European Resuscitation Council Guidelines for Resuscitation ... - CPR

18 de 0ctubre de 2010 www.elsuapdetodos.com1328 C.D. Deakin et al. / Resuscitation 81 (2010) 1305–13524g Peri-arrest arrhythmiasTreatment optionsThe correct identification and treatment of arrhythmias in thecritically ill patient may prevent cardiac arrest from occurring orfrom reoccurring after successful initial resuscitation. The treatmentalgorithms described in this section have been designed toenable the non-specialist ALS provider to treat the patient effectivelyand safely in an emergency; for this reason, they have beenkept as simple as possible. If patients are not acutely ill there maybe several other treatment options, including the use of drugs (oralor parenteral) that will be less familiar to the non-expert. In this situationthere will be time to seek advice from cardiologists or othersenior doctors with the appropriate expertise.More comprehensive information on the management ofarrhythmias can be found at www.escardio.org.Principles of treatmentThe initial assessment and treatment of a patient with anarrhythmia should follow the ABCDE approach. Key elements inthis process include assessing for adverse signs; administration ofhigh flow oxygen; obtaining intravenous access, and establishingmonitoring (ECG, blood pressure, SpO 2 ). Whenever possible, recorda 12-lead ECG; this will help determine the precise rhythm, eitherbefore treatment or retrospectively. Correct any electrolyte abnormalities(e.g., K + ,Mg 2+ ,Ca 2+ ). Consider the cause and context ofarrhythmias when planning treatment.The assessment and treatment of all arrhythmias addresses twofactors: the condition of the patient (stable versus unstable), andthe nature of the arrhythmia. Anti-arrhythmic drugs are slower inonset and less reliable than electrical cardioversion in converting atachycardia to sinus rhythm; thus, drugs tend to be reserved for stablepatients without adverse signs, and electrical cardioversion isusually the preferred treatment for the unstable patient displayingadverse signs.Adverse signsThe presence or absence of adverse signs or symptoms will dictatethe appropriate treatment for most arrhythmias. The followingadverse factors indicate a patient who is unstable because of thearrhythmia.1. Shock—this is seen as pallor, sweating, cold and clammy extremities(increased sympathetic activity), impaired consciousness(reduced cerebral blood flow), and hypotension (e.g., systolicblood pressure < 90 mm Hg).2. Syncope—loss of consciousness, which occurs as a consequenceof reduced cerebral blood flow.3. Heart failure—arrhythmias compromise myocardial performanceby reducing coronary artery blood flow. In acutesituations this is manifested by pulmonary oedema (failure of theleft ventricle) and/or raised jugular venous pressure, and hepaticengorgement (failure of the right ventricle).4. Myocardial ischaemia—this occurs when myocardial oxygenconsumption exceeds delivery. Myocardial ischaemia maypresent with chest pain (angina) or may occur without pain asan isolated finding on the 12 lead ECG (silent ischaemia). Thepresence of myocardial ischaemia is especially important if thereis underlying coronary artery disease or structural heart diseasebecause it may cause further life-threatening complicationsincluding cardiac arrest.Having determined the rhythm and the presence or absence ofadverse signs, the options for immediate treatment are categorisedas:1. Electrical (cardioversion, pacing).2. Pharmacological (anti-arrhythmic (and other) drugs).TachycardiasIf the patient is unstableIf the patient is unstable and deteriorating, with any of theadverse signs and symptoms described above being caused bythe tachycardia, attempt synchronised cardioversion immediately(Fig. 4.11). In patients with otherwise normal hearts, serioussigns and symptoms are uncommon if the ventricular rate is