European Resuscitation Council Guidelines for Resuscitation ... - CPR

More documents

Recommendations

Info

18 de 0ctubre de 2010 www.elsuapdetodos.com1232 J.P. Nolan et al. / Resuscitation 81 (2010) 1219–1276www.elsuapdetodos.comFig. 1.6. ALS cardiac arrest algorithm. © 2010 ERC.• The quality of chest compressions during in-hospital CPR isfrequently sub-optimal. 224,225 The importance of uninterruptedchest compressions cannot be over emphasised. Even short interruptionsto chest compressions are disastrous for outcome andevery effort must be made to ensure that continuous, effectivechest compression is maintained throughout the resuscitationattempt. The team leader should monitor the quality of CPR andalternate CPR providers if the quality of CPR is poor. ContinuousETCO 2 monitoring can be used to indicate the quality of CPR:although an optimal target for ETCO 2 during CPR has not beenestablished, a value of less than 10 mm Hg (1.4 kPa) is associatedwith failure to achieve ROSC and may indicate that the quality ofchest compressions should be improved. If possible, the personproviding chest compressions should be changed every 2 min, butwithout causing long pauses in chest compressions.ALS treatment algorithmAlthough the ALS cardiac arrest algorithm (Fig. 1.6) is applicableto all cardiac arrests, additional interventions may be indicated forcardiac arrest caused by special circumstances (see Section 8). 10The interventions that unquestionably contribute to improvedsurvival after cardiac arrest are prompt and effective bystander BLS,uninterrupted, high-quality chest compressions and early defibrillationfor VF/VT. The use of adrenaline has been shown to increaseROSC, but no resuscitation drugs or advanced airway interventionshave been shown to increase survival to hospital discharge aftercardiac arrest. 226–229 Thus, although drugs and advanced airwaysare still included among ALS interventions, they are of secondaryimportance to early defibrillation and high-quality, uninterruptedchest compressions.
As with previous guidelines, the ALS algorithm distinguishesbetween shockable and non-shockable rhythms. Each cycle isbroadly similar, with a total of 2 min of CPR being given beforeassessing the rhythm and where indicated, feeling for a pulse.Adrenaline 1 mg is given every 3–5 min until ROSC is achieved– the timing of the initial dose of adrenaline is describedbelow.Shockable rhythms (ventricular fibrillation/pulselessventricular tachycardia)The first monitored rhythm is VF/VT in approximately 25% ofcardiac arrests, both in- 36 or out-of-hospital. 24,25,146 VF/VT willalso occur at some stage during resuscitation in about 25% ofcardiac arrests with an initial documented rhythm of asystole orPEA. 36 Having confirmed cardiac arrest, summon help (includingthe request for a defibrillator) and start CPR, beginning withchest compressions, with a CV ratio of 30:2. When the defibrillatorarrives, continue chest compressions while applying the paddles orself-adhesive pads. Identify the rhythm and treat according to theALS algorithm.• If VF/VT is confirmed, charge the defibrillator while anotherrescuer continues chest compressions. Once the defibrillator ischarged, pause the chest compressions, quickly ensure that allrescuers are clear of the patient and then give one shock (360-Jmonophasic or 150–200 J biphasic).• Minimise the delay between stopping chest compressions anddelivery of the shock (the preshock pause); even 5–10 s delaywill reduce the chances of the shock being successful. 71,110• Without reassessing the rhythm or feeling for a pulse, resume CPR(CV ratio 30:2) immediately after the shock, starting with chestcompressions. Even if the defibrillation attempt is successful inrestoring a perfusing rhythm, it takes time until the post-shockcirculation is established 230 and it is very rare for a pulse tobe palpable immediately after defibrillation. 231 Furthermore, thedelay in trying to palpate a pulse will further compromise themyocardium if a perfusing rhythm has not been restored. 232• Continue CPR for 2 min, then pause briefly to assess the rhythm; ifstill VF/VT, give a second shock (360-J monophasic or 150–360-Jbiphasic). Without reassessing the rhythm or feeling for a pulse,resume CPR (CV ratio 30:2) immediately after the shock, startingwith chest compressions.• Continue CPR for 2 min, then pause briefly to assess the rhythm;if still VF/VT, give a third shock (360-J monophasic or 150–360-Jbiphasic). Without reassessing the rhythm or feeling for a pulse,resume CPR (CV ratio 30:2) immediately after the shock, startingwith chest compressions. If IV/IO access has been obtained, giveadrenaline 1 mg and amiodarone 300 mg once compressions haveresumed. If ROSC has not been achieved with this 3rd shock theadrenaline will improve myocardial blood flow and may increasethe chance of successful defibrillation with the next shock. Inanimal studies, peak plasma concentrations of adrenaline occurat about 90 s after a peripheral injection. 233 If ROSC has beenachieved after the 3rd shock it is possible that the bolus dose ofadrenaline will cause tachycardia and hypertension and precipitaterecurrence of VF. However, naturally occurring adrenalineplasma concentrations are high immediately after ROSC, 234 andany additional harm caused by exogenous adrenaline has notbeen studied. Interrupting chest compressions to check for a perfusingrhythm midway in the cycle of compressions is also likelyto be harmful. The use of waveform capnography may enableROSC to be detected without pausing chest compressions andmay be a way of avoiding a bolus injection of adrenaline afterROSC has been achieved. Two prospective human studies have18 de 0ctubre de 2010 www.elsuapdetodos.comJ.P. Nolan et al. / Resuscitation 81 (2010) 1219–1276 1233shown that a significant increase in end-tidal CO 2 occurs whenreturn of spontaneous circulation occurs. 235,236• After each 2-min cycle of CPR, if the rhythm changes to asystoleor PEA, see ‘non-shockable rhythms’ below. If a non-shockablerhythm is present and the rhythm is organised (complexes appearregular or narrow), try to palpate a pulse. Rhythm checks shouldbe brief, and pulse checks should be undertaken only if an organisedrhythm is observed. If there is any doubt about the presenceof a pulse in the presence of an organised rhythm, resume CPR. IfROSC has been achieved, begin post-resuscitation care.Regardless of the arrest rhythm, give further doses of adrenaline1 mg every 3–5 min until ROSC is achieved; in practice, thiswill be once every two cycles of the algorithm. If signs oflife return during CPR (purposeful movement, normal breathing,or coughing), check the monitor; if an organised rhythmis present, check for a pulse. If a pulse is palpable, continuepost-resuscitation care and/or treatment of peri-arrest arrhythmia.If no pulse is present, continue CPR. Providing CPR witha CV ratio of 30:2 is tiring; change the individual undertakingcompressions every 2 min, while minimising the interruption incompressions.Precordial thumpA single precordial thump has a very low success rate for cardioversionof a shockable rhythm 237–239 and is likely to succeedonly if given within the first few seconds of the onset of a shockablerhythm. 240 There is more success with pulseless VT thanwith VF. Delivery of a precordial thump must not delay calling forhelp or accessing a defibrillator. It is therefore appropriate therapyonly when several clinicians are present at a witnessed, monitoredarrest, and when a defibrillator is not immediately to hand. 241 Inpractice, this is only likely to be in a critical care environment suchas the emergency department or ICU. 239Airway and ventilationDuring the treatment of persistent VF, ensure good-quality chestcompressions between defibrillation attempts. Consider reversiblecauses (4 Hs and 4 Ts) and, if identified, correct them. Check theelectrode/defibrillating paddle positions and contacts, and the adequacyof the coupling medium, e.g., gel pads. Tracheal intubationprovides the most reliable airway, but should be attempted only ifthe healthcare provider is properly trained and has regular, ongoingexperience with the technique. Personnel skilled in advancedairway management should attempt laryngoscopy and intubationwithout stopping chest compressions; a brief pause in chest compressionsmay be required as the tube is passed through the vocalcords, but this pause should not exceed 10 s. Alternatively, to avoidany interruptions in chest compressions, the intubation attemptmay be deferred until return of spontaneous circulation. No studieshave shown that tracheal intubation increases survival after cardiacarrest. After intubation, confirm correct tube position and secure itadequately. Ventilate the lungs at 10 breaths min −1 ; do not hyperventilatethe patient. Once the patient’s trachea has been intubated,continue chest compressions, at a rate of 100 min −1 without pausingduring ventilation.In the absence of personnel skilled in tracheal intubation, asupraglottic airway device (e.g., laryngeal mask airway) is anacceptable alternative (Section 4e). Once a supraglottic airwaydevice has been inserted, attempt to deliver continuous chestcompressions, uninterrupted during ventilation. If excessive gasleakage causes inadequate ventilation of the patient’s lungs, chestcompressions will have to be interrupted to enable ventilation(using a CV ratio of 30:2).www.elsuapdetodos.com
Page 1: Resuscitation 81 (2010) 1219-127618
Page 4 and 5: 18 de 0ctubre de 2010 www.elsuapdet
Page 7: If there is more than one rescuer p
Page 64 and 65:
18 de 0ctubre de 2010 www.elsuapdet
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Resuscitation 81 (2010) 1364-138818
Page 148 and 149:
Page 150 and 151:
Page 152 and 153:
Page 154 and 155:
Page 156 and 157:
Page 158 and 159:
Page 160 and 161:
Page 162 and 163:
Page 164 and 165:
Page 166 and 167:
Page 168 and 169:
Page 170 and 171:
Page 172 and 173:
Page 174 and 175:
Page 176 and 177:
Page 178 and 179:
Page 180 and 181:
Page 182 and 183:
Resuscitation 81 (2010) 1400-143318
Page 184 and 185:
Page 186 and 187:
Page 188 and 189:
Page 190 and 191:
Page 192 and 193:
Page 194 and 195:
Page 196 and 197:
Page 198 and 199:
Page 202 and 203:
Page 204 and 205:
Page 206 and 207:
Page 208 and 209:
Page 210 and 211:
Page 212 and 213:
Page 214 and 215:
Page 216 and 217:
Resuscitation 81 (2010) 1434-144418
Page 218 and 219:
Page 220 and 221:
Page 222 and 223:
Page 224 and 225:
Page 226 and 227:
Page 228 and 229:
Page 230 and 231:
Page 232 and 233:
show all

European Resuscitation Council Guidelines for Resuscitation ... - CPR

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?