European Resuscitation Council Guidelines for Resuscitation ... - CPR

18 de 0ctubre de 2010 www.elsuapdetodos.comJ. Soar et al. / Resuscitation 81 (2010) 1400–1433 1421Airway managementFluids and blood transfusion on sceneEffective airway management is essential to maintain oxygenationof the severely compromised trauma patient. In one study,tracheal intubation on scene of patients with TCRA doubled the toleratedperiod of CPR before emergency department thoracotomy –the mean duration of CPR for survivors who were intubated in thefield was 9.1 versus 4.2 min for those were not intubated. 447Tracheal intubation in trauma patients is a difficult procedurewith a high failure rate if carried out by less experienced careproviders. 458–462 Use basic airway management manoeuvres andalternative airways to maintain oxygenation if tracheal intubationcannot be accomplished immediately. If these measures fail a surgicalairway is indicated.VentilationIn low cardiac output conditions, positive pressure ventilationcauses further circulatory depression, or even cardiac arrest, byimpeding venous return to the heart. 463 Monitor ventilation withcontinuous waveform capnography and adjust to achieve normocapnia.This may enable slow respiratory rates and low tidalvolumes and the corresponding decrease in transpulmonary pressuremay increase venous return and cardiac output.Chest decompressionEffective decompression of a tension pneumothorax can beachieved quickly by lateral or anterior thoracostomy, which, in thepresence of positive pressure ventilation, is likely to be more effectivethan needle thoracostomy and quicker than inserting a chesttube. 464Effectiveness of chest compressions in TCRAIn hypovolaemic cardiac arrest, chest compressions are unlikelyto be as effective as in cardiac arrest from other causes. 465 Howevermost survivors of TCRA have reasons other than pure hypovolaemiafor their arrest and these patients may benefit from standardadvanced life support interventions. 436,438,440 Patients with cardiactamponade are also less likely to benefit from chest compressionsand should, where possible, have immediate surgical release oftamponade. Return of spontaneous circulation with advanced lifesupport in patients with TCRA has been described and chest compressionsare still the standard of care in patients with cardiac arrestirrespective of aetiology.Haemorrhage controlEarly haemorrhage control is vital. Handle the patient gentlyat all times to prevent clot disruption. Apply external compression,and pelvic and limb splints when appropriate. Delays insurgical haemostasis are disastrous for patients with exsanguinatingtrauma. Recent conflicts have seen a resurgence in the useof tourniquets to stop life-threatening limb haemorrhage. 466 It isunlikely that the same benefits will be seen in civilian trauma practice.Fluid resuscitation of trauma patients before haemorrhage iscontrolled is controversial and there is no clear consensus onwhen it should be started and what fluids should be given. 468,469Limited evidence and general consensus support a more conservativeapproach to intravenous fluid infusion, with permissivehypotension until surgical haemostasis is achieved. 470,471 In the UK,the National Institute for Clinical Excellence (NICE) has publishedguidelines on pre-hospital fluid replacement in trauma. 472 The recommendationsinclude giving 250 ml boluses of crystalloid solutionuntil a radial pulse is achieved and not delaying rapid transportof trauma victims for fluid infusion in the field. Pre-hospital fluidtherapy may have a role in prolonged entrapments but there is noreliable evidence for this. 473,474UltrasoundUltrasound is a valuable tool in the evaluation of thecompromised trauma patient. Haemoperitoneum, haemo-or pneumothoraxand cardiac tamponade can be diagnosed reliably inminutes even in the pre-hospital phase. 475 Diagnostic peritoneallavage and needle pericardiocentesis have virtually disappearedfrom clinical practice since the introduction of sonography intrauma care. Pre-hospital ultrasound is now available, although itsbenefits are yet to be proven. 476VasopressorsThe possible role of vasopressors (e.g., vasopressin) in traumaresuscitation is unclear and is based mainly on case reports. 4778j. Cardiac arrest associated with pregnancyOverviewMortality related to pregnancy in developed countries is rare,occurring in an estimated 1:30,000 deliveries. 478 The fetus mustalways be considered when an adverse cardiovascular event occursin a pregnant woman. Fetal survival usually depends on maternalsurvival. Resuscitation guidelines for pregnancy are basedlargely on case series, extrapolation from non-pregnant arrests,manikin studies and expert opinion based on the physiologyof pregnancy and changes that occur in normal labour. Studiestend to address causes in developed countries, whereas the mostpregnancy-related deaths occur in developing countries. Therewere an estimated 342,900 maternal deaths (death during pregnancy,childbirth, or in the 42 days after delivery) worldwide in2008. 479Significant physiological changes occur during pregnancy, e.g.,cardiac output, blood volume, minute ventilation and oxygen consumptionall increase. Furthermore, the gravid uterus can causesignificant compression of iliac and abdominal vessels when themother is in the supine position, resulting in reduced cardiac outputand hypotension.www.elsuapdetodos.comCausesPericardiocentesisIn patients with suspected trauma-related cardiac tamponade,needle pericardiocentesis is probably not a useful procedure. 467There is no evidence of benefit in the literature. It may increasescene time, can cause myocardial injury and delays effective therapeuticmeasures such as emergency thoracotomy.There are many causes of cardiac arrest in pregnant women. Areview of nearly 2 million pregnancies in the UK 480 showed thatmaternal deaths (death during pregnancy, childbirth, or in the 42days after delivery) between 2003 and 2005 were associated with:• cardiac disease;• pulmonary embolism;