European Resuscitation Council Guidelines for Resuscitation ... - CPR

More documents

Recommendations

Info

18 de 0ctubre de 2010 www.elsuapdetodos.com1416 J. Soar et al. / Resuscitation 81 (2010) 1400–1433a systemic allergic reaction, the patient needs careful observationand symptomatic treatment using the ABCDE approach.Intramuscular (IM) adrenaline. The intramuscular (IM) routeis the best for most individuals who have to give adrenaline totreat anaphylaxis. Monitor the patient as soon as possible (pulse,blood pressure, ECG, and pulse oximetry). This will help monitorthe response to adrenaline. The IM route has several benefits:• There is a greater margin of safety.• It does not require intravenous access.• The IM route is easier to learn.The best site for IM injection is the anterolateral aspect of themiddle third of the thigh. The needle for injection needs to be longenough to ensure that the adrenaline is injected into muscle. 360The subcutaneous or inhaled routes for adrenaline are not recommendedfor the treatment of anaphylaxis because they are lesseffective than the IM route. 361–363Adrenaline IM dose. The evidence for the recommended doses isweak. Doses are based on what is considered to be safe and practicalto draw up and inject in an emergency.(The equivalent volume of 1:1000 adrenaline is shown inbrackets)>12 years and adults: 500 g IM (0.5 ml)>6–12 years: 300 g IM (0.3 ml)>6 months–6 years: 150 g IM (0.15 ml)
18 de 0ctubre de 2010 www.elsuapdetodos.comJ. Soar et al. / Resuscitation 81 (2010) 1400–1433 1417Mast cell tryptaseThe specific test to help confirm a diagnosis of anaphylaxis ismeasurement of mast cell tryptase. Tryptase is the major proteincomponent of mast cell secretory granules. In anaphylaxis, mastcell degranulation leads to markedly increased blood tryptase concentrations.Tryptase concentrations in the blood may not increasesignificantly until 30 min or more after the onset of symptoms, andpeak 1–2 h after onset. 385 The half-life of tryptase is short (approximately2 h), and concentrations may be back to normal within6–8 h, so timing of any blood samples is very important. The timeof onset of the anaphylaxis is the time when symptoms were firstnoticed.patient’s general practitioner. All patients presenting with anaphylaxisshould be referred to an allergy clinic to identify the cause,and thereby reduce the risk of future reactions and prepare thepatient to manage future episodes themselves. Patients need toknow the allergen responsible and how to avoid it. Patients needto be able to recognise the early symptoms of anaphylaxis, so thatthey can summon help quickly and prepare to use their emergencymedication. Although there are no randomised clinical trials, thereis evidence that individualised action plans for self-managementshould decrease the risk of recurrence. 3918h. Cardiac arrest following cardiac surgery(a) Minimum: one sample at 1–2 h after the start of symptoms.(b) Ideally: three timed samples:• Initial sample as soon as feasible after resuscitation has started –do not delay resuscitation to take sample.• Second sample at 1–2 h after the start of symptoms• Third sample either at 24 h or in convalescence (for example in afollow-up allergy clinic). This provides baseline tryptase levels –some individuals have an elevated baseline level.Serial samples have better specificity and sensitivity than a singlemeasurement in the confirmation of anaphylaxis. 386Discharge and follow-upPatients who have had suspected anaphylaxis (i.e., an airway,breathing or circulation (ABC) problem) should be treated andthen observed in a clinical area with facilities for treating lifethreateningABC problems. Patients with a good response to initialtreatment should be warned of the possibility of an early recurrenceof symptoms and in some circumstances should be keptunder observation. The exact incidence of biphasic reactions isunknown. Although studies quote an incidence of 1–20%, it is notclear whether all the patients in these studies actually had an anaphylaxisand whether the initial treatment was appropriate. 387There is no reliable way of predicting who will have a biphasicreaction. It is therefore important that decisions about dischargeare made for each patient by an experienced clinician.Before discharge from hospital all patients must be:• Reviewed by a senior clinician.• Given clear instructions to return to hospital if symptoms return.• Considered for antihistamines and oral steroids therapy for up to3 days. This is helpful for treatment of urticaria and may decreasethe chance of further reaction.• Considered for an adrenaline auto-injector, or given areplacement. 388–390• Have a plan for follow-up, including contact with the patient’sgeneral practitioner.An adrenaline auto-injector is an appropriate treatment forpatients at increased risk of idiopathic anaphylaxis, or for anyoneat continued high risk of reaction, e.g., to triggers such as venomstings and food-induced reactions (unless easy to avoid). An autoinjectoris not usually necessary for patients who have suffereddrug-induced anaphylaxis, unless it is difficult to avoid the drug.Ideally, all patients should be assessed by an allergy specialist andhave a treatment plan based on their individual risk.Individuals provided with an auto-injector on discharge fromhospital must be given instructions and training on when and howto use it. Ensure appropriate follow-up including contact with theCardiac arrest following major cardiac surgery is relativelycommon in the immediate post-operative phase, with a reportedincidence of 0.7–2.9%. 392–400 It is usually preceded by physiologicaldeterioration, 401 although it can occur suddenly in stablepatients. 398 There are usually specific causes of cardiac arrest, suchas tamponade, hypovolaemia, myocardial ischaemia, tension pneumothorax,or pacing failure. These are all potentially reversible andif treated promptly cardiac arrest after cardiac surgery has a relativelyhigh survival rate. If cardiac arrest occurs during the first24 h after cardiac surgery, the rate of survival to hospital dischargeis 54% 399 to 79% 398,402 in adults and 41% in children. 401Key to the successful resuscitation of cardiac arrest in thesepatients is the need to perform emergency resternotomy early,especially in the context of tamponade or haemorrhage, whereexternal chest compressions may be ineffective.Identification of cardiac arrestPatients in the ICU are highly monitored and an arrest is mostlikely to be signalled by monitoring alarms where absence of pulsationor perfusing pressure on the arterial line, loss of pulse oximeter,pulmonary artery (PA) trace, or end-tidal CO 2 trace can be sufficientto indicate cardiac arrest without the need to palpate a centralpulse.Starting CPRStart external chest compressions immediately in all patientswho collapse without an output. Consider reversible causes:hypoxia – check tube position, ventilate with 100% oxygen; tensionpneumothorax – clinical examination, thoracic ultrasound;hypovolaemia, pacing failure. In asystole, secondary to a loss ofcardiac pacing, external massage may be delayed momentarily aslong as the surgically inserted temporary pacing wires can be connectedrapidly and pacing re-established (DDD at 100 min −1 atmaximum amplitude). The effectiveness of compressions may beverified by looking at the arterial trace, aiming to achieve a systolicblood pressure of at least 80 mmHg at a rate of 100 min −1 .Inability to attain this pressure may indicate tamponade, tensionpneumothorax, or exanguinating haemorrhage and should precipitateemergency resternotomy. Intra-aortic balloon pumps shouldbe changed to pressure triggering during CPR. In PEA, switch off thepacemaker – a temporary pacemaker may potentially hide underlyingVF.www.elsuapdetodos.comDefibrillationThere is concern that external chest compressions can causesternal disruption or cardiac damage. 403–406 In the post-cardiacsurgery ICU, a witnessed and monitored VF/VT cardiac arrest shouldbe treated immediately with up to three quick successive (stacked)defibrillation attempts. Three failed shocks in the post-cardiac
Page 1:
Resuscitation 81 (2010) 1219-127618
Page 4 and 5:
18 de 0ctubre de 2010 www.elsuapdet
Page 7:
If there is more than one rescuer p
Page 10 and 11:
Page 12 and 13:
Page 14 and 15:
Page 16 and 17:
Page 18 and 19:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Resuscitation 81 (2010) 1364-138818
Page 148 and 149: 18 de 0ctubre de 2010 www.elsuapdet
Page 182 and 183: Resuscitation 81 (2010) 1400-143318
Page 216 and 217: Resuscitation 81 (2010) 1434-144418
show all

European Resuscitation Council Guidelines for Resuscitation ... - CPR

Create successful ePaper yourself

Delete template?

Save as template?