European Resuscitation Council Guidelines for Resuscitation ... - CPR

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18 de 0ctubre de 2010 www.elsuapdetodos.com1244 J.P. Nolan et al. / Resuscitation 81 (2010) 1219–1276(2) Bypassing a closer but non-PCI capable hospital and taking measuresto shorten the delay to intervention if PPCI is the chosenstrategy.(3) Procedures in special situations e.g., for patients successfullyresuscitated from non-traumatic cardiac arrest, patients withshock or patients with non-STEMI-ACS who are unstable orhave signs of very high risk.Reperfusion strategy in patients presenting with STEMIFor patients presenting with STEMI within 12 h of symptomonset, reperfusion should be initiated as soon as possible independentof the method chosen. 414,442–444 Reperfusion may be achievedwith fibrinolysis, with PPCI, or a combination of both. Efficacy ofreperfusion therapy is profoundly dependent on the duration ofsymptoms. Fibrinolysis is effective specifically in the first 2–3 hafter symptom onset; PPCI is less time sensitive. 445 Giving fibrinolyticsout-of-hospital to patients with STEMI or signs andsymptoms of an ACS with presumed new LBBB is beneficial. Fibrinolytictherapy can be given safely by trained paramedics, nursesor physicians using an established protocol. 446–451 The efficacy isgreatest within the first 3 h of the onset of symptoms. 452 Patientswith symptoms of ACS and ECG evidence of STEMI (or presumablynew LBBB or true posterior infarction) presenting directly tothe ED should be given fibrinolytic therapy as soon as possibleunless there is timely access to PPCI. Healthcare professionals whogive fibrinolytic therapy must be aware of its contraindications andrisks.Primary percutaneous interventionCoronary angioplasty with or without stent placement hasbecome the first-line treatment for patients with STEMI, becauseit has been shown to be superior to fibrinolysis in the combinedendpoints of death, stroke and reinfarction in several studies andmeta-analyses. 453,454Fibrinolysis versus primary PCISeveral reports and registries comparing fibrinolytic (includingpre-hospital administration) therapy with PPCI showed a trend ofimproved survival if fibrinolytic therapy was initiated within 2 hof onset of symptoms and was combined with rescue or delayedPCI. 455–457 If PPCI cannot be accomplished within an adequatetimeframe, independent of the need for emergent transfer, thenimmediate fibrinolysis should be considered unless there is acontraindication. For those STEMI patients presenting in shock,primary PCI (or coronary artery bypass surgery) is the preferredreperfusion treatment. Fibrinolysis should be considered only ifthere is a substantial delay to PCI.Triage and inter-facility transfer for primary PCIThe risk of death, reinfarction or stroke is reduced if patientswith STEMI are transferred promptly from community hospitalsto tertiary care facilities for PPCI. 383,454,458 It is less clear whetherimmediate fibrinolytic therapy (in- or out-of-hospital) or transferfor PPCI is superior for younger patients presenting with anteriorinfarction and within a short duration of
Fig. 1.11. Paediatric basic life support algorithm for those with a duty to respond.18 de 0ctubre de 2010 www.elsuapdetodos.comJ.P. Nolan et al. / Resuscitation 81 (2010) 1219–1276 1245◦ At the same time, with your fingertip(s) under the point of thechild’s chin, lift the chin. Do not push on the soft tissues underthe chin as this may obstruct the airway.◦ If you still have difficulty in opening the airway, try a jawthrust: place the first two fingers of each hand behind eachside of the child’s mandible and push the jaw forward.4. Keeping the airway open, look, listen and feel for normal breathingby putting your face close to the child’s face and looking alongthe chest:• Look for chest movements.• Listen at the child’s nose and mouth for breath sounds.• Feel for air movement on your cheek.In the first few minutes after a cardiac arrest a child may betaking slow infrequent gasps. Look, listen and feel for no more than10 s before deciding—if you have any doubt whether breathing isnormal, act as if it is not normal:5A. If the child is breathing normally:• Turn the child on his side into the recovery position (see below)• Send or go for help—call the local emergency number for anambulance.• Check for continued breathing.5B. If breathing is not normal or absent:• Remove carefully any obvious airway obstruction.• Give five initial rescue breaths.• While performing the rescue breaths note any gag or coughresponse to your action. These responses or their absence willform part of your assessment of ‘signs of life’, which will bedescribed later.Rescue breaths for a child over 1 year of age:• Ensure head tilt and chin lift.• Pinch the soft part of the nose closed with the index finger andthumb of your hand on his forehead.• Allow the mouth to open, but maintain chin lift.• Take a breath and place your lips around the mouth, making surethat you have a good seal.• Blow steadily into the mouth over about 1–1.5 s watching forchest rise.• Maintain head tilt and chin lift, take your mouth away from thevictim and watch for his chest to fall as air comes out.• Take another breath and repeat this sequence five times. Identifyeffectiveness by seeing that the child’s chest has risen and fallen ina similar fashion to the movement produced by a normal breath.www.elsuapdetodos.comRescue breaths for an infant:The following sequence is to be followed by those with a dutyto respond to paediatric emergencies (usually health professionalteams) (Fig. 1.11).1. Ensure the safety of rescuer and child.2. Check the child’s responsiveness.• Gently stimulate the child and ask loudly: Are you all right?3A. If the child responds by answering or moving:• Leave the child in the position in which you find him (providedhe is not in further danger).• Check his condition and get help if needed.• Reassess him regularly.3B. If the child does not respond:• Shout for help.• Turn carefully the child on his back.• Open the child’s airway by tilting the head and lifting the chin.◦ Place your hand on his forehead and gently tilt his head back.• Ensure a neutral position of the head and a chin lift.• Take a breath and cover the mouth and nose of the infant withyour mouth, making sure you have a good seal. If the nose andmouth cannot be covered in the older infant, the rescuer mayattempt to seal only the infant’s nose or mouth with his mouth(if the nose is used, close the lips to prevent air escape).• Blow steadily into the infant’s mouth and nose over 1–1.5 s, sufficientto make the chest visibly rise.• Maintain head position and chin lift, take your mouth away fromthe victim and watch for his chest to fall as air comes out.• Take another breath and repeat this sequence five times.For both infants and children, if you have difficulty achieving aneffective breath, the airway may be obstructed:• Open the child’s mouth and remove any visible obstruction. Donot perform a blind finger sweep.
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European Resuscitation Council Guidelines for Resuscitation ... - CPR

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