European Resuscitation Council Guidelines for Resuscitation ... - CPR

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18 de 0ctubre de 2010 www.elsuapdetodos.com1370 D. Biarent et al. / Resuscitation 81 (2010) 1364–1388Back blows in infants.• Support the infant in a head downward, prone position, to enablegravity to assist removal of the foreign body.• A seated or kneeling rescuer should be able to support the infantsafely across their lap.• Support the infant’s head by placing the thumb of one hand, atthe angle of the lower jaw, and one or two fingers from the samehand, at the same point on the other side of the jaw.• Do not compress the soft tissues under the infant’s jaw, as thiswill exacerbate the airway obstruction.• Deliver up to five sharp back blows with the heel of one hand inthe middle of the back between the shoulder blades.• The aim is too relieve the obstruction with each blow rather thanto give all five.3. Unconscious child with FBAOIf the child with FBAO is, or becomes, unconscious, place him ona firm, flat surface. Call out, or send, for help if it is still not available.Do not leave the child at this stage; proceed as follows:Airway opening. Open the mouth and look for any obviousobject. If one is seen, make an attempt to remove it with a singlefinger sweep. Do not attempt blind or repeated finger sweeps– these can impact the object more deeply into the pharynx andcause injury.Rescue breaths. Open the airway using a head tilt/chin lift andattempt five rescue breaths. Assess the effectiveness of each breath:if a breath does not make the chest rise, reposition the head beforemaking the next attempt.Back blows in children over 1 year.• Back blows are more effective if the child is positioned head down.• A small child may be placed across the rescuer’s lap as with theinfant.• If this is not possible, support the child in a forward leaning positionand deliver the back blows from behind.If back blows fail to dislodge the object, and the child is stillconscious, use chest thrusts for infants or abdominal thrusts forchildren. Do not use abdominal thrusts (Heimlich manoeuvre) ininfants.Chest thrusts for infants.• Turn the infant into a head downward supine position. This isachieved safely by placing the free arm along the infant’s backand encircling the occiput with the hand.• Support the infant down your arm, which is placed down (oracross) your thigh.• Identify the landmark for chest compressions (on the lower half ofthe sternum, approximately a finger’s breadth above the xiphisternum).• Give five chest thrusts; these are similar to chest compressionsbut sharper and delivered at a slower rate.Abdominal thrusts for children over 1 year.• Stand or kneel behind the child; place your arms under the child’sarms and encircle his torso.• Clench your fist and place it between the umbilicus and xiphisternum.• Grasp this hand with the other hand and pull sharply inwards andupwards.• Repeat up to five times.• Ensure that pressure is not applied to the xiphoid process or thelower rib cage – this may cause abdominal trauma.Following the chest or abdominal thrusts, re-assess the child.If the object has not been expelled and the victim is still conscious,continue the sequence of back blows and chest (for infant)or abdominal (for children) thrusts. Call out, or send, for help if it isstill not available. Do not leave the child at this stage.If the object is expelled successfully, assess the child’s clinicalcondition. It is possible that part of the object may remain in therespiratory tract and cause complications. If there is any doubt, seekmedical assistance. Abdominal thrusts may cause internal injuriesand all victims treated with abdominal thrusts should be examinedby a doctor. 5Chest compressions and CPR.• Attempt five rescue breaths and if there is no response (moving,coughing, spontaneous breaths) proceed to chest compressionswithout further assessment of the circulation.• Follow the sequence for single rescuer CPR (step 7B above) forapproximately a minute before summoning the EMS (if this hasnot already been done by someone else).• When the airway is opened for attempted delivery of rescuebreaths, look to see if the foreign body can be seen in the mouth.• If an object is seen, attempt to remove it with a single fingersweep.• If it appears the obstruction has been relieved, open and checkthe airway as above; deliver rescue breaths if the child is notbreathing.• If the child regains consciousness and exhibits spontaneouseffective breathing, place him in a safe position on his side (recoveryposition) and monitor breathing and conscious level whilstawaiting the arrival of the EMS.B. Paediatric advanced life supportPrevention of cardiopulmonary arrestIn children, secondary cardiopulmonary arrests, caused byeither respiratory or circulatory failure, are more frequent thanprimary arrests caused by arrhythmias. 56–61 So-called asphyxialarrests or respiratory arrests are also more common in young adulthood(e.g., trauma, drowning, poisoning). 62,63 The outcome fromcardiopulmonary arrests in children is poor; identification of theantecedent stages of cardiac or respiratory failure is a priority, aseffective early intervention may be life saving.The order of assessment and intervention for any seriously ill orinjured child follows the ABC principles.• A indicates airway (Ac for airway and cervical spine stabilisationfor the injured child).• B indicates breathing.• C indicates circulation (with haemorrhage control in injuredchild).www.elsuapdetodos.comInterventions are made at each step of the assessment as abnormalitiesare identified. The next step of the assessment is not starteduntil the preceding abnormality has been managed and correctedif possible. Summoning a paediatric rapid response team or medicalemergency team may reduce the risk of respiratory and/orcardiac arrest in hospitalised children outside the intensive caresetting. 64–69 This team should include at least one paediatricianwith specific knowledge in the field and one specialised nurse, andshould be called to evaluate a potentially critically ill child who is
18 de 0ctubre de 2010 www.elsuapdetodos.comD. Biarent et al. / Resuscitation 81 (2010) 1364–1388 1371not already in a paediatric intensive care unit (PICU) or paediatricemergency department (ED).Diagnosing respiratory failure: assessment of A and B• Unresponsiveness to pain (coma).• Apnoea or gasping respiratory pattern.• Absent circulation.• Pallor or deep cyanosis.Assessment of a potentially critically ill child starts with assessmentof airway (A) and breathing (B). Abnormalities in airwaypatency or gas exchange in the lungs can lead to respiratory failure.Signs of respiratory failure include:• Respiratory rate outside the normal range for the child’s age –either too fast or too slow.• Initially increasing work of breathing, which may progress toinadequate/decreased work of breathing as the patient tires orcompensatory mechanisms fail, additional noises such as stridor,wheeze, grunting, or the loss of breath sounds.• Decreased tidal volume marked by shallow breathing, decreasedchest expansion or decreased air entry at auscultation.• Hypoxaemia (without/with supplemental oxygen) generallyidentified by cyanosis but best evaluated by pulse oximetry.There may be associated signs in other organ systems that areeither affected by inadequate ventilation and oxygenation or act tocompensate the respiratory problem. These are detectable in stepC of the assessment and include:• Increasing tachycardia (compensatory mechanism in an attemptto increase oxygen delivery).• Pallor.• Bradycardia (ominous indicator of the loss of compensatorymechanisms).• Alteration in the level of consciousness (a sign that compensatorymechanisms are overwhelmed).Diagnosing circulatory failure: assessment of CCirculatory failure (or shock) is characterised by a mismatchbetween metabolic demand by the tissues and delivery of oxygenand nutrients by the circulation. 70 Physiological compensatorymechanisms lead to changes in the heart rate, in the systemicvascular resistance (which commonly increases as an adaptiveresponse) and in tissue and organ perfusion. Signs of circulatoryfailure include:• Increased heart rate (bradycardia is an ominous sign of physiologicaldecompensation).• Decreased systemic blood pressure.• Decreased peripheral perfusion (prolonged capillary refill time,decreased skin temperature, pale or mottled skin).• Weak or absent peripheral pulses.• Decreased or increased intravascular volume.• Decreased urine output and metabolic acidosis.Other systems may be affected, for example:• Respiratory frequency may be increased initially, in an attempt toimprove oxygen delivery, later becoming slow and accompaniedby decompensated circulatory failure.• Level of consciousness may decrease because of poor cerebralperfusion.Diagnosing cardiopulmonary arrestSigns of cardiopulmonary arrest include:Palpation of a pulse is not reliable as the sole determinant of theneed for chest compressions. 71,72 If cardiac arrest is suspected, andin the absence of signs of life, rescuers (lay and professional) shouldbegin CPR unless they are certain they can feel a central pulsewithin 10 s (infants – brachial or femoral artery; children – carotidor femoral artery). If there is any doubt, start CPR. 72–75 If personnelskilled in echocardiography are available, this investigation mayhelp to detect cardiac activity and potentially treatable causes forthe arrest. 76 However, echocardiography must not interfere withthe performance of chest compressions.Management of respiratory and circulatory failureIn children, there are many causes of respiratory and circulatoryfailure and they may develop gradually or suddenly. Both maybe initially compensated but will normally decompensate withoutadequate treatment. Untreated decompensated respiratory or circulatoryfailure will lead to cardiopulmonary arrest. Hence, the aimof paediatric life support is early and effective intervention in childrenwith respiratory and circulatory failure to prevent progressionto full arrest.Airway and breathing• Open the airway and ensure adequate ventilation and oxygenation.Deliver high-flow oxygen.• Establish respiratory monitoring (first line – pulse oximetry/SpO 2 ).• Achieving adequate ventilation and oxygenation may require useof airway adjuncts, bag-mask ventilation (BMV), use of a laryngealmask airway (LMA), securing a definitive airway by trachealintubation and positive pressure ventilation.• Very rarely, a surgical airway may be required.www.elsuapdetodos.comCirculation• Establish cardiac monitoring (first line – pulse oximetry/SpO 2 ,electrocardiography/ECG and non-invasive blood pressure/NIBP).• Secure intravascular access. This may be by peripheral intravenous(IV) or by intraosseous (IO) cannulation. If already in situ,a central intravenous catheter should be used.• Give a fluid bolus (20 ml kg −1 ) and/or drugs (e.g., inotropes, vasopressors,anti-arrhythmics) as required.• Isotonic crystalloids are recommended as initial resuscitationfluid in infants and children with any type of shock, includingseptic shock. 77–80• Assess and re-assess the child continuously, commencing eachtime with the airway before proceeding to breathing and thenthe circulation.• During treatment, capnography, invasive monitoring of arterialblood pressure, blood gas analysis, cardiac output monitoring,echocardiography and central venous oxygen saturation (ScvO 2 )may be useful to guide the treatment of respiratory and/or circulatoryfailure.
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