarction do so within an hour of the onset ● VF rhythm at onset in 85-90% of patients 10
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Page 6 and 7: Contents Contributors Introduction
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