European Resuscitation Council Guidelines for Resuscitation ... - CPR

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18 de 0ctubre de 2010 www.elsuapdetodos.com1376 D. Biarent et al. / Resuscitation 81 (2010) 1364–1388Shockable – VF/pulseless VTAttempt defibrillation immediately (4 J kg −1 ):Fig. 6.8. Paddle positions for defibrillation – child.shocks. 36,49,51–53,266 Animal models show better results with paediatricdoses of 3–4 J kg −1 than with lower doses, 49 or adult doses. 38Clinical studies in children indicate that doses of 2 J kg −1 are insufficientin most cases. 12,38,42 Doses larger than 4 J kg −1 (as much as9Jkg −1 ) have defibrillated children effectively with negligible sideeffects. 29,48 When using a manual defibrillator, use 4 J kg −1 (preferablybiphasic but monophasic waveform is also acceptable) for thefirst and subsequent shocks.If no manual defibrillator is available, use an AED that canrecognise paediatric shockable rhythms. 31,32,267 The AED shouldbe equipped with a dose attenuator which decreases the deliveredenergy to a lower dose more suitable for children aged 1–8years (50–75 J). 34,37 If such an AED in not available, use a standardAED and the preset adult energy levels. For children above8 years, use a standard AED with standard paddles. Although theevidence to support a recommendation for the use of AEDs (preferablywith dose attenuator) in children less than 1 year is limited tocase reports, 39,40 it is acceptable if no other option is available.Advanced management of cardiopulmonary arrest(Fig. 6.9)ABCCommence and continue with basic life supportOxygenate and ventilate with BMV• Provide positive pressure ventilation with a high inspired oxygenconcentration• Give five rescue breaths followed by external chest compressionand positive pressure ventilation in the ratio of 15:2• Avoid rescuer fatigue by frequently changing the rescuer performingchest compressions• Establish cardiac monitoringAssess cardiac rhythm and signs of life(±check for a central pulse for no more than 10 s)Non-shockable – asystole, pulseless electrical activity (PEA)• Give adrenaline IV or IO (10 gkg −1 ) and repeat every 3–5 min.• Identify and treat any reversible causes (4 Hs and 4 Ts) (Fig. 6.10).• Charge the defibrillator while another rescuer continues chestcompressions.• Once the defibrillator is charged, pause the chest compressions,ensure that all rescuers are clear of the patient. Minimise thedelay between stopping chest compressions and delivery of theshock – even 5–10 s delay will reduce the chances of the shockbeing successful. 268,269• Give one shock.• Resume CPR as soon as possible without re-assessing the rhythm.• After 2 min, check briefly the cardiac rhythm on the monitor.• Give second shock (4 J kg −1 ) if still in VF/pulseless VT.• Give CPR for 2 min as soon as possible without re-assessing therhythm.• Pause briefly to assess the rhythm; if still in VF/pulseless VT givea third shock at 4 J kg −1 .• Give adrenaline 10 gkg −1 and amiodarone 5 mg kg −1 after thethird shock once CPR has been resumed.• Give adrenaline every alternate cycle (i.e., every 3–5 min duringCPR).• Give a second dose of amiodarone 5 mg/kg 270 if still inVF/pulseless VT after the fifth shock.If the child remains in VF/pulseless VT, continue to alternateshocks of 4 J kg −1 with 2 min of CPR. If signs of life become evident,check the monitor for an organised rhythm; if this is present, checkfor signs of life and a central pulse and evaluate the haemodynamicsof the child (blood pressure, peripheral pulse, capillary refill time).Identify and treat any reversible causes (4 Hs and 4 Ts) rememberingthat the first 2 Hs (hypoxia and hypovolaemia) have thehighest prevalence in critically ill or injured children (Fig. 6.11).If defibrillation was successful but VF/pulseless VT recurs,resume CPR, give amiodarone and defibrillate again at 4 J Kg −1 . Starta continuous infusion of amiodarone.Reversible causes of cardiac arrestThe reversible causes of cardiac arrest can be considered quicklyby recalling the 4 Hs and 4 Ts:www.elsuapdetodos.com• Hypoxia.• Hypovolaemia.• Hyper/hypokalaemia.• Hypothermia.• Tension pneumothorax.• Toxic/therapeutic disturbances.• Tamponade (coronary or pulmonary).• Thrombosis (coronary or pulmonary).Sequence of events in cardiopulmonary arrest1. When a child becomes unresponsive, without signs of life (nobreathing, cough or any detectable movement), start CPR immediately.2. Provide BMV with 100% oxygen.3. Commence monitoring. Send for a manual defibrillator or an AEDto identify and treat shockable rhythms as quickly as possible.In the less common circumstance of a witnessed sudden collapse,early activation of the emergency services and getting anAED may be more appropriate; start CPR as soon as possible.
18 de 0ctubre de 2010 www.elsuapdetodos.comD. Biarent et al. / Resuscitation 81 (2010) 1364–1388 1377www.elsuapdetodos.comFig. 6.9. Paediatric advanced life support algorithm.Cardiac monitoringPosition the cardiac monitor leads or defibrillation paddlesas soon as possible to enable differentiation between a shockableand a non-shockable cardiac rhythm. Invasive monitoringof systemic blood pressure may help to improve effectiveness ofchest compression 271 but must not delay the provision of basic oradvanced resuscitation.Shockable rhythms are pulseless VT and VF. These rhythms aremore likely after sudden collapse in children with heart disease oradolescents. 41–43 Non-shockable rhythms are pulseless electricalactivity (PEA), bradycardia (
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