European Resuscitation Council Guidelines for Resuscitation ... - CPR

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18 de 0ctubre de 2010 www.elsuapdetodos.com1406 J. Soar et al. / Resuscitation 81 (2010) 1400–1433ride in high doses can overcome some of the adverse effects, itrarely restores normal cardiovascular status. Haemodynamic instabilitymay respond to high doses of insulin given with glucosesupplementation and electrolyte monitoring in addition to standardtreatments including fluids and inotropic drugs. 133–148 Otherpotentially useful treatments include glucagon, vasopressin andphosphodiesterse inhibitors. 139,149DigoxinAlthough cases of digoxin poisoning are fewer than those involvingcalcium channel and beta-blockers, the mortality rate fromdigoxin is far greater. Other drugs including calcium channelblockers and amiodarone can also cause plasma concentrations ofdigoxin to rise. Atrioventricular conduction abnormalities and ventricularhyperexcitability due to digoxin toxicity can lead to severearrhythmias and cardiac arrest.Patients at risk of cardiac arrestStandard resuscitation measures and specific antidote therapywith digoxin-specific antibody fragments should be used if thereare arrhythmias associated with haemodynamic instability. 150–163Antibody-specific therapy may also be effective in poisoning fromplants as well as Chinese herbal medications containing digitalisglycosides. 150,164,165 Digoxin-specific antibody fragments interferewith digoxin immunoassay measurements and can lead to overestimationof plasma digoxin concentrations.CyanideCyanide is generally considered to be a rare cause of acute poisoning;however, cyanide exposure occurs relatively frequently inpatients with smoke inhalation from residential or industrial fires.Its main toxicity results from inactivation of cytochrome oxidase(at cytochrome a3), thus uncoupling mitochondrial oxidative phosphorylationand inhibiting cellular respiration, even in the presenceof adequate oxygen supply. Tissues with the highest oxygen needs(brain and heart) are the most severely affected by acute cyanidepoisoning.Patients at risk of cardiac arrestPatients with severe cardiovascular toxicity (cardiac arrest, cardiovascularinstability, metabolic acidosis, or altered mental status)caused by known or suspected cyanide poisoning should receivecyanide antidote therapy in addition to standard resuscitation,including oxygen. Initial therapy should include a cyanide scavenger(either intravenous hydroxocobalamin or a nitrite – i.e.,intravenous sodium nitrite and/or inhaled amyl nitrite), followedas soon as possible by intravenous sodium thiosulphate. 166–175Hydroxocobalamin and nitrites are equally effective but hydroxocobalaminmay be safer because it does not cause methaemoglobinformation or hypotension.Modifications to BLS/ALSIn case of cardiac arrest caused by cyanide, standard ALS treatmentwill fail to restore spontaneous circulation as long as cellularrespiration is blocked. Antidote treatment is needed for reactivationof cytochrome oxidase.Carbon monoxideCarbon monoxide poisoning is common. There were about25,000 carbon monoxide related hospital admissions reported inthe US in 2005. 176 Patients who develop cardiac arrest causedby carbon monoxide rarely survive to hospital discharge, even ifreturn of spontaneous circulation is achieved; however, hyperbaricoxygen therapy may be considered in these patients as itmay reduce the risk of developing persistent or delayed neurologicalinjury. 177–185 The risks inherent in transporting criticallyill post-arrest patients to a hyperbaric facility may be significant,and must be weighed against the possibility of benefit on a caseby-casebasis. Patients who develop myocardial injury caused bycarbon monoxide have an increased risk of cardiac and all-causemortality lasting at least 7 years after the event; it is reasonable torecommend cardiology follow-up for these patients. 186,1878c. DrowningOverviewDrowning is a common cause of accidental death in Europe.After drowning the duration of hypoxia is the most critical factorin determining the victim’s outcome; therefore, oxygenation, ventilation,and perfusion should be restored as rapidly as possible.Immediate resuscitation at the scene is essential for survival andneurological recovery after a drowning incident. This will requireprovision of CPR by a bystander and immediate activation of theEMS system. Victims who have spontaneous circulation and breathingwhen they reach hospital usually recover with good outcomes.Research into drowning is limited in comparison with primary cardiacarrest and there is a need for further research in this area. 188These guidelines are intended for healthcare professionals and certaingroups of lay responders that have a special interest in the careof the drowning victim, e.g., lifeguards.EpidemiologyThe World Health Organization (WHO) estimates that, worldwide,drowning accounts for approximately 450,000 deaths eachyear. A further 1.3 million disability-adjusted life-years are losteach year as a result of premature death or disability fromdrowning 189 ; 97% of deaths from drowning occur in low- andmiddle-income countries. 189 In 2006 there were 312 accidentaldeaths from drowning in the United Kingdom 190 and 3582 inthe United States, 191 yielding an annual incidence of drowning of0.56 and 1.2 per 100,000 population, respectively. 192 Death fromdrowning is more common in young males, and is the leadingcause of accidental death in Europe in this group. 189 Factors associatedwith drowning (e.g., suicide, traffic accidents, alcohol and drugabuse) varies between countries. 193www.elsuapdetodos.comDefinitions, classifications and reportingOver 30 different terms have been used to describe theprocess and outcome from submersion- and immersion-relatedincidents. 194 The International Liaison Committee on Resuscitation(ILCOR) defines drowning as “a process resulting in primaryrespiratory impairment from submersion/immersion in a liquidmedium. Implicit in this definition is that a liquid/air interfaceis present at the entrance of the victim’s airway, preventing thevictim from breathing air. The victim may live or die after this process,but whatever the outcome, he or she has been involved in adrowning incident”. 195 Immersion means to be covered in water orother fluid. For drowning to occur, usually at least the face and airwaymust be immersed. Submersion implies that the entire body,including the airway, is under the water or other fluid.ILCOR recommends that the following terms, previously used,should no longer be used: dry and wet drowning, active and passivedrowning, silent drowning, secondary drowning and drowned versusnear-drowned. 195 The Utstein drowning style should be used
18 de 0ctubre de 2010 www.elsuapdetodos.comJ. Soar et al. / Resuscitation 81 (2010) 1400–1433 1407when reporting outcomes from drowning incidents to improveconsistency in information between studies. 195Pathophysiologywater-slide use, signs of trauma or signs of alcohol intoxication. Ifthe victim is pulseless and apnoeic remove them from the water asquickly as possible (even if a back support device is not available),while attempting to limit neck flexion and extension.The pathophysiology of drowning has been described indetail. 195,196 In brief, after submersion, the victim initially breathholds before developing laryngospasm. During this time the victimfrequently swallows large quantities of water. As breath holding/laryngospasmcontinues, hypoxia and hypercapnia develops.Eventually these reflexes abate and the victim aspirates waterinto their lungs leading to worsening hypoxaemia. Without rescueand restoration of ventilation the victim will become bradycardicbefore sustaining a cardiac arrest. The key feature to note in thepathophysiology of drowning is that cardiac arrest occurs as a consequenceof hypoxia and correction of hypoxaemia is critical toobtaining a return of spontaneous circulation.TreatmentTreatment of a drowning victim involves four distinct but interrelatedphases. These comprise (i) aquatic rescue, (ii) basic lifesupport, (iii) advanced life support, and (iv) post-resuscitation care.Rescue and resuscitation of the drowning victim almost alwaysinvolves a multi-professional team approach. The initial rescuefrom the water is usually undertaken either by bystanders or thosewith a duty to respond such as trained lifeguards or lifeboat operators.Basic life support is often provided by the initial respondersbefore arrival of the emergency medical services. Resuscitationfrequently continues into hospital where, if return of spontaneouscirculation is achieved, transfer to critical care often follows.Drowning incidents vary in their complexity from an incidentinvolving a single victim to one that involves several or multiplevictims. The emergency response will vary according to the numberof victims involved and available resources. If the number ofvictims outweighs the available resources then a system of triageto determine who to prioritise for treatment is likely to be necessary.The remainder of this section will focus on the management ofthe individual drowning victim where there are sufficient resourcesavailable.Basic life supportAquatic rescue and recovery from the water. Always be aware ofpersonal safety and minimize the danger to yourself and the victimat all times. Whenever possible, attempt to save the drowningvictim without entry into the water. Talking to the victim, reachingwith a rescue aid (e.g., stick or clothing), or throwing a ropeor buoyant rescue aid may be effective if the victim is close to dryland. Alternatively, use a boat or other water vehicle to assist withthe rescue. Avoid entry into the water whenever possible. If entryinto the water is essential, take a buoyant rescue aid or flotationdevice. 197 It is safer to enter the water with two rescuers than alone.Never dive head first in the water when attempting a rescue. Youmay lose visual contact with the victim and run the risk of a spinalinjury.Remove all drowning victims from the water by the fastest andsafest means available and resuscitate as quickly as possible. Theincidence of cervical spine injury in drowning victims is very low(approximately 0.5%). 198 Spinal immobilisation can be difficult toperform in the water and can delay removal from the water andadequate resuscitation of the victim. Poorly applied cervical collarscan also cause airway obstruction in unconscious patients. 199 Cervicalspine immobilisation is not indicated unless signs of severeinjury are apparent or the history is consistent with the possibilityof severe injury. 200 These circumstances include a history of diving,Rescue breathing. The first and most important treatment forthe drowning victim is alleviation of hypoxaemia. Prompt initiationof rescue breathing or positive pressure ventilation increasessurvival. 201–204 If possible supplement rescue breaths/ventilationswith oxygen. 205 Give five initial ventilations/rescue breaths as soonas possible.Rescue breathing can be initiated whilst the victim is still in shallowwater provided the safety of the rescuer is not compromised.It is likely to be difficult to pinch the victim’s nose, so mouth-tonoseventilation may be used as an alternative to mouth-to-mouthventilation.If the victim is in deep water, open their airway and if there isno spontaneous breathing start in-water rescue breathing if trainedto do so. In-water resuscitation is possible, 206 but should ideally beperformed with the support of a buoyant rescue aid. 207 Give 10–15rescue breaths over approximately 1 min. 207 If normal breathingdoes not start spontaneously, and the victim is
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