European Resuscitation Council Guidelines for Resuscitation ... - CPR

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18 de 0ctubre de 2010 www.elsuapdetodos.com1374 D. Biarent et al. / Resuscitation 81 (2010) 1364–1388ficult to establish during resuscitation of an infant or child. Incritically ill children, whenever venous access is not readily attainableintraosseous access should be considered early, especiallyif the child is in cardiac arrest or decompensated circulatoryfailure. 155–157 In any case, in critically ill children, if attempts atestablishing intravenous (IV) access are unsuccessful after 1 min,insert an intraosseous (IO) needle instead. 155,158Intraosseous accessIntraosseous access is a rapid, safe, and effective route to givedrugs, fluids and blood products. 159–168 The onset of action andtime to achieve adequate plasma drug concentrations are similarto that achieved via the central venous route. 169,170 Bonemarrow samples can be used to cross match for blood type orgroup 171 for chemical analysis 172,173 and for blood gas measurement(the values are comparable to central venous blood gases ifno drug has been injected in the cavity). 172,174–176 However samplescan damage autoanalysers and should be used preferably incartridge analyser. Flush each drug with a bolus of normal salineto ensure dispersal beyond the marrow cavity, and to achievefaster distribution to the central circulation. Inject large bolusesof fluid using manual pressure. Intraosseous access can be maintaineduntil definitive IV access has been established. The benefitsof semi-automated IO devices remain to be seen but preliminaryexperiences show them to be rapid and effective for obtaining circulatoryaccess. 167,168,177,178Intravenous accessPeripheral IV access provides plasma concentrations ofdrugs and clinical responses equivalent to central or IOaccess. 156,157,179–181 Central venous lines provide more securelong-term access but, compared with IO or peripheral IV access,offer no advantages during resuscitation. 156,179–181Tracheal tube accessIntraosseous or IV access should be definitely preferred to thetracheal route for giving drugs. 182 Drugs given via the trachea havehighly variable absorption but, for guidance, the following dosageshave been recommended:Adrenaline100 gkg −1Lidocaine2–3 mg kg −1Atropine30 gkg −1The optimal dose of naloxone is not known.Dilute the drug in 5 ml of normal saline and follow administrationwith five ventilations. 183–185 Do not give non-lipid solublemedications (e.g., glucose, bicarbonate, calcium) via the trachealtube because they will damage the airway mucosa.Fluids and drugsVolume expansion is indicated when a child shows signs ofcirculatory failure in the absence of volume overload. 186 Isotoniccrystalloids are recommended as the initial resuscitation fluid forinfants and children with any type of circulatory failure.If systemic perfusion is inadequate, give a bolus of 20 ml kg −1 ofan isotonic crystalloid even if the systemic blood pressure is normal.Following every bolus, re-assess the child’s clinical state, using ABC,to decide whether a further bolus or other treatment is required.There are insufficient data to make recommendations about theuse of hypertonic saline for circulatory failure associated with headinjuries or hypovolaemia. 187,188There are also insufficient data to recommend delayedfluid resuscitation in the hypotensive child with blunttrauma. 189 Avoid dextrose containing solutions unless thereis hypoglycaemia. 190–193 Monitor glucose levels and avoid hypoglycaemia;infants and small children are particularly prone tohypoglycaemia.AdenosineAdenosine is an endogenous nucleotide that causes a brief atrioventricular(AV) block and impairs accessory bundle re-entry atthe level of the AV node. Adenosine is recommended for the treatmentof supraventricular tachycardia (SVT). 194 It is safe becauseit has a short half-life (10 s); give it intravenously via upper limbor central veins to minimise the time taken to reach the heart.Give adenosine rapidly, followed by a flush of 3–5 ml of normalsaline. 195 Adenosine must be used with caution in asthmatics, secondor third degree AV block, long QT syndromes and in cardiactransplant recipients.Adrenaline (epinephrine)Adrenaline is an endogenous catecholamine with potent , 1and 2 adrenergic actions. It is placed prominently in the cardiacarrest treatment algorithms for non-shockable and shockablerhythms. Adrenaline induces vasoconstriction, increases diastolicpressure and thereby improves coronary artery perfusion pressure,enhances myocardial contractility, stimulates spontaneouscontractions, and increases the amplitude and frequency of VF, soincreasing the likelihood of successful defibrillation.The recommended IV/IO dose of adrenaline in children forthe first and for subsequent doses is 10 gkg −1 . The maximumsingle dose is 1 mg. If needed, give further doses ofadrenaline every 3–5 min. Intratracheal adrenaline is no longerrecommended, 196–199 but if this route is ever used, the dose is tentimes this (100 gkg −1 ).The use of higher doses of adrenaline via the IV or IO routeis not recommended routinely as it does not improve survival orneurological outcome after cardiopulmonary arrest. 200–203Once spontaneous circulation is restored, a continuous infusionof adrenaline may be required. Its haemodynamic effects aredose related; there is also considerable variability in responsebetween children; therefore, titrate the infusion dose to thedesired effect. High infusion rates may cause excessive vasoconstriction,compromising extremity, mesenteric, and renal bloodflow. High-dose adrenaline can cause severe hypertension andtachyarrhythmias. 204To avoid tissue damage it is essential to give adrenaline througha secure intravascular line (IV or IO). Adrenaline (and other catecholamines)is inactivated by alkaline solutions and should neverbe mixed with sodium bicarbonate. 205www.elsuapdetodos.comAmiodaroneAmiodarone is a non-competitive inhibitor of adrenergic receptors:it depresses conduction in myocardial tissue and thereforeslows AV conduction, and prolongs the QT interval and therefractory period. Except when given for the treatment of refractoryVF/pulseless VT, amiodarone must be injected slowly (over10–20 min) with systemic blood pressure and ECG monitoring toavoid causing hypotension. This side effect is less common with theaqueous solution. 206 Other rare but significant adverse effects arebradycardia and polymorphic VT. 207AtropineAtropine accelerates sinus and atrial pacemakers by blockingthe parasympathetic response. It may also increase AV conduction.Small doses (< 100 g) may cause paradoxical bradycardia. 208 In
adycardia with poor perfusion that is unresponsive to ventilationand oxygenation, the first line drug is adrenaline, not atropine.Atropine is recommended for bradycardia caused by increasedvagal tone or cholinergic drug toxicity. 209–212CalciumCalcium is essential for myocardial function 213,214 but routineuse of calcium does not improve the outcome from cardiopulmonaryarrest. 215–217Calcium is indicated in the presence of hypocalcaemia,calcium channel blocker overdose, hypermagnesaemia andhyperkalaemia. 218–220GlucoseData from neonates, children and adults indicate that bothhyper- and hypo-glycaemia are associated with poor outcome aftercardiopulmonary arrest, 221–223 but it is uncertain if this is causativeor merely an association. 224 Check blood or plasma glucose concentrationand monitor closely in any ill or injured child, including aftercardiac arrest. Do not give glucose-containing fluids during CPRunless hypoglycaemia is present. Avoid hyper- and hypo-glycaemiafollowing ROSC. Strict glucose control has not shown survival benefitsin adults when compared with moderate glucose control 225,226and it increases the risk of hypoglycaemia in neonates, children andadults. 227–231MagnesiumThere is no evidence for giving magnesium routinely duringcardiopulmonary arrest. 232 Magnesium treatment is indicated inthe child with documented hypomagnesaemia or with torsades depointes VT regardless of the cause. 233Sodium bicarbonateDo not give sodium bicarbonate routinely during cardiopulmonaryarrest or after ROSC. 220,234,235 After effective ventilationand chest compressions have been achieved and adrenaline given,sodium bicarbonate may be considered for the child with prolongedcardiopulmonary arrest and/or severe metabolic acidosis. Sodiumbicarbonate may also be considered in case of haemodynamicinstability and co-existing hyperkalaemia, or in the managementof tricyclic antidepressant drug overdose. Excessive quantities ofsodium bicarbonate may impair tissue oxygen delivery, producehypokalaemia, hypernatraemia, hyperosmolality, and inactivatecatecholamines.LidocaineLidocaine is less effective than amiodarone for defibrillationresistantVF/pulseless VT in adults 236 and therefore is not the firstline treatment in defibrillation-resistant VF/pulseless VT in children.ProcainamideProcainamide slows intra-atrial conduction and prolongs theQRS and QT intervals. It can be used in SVT 237–239 or VT 240 resistantto other medications in the haemodynamically stable child.However, paediatric data are sparse and procainamide should beused cautiously. 241,242 Procainamide is a potent vasodilator and cancause hypotension: infuse it slowly with careful monitoring. 243–24518 de 0ctubre de 2010 www.elsuapdetodos.comD. Biarent et al. / Resuscitation 81 (2010) 1364–1388 1375Vasopressin – terlipressinVasopressin is an endogenous hormone that acts at specificreceptors, mediating systemic vasoconstriction (via V 1 receptor)and the reabsorption of water in the renal tubule (by the V 2receptor). 246 There is currently insufficient evidence to support orrefute the use of vasopressin or terlipressin as an alternative to,or in combination with, adrenaline in any cardiac arrest rhythm inadults or children. 247–258Some studies have reported that terlipressin (a long-actinganalogue of vasopressin with comparable effects) improves haemodynamicsin children with refractory, vasodilatory septic shock,but its impact on survival is less clear. 255–257,259,260 Two paediatricseries suggested that terlipressin could be effective in refractorycardiac arrest. 258,261These drugs could be used in cardiac arrest refractory to severaladrenaline doses.DefibrillatorsDefibrillators are either automatically or manually operated,and may be capable of delivering either monophasic or biphasicshocks. Manual defibrillators capable of delivering the full energyrequirements from neonates upwards must be available withinhospitals and in other healthcare facilities caring for children atrisk of cardiopulmonary arrest. Automated external defibrillators(AEDs) are preset for all variables including the energy dose.Pad/paddle size for defibrillationSelect the largest possible available paddles to provide good contactwith the chest wall. The ideal size is unknown but there shouldbe good separation between the pads. 13,262,263Recommended sizes are:• 4.5 cm diameter for infants and children weighing 10 kg (older than 1 year).To decrease skin and thoracic impedance, an electrically conductinginterface is required between the skin and the paddles.Preformed gel pads or self-adhesive defibrillation electrodes areeffective. Do not use ultrasound gel, saline-soaked gauze, alcoholsoakedgauze/pads or ultrasound gel.www.elsuapdetodos.comPosition of the paddlesApply the paddles firmly to the bare chest in the antero-lateralposition, one paddle placed below the right clavicle and the otherin the left axilla (Fig. 6.8). If the paddles are too large and there is adanger of charge arcing across the paddles, one should be placed onthe upper back, below the left scapula and the other on the front,to the left of the sternum. This is known as the antero-posteriorposition and is also acceptable.Optimal paddle forceTo decrease transthoracic impedance during defibrillation,apply a force of 3 kg for children weighing < 10 kg and 5 kg for largerchildren. 264,265 In practice, this means that the paddles should beapplied firmly.Energy dose in childrenThe ideal energy dose for safe and effective defibrillationis unknown. Biphasic shocks are at least as effective and produceless post-shock myocardial dysfunction than monophasic
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