European Resuscitation Council Guidelines for Resuscitation ... - CPR

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