European Resuscitation Council Guidelines for Resuscitation ... - CPR

several hours, whereas decisions on treatment are dependent onthe clinical signs at presentation.• History, clinical examinations, biomarkers, ECG criteria and riskscores are unreliable for the identification of patients who maybe safely discharged early.• The role of chest pain observation units (CPUs) is to identify, byusing repeated clinical examinations, ECG and biomarker testing,those patients who require admission for invasive procedures.This may include provocative testing and, in selected patients,imaging procedures such as cardiac computed tomography, magneticresonance imaging, etc.• Non-steroidal anti-inflammatory drugs (NSAIDs) should beavoided.• Nitrates should not be used for diagnostic purposes.• Supplementary oxygen is to be given only to those patients withhypoxaemia, breathlessness or pulmonary congestion. Hyperoxaemiamay be harmful in uncomplicated infarction.• Guidelines for treatment with acetyl salicylic acid (ASA) havebeen made more liberal: ASA may now be given by bystanderswith or without EMS dispatcher assistance.• Revised guidance for new anti-platelet and anti-thrombin treatmentfor patients with ST elevation myocardial infarction (STEMI)and non-STEMI-ACS based on therapeutic strategy.• Gp IIb/IIIa inhibitors before angiography/percutaneous coronaryintervention (PCI) are discouraged.• The reperfusion strategy in STEMI has been updated:◦ Primary PCI (PPCI) is the preferred reperfusion strategy providedit is performed in a timely manner by an experiencedteam.◦ A nearby hospital may be bypassed by the EMS provided PPCIcan be achieved without too much delay.◦ The acceptable delay between start of fibrinolysis and first ballooninflation varies widely between about 45 and 180 mindepending on infarct localisation, age of the patient, and durationof symptoms.◦ ‘Rescue PCI’ should be undertaken if fibrinolysis fails.◦ The strategy of routine PCI immediately after fibrinolysis (‘facilitatedPCI’) is discouraged.◦ Patients with successful fibrinolysis but not in a PCI-capablehospital should be transferred for angiography and eventualPCI, performed optimally 6–24 h after fibrinolysis (the‘pharmaco-invasive’ approach).◦ Angiography and, if necessary, PCI may be reasonable inpatients with ROSC after cardiac arrest and may be part of astandardised post-cardiac arrest protocol.◦ To achieve these goals, the creation of networks including EMS,non PCI capable hospitals and PCI hospitals is useful.• Recommendations for the use of beta-blockers are morerestricted: there is no evidence for routine intravenous betablockersexcept in specific circumstances such as for thetreatment of tachyarrhythmias. Otherwise, beta-blockers shouldbe started in low doses only after the patient is stabilised.• Guidelines on the use of prophylactic anti-arrhythmicsangiotensin, converting enzyme (ACE) inhibitors/angiotensinreceptor blockers (ARBs) and statins are unchanged.Paediatric life supportMajor changes in these new guidelines for paediatric life supportinclude 8,17 :• Recognition of cardiac arrest – Healthcare providers cannot reliablydetermine the presence or absence of a pulse in less than10 s in infants or children. Healthcare providers should lookfor signs of life and if they are confident in the technique,18 de 0ctubre de 2010 www.elsuapdetodos.comJ.P. Nolan et al. / Resuscitation 81 (2010) 1219–1276 1221they may add pulse palpation for diagnosing cardiac arrestand decide whether they should begin chest compressions ornot. The decision to begin CPR must be taken in less than10 s. According to the child’s age, carotid (children), brachial(infants) or femoral pulse (children and infants) checks may beused.• The CV ratio used for children should be based on whetherone, or more than one rescuer is present. Lay rescuers, whousually learn only single-rescuer techniques, should be taughtto use a ratio of 30 compressions to 2 ventilations, which isthe same as the adult guidelines and enables anyone trainedin BLS to resuscitate children with minimal additional information.Rescuers with a duty to respond should learn and usea 15:2 CV ratio; however, they can use the 30:2 ratio if theyare alone, particularly if they are not achieving an adequatenumber of compressions. Ventilation remains a very importantcomponent of CPR in asphyxial arrests. Rescuers who areunable or unwilling to provide mouth-to-mouth ventilationshould be encouraged to perform at least compression-onlyCPR.• The emphasis is on achieving quality compressions of an adequatedepth with minimal interruptions to minimise no-flowtime. Compress the chest to at least one third of the anteriorposteriorchest diameter in all children (i.e., approximately 4 cmin infants and approximately 5 cm in children). Subsequentcomplete release is emphasised. For both infants and children,the compression rate should be at least 100 but not greaterthan 120 min −1 . The compression technique for infants includestwo-finger compression for single rescuers and the two-thumbencircling technique for two or more rescuers. For older children,a one- or two-hand technique can be used, according to rescuerpreference.• Automated external defibrillators (AEDs) are safe and successfulwhen used in children older than 1 year of age. Purposemadepaediatric pads or software attenuate the output of themachine to 50–75 J and these are recommended for childrenaged 1–8 years. If an attenuated shock or a manually adjustablemachine is not available, an unmodified adult AED may be usedin children older than 1 year. There are case reports of successfuluse of AEDs in children aged less than 1 year; in therare case of a shockable rhythm occurring in a child less than1 year, it is reasonable to use an AED (preferably with doseattenuator).• To reduce the no flow time, when using a manual defibrillator,chest compressions are continued while applying and chargingthe paddles or self-adhesive pads (if the size of the child’schest allows this). Chest compressions are paused briefly oncethe defibrillator is charged to deliver the shock. For simplicity andconsistency with adult BLS and ALS guidance, a single-shock strategyusing a non-escalating dose of 4 J kg −1 (preferably biphasic,but monophasic is acceptable) is recommended for defibrillationin children.• Cuffed tracheal tubes can be used safely in infants and young children.The size should be selected by applying a validated formula.• The safety and value of using cricoid pressure during trachealintubation is not clear. Therefore, the application of cricoid pressureshould be modified or discontinued if it impedes ventilationor the speed or ease of intubation.• Monitoring exhaled carbon dioxide (CO 2 ), ideally by capnography,is helpful to confirm correct tracheal tube position andrecommended during CPR to help assess and optimize its quality.• Once spontaneous circulation is restored, inspired oxygen shouldbe titrated to limit the risk of hyperoxaemia.• Implementation of a rapid response system in a paediatric inpatientsetting may reduce rates of cardiac and respiratory arrestand in-hospital mortality.www.elsuapdetodos.com