European Resuscitation Council Guidelines for Resuscitation ... - CPR

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18 de 0ctubre de 2010 www.elsuapdetodos.com1250 J.P. Nolan et al. / Resuscitation 81 (2010) 1219–1276Echocardiography may be used to identify potentially treatablecauses of cardiac arrest in children. Cardiac activity can be rapidlyvisualised 527 and pericardial tamponade diagnosed. 268 However,appropriately skilled operators must be available and its use shouldbe balanced against the interruption to chest compressions duringexamination.ArrhythmiasUnstable arrhythmias. Check for signs of life and the centralpulse of any child with an arrhythmia; if signs of life are absent,treat as for cardiopulmonary arrest. If the child has signs of life anda central pulse, evaluate the haemodynamic status. Whenever thehaemodynamic status is compromised, the first steps are:1. Open the airway.2. Give oxygen and assist ventilation as necessary.3. Attach ECG monitor or defibrillator and assess the cardiacrhythm.4. Evaluate if the rhythm is slow or fast for the child’s age.5. Evaluate if the rhythm is regular or irregular.6. Measure QRS complex (narrow complexes: 0.08 s).7. The treatment options are dependent on the child’s haemodynamicstability.Bradycardia is caused commonly by hypoxia, acidosis and/orsevere hypotension; it may progress to cardiopulmonary arrest.Give 100% oxygen, and positive pressure ventilation if required,to any child presenting with bradyarrhythmia and circulatory failure.If a poorly perfused child has a heart rate
A child who regains a spontaneous circulation, but remainscomatose after cardiopulmonary arrest, may benefit from beingcooled to a core temperature of 32–34 ◦ C for at least 24 h. The successfullyresuscitated child with hypothermia and ROSC should notbe actively rewarmed unless the core temperature is below 32 ◦ C.Following a period of mild hypothermia, rewarm the child slowlyat 0.25–0.5 ◦ Ch −1 .These guidelines are based on evidence from the use of therapeutichypothermia in neonates and adults. At the time of writing,there are ongoing, prospective, multicentre trials of therapeutichypothermia in children following in- and out-of-hospital cardiacarrest. (www.clinicaltrials.gov; NCT00880087 and NCT00878644)Fever is common following cardiopulmonary resuscitation andis associated with a poor neurological outcome, 346,348,349 the riskincreasing for each degree of body temperature greater than37 ◦ C. 349 There are limited experimental data suggesting thatthe treatment of fever with antipyretics and/or physical coolingreduces neuronal damage. 567,568 Antipyretics and accepted drugsto treat fever are safe; therefore, use them to treat fever aggressively.Glucose controlBoth hyper- and hypo-glycaemia may impair outcome of criticallyill adults and children and should be avoided, but tight glucosecontrol may also be harmful. Although there is insufficient evidenceto support or refute a specific glucose management strategyin children with ROSC after cardiac arrest, 3,569,570 it is appropriateto monitor blood glucose and avoid hypoglycaemia as well assustained hyperglycaemia.Resuscitation of babies at birthPreparationRelatively few babies need any resuscitation at birth. Of thosethat do need help, the overwhelming majority will require onlyassisted lung aeration. A small minority may need a brief periodof chest compressions in addition to lung aeration. Of 100,000babies born in Sweden in one year, only 10 per 1000 (1%) babiesof 2.5 kg or more appeared to need resuscitation at delivery. 571 Ofthose babies receiving resuscitation, 8 per 1000 responded to maskinflation and only 2 per 1000 appeared to need intubation. Thesame study tried to assess the unexpected need for resuscitationat birth and found that for low risk babies, i.e., those born after 32weeks gestation and following an apparently normal labour, about2 per 1000 (0.2%) appeared to need resuscitation at delivery. Ofthese, 90% responded to mask inflation alone while the remaining10% appeared not to respond to mask inflation and therefore wereintubated at birth (Fig. 1.14).Resuscitation or specialist help at birth is more likely to beneeded by babies with intrapartum evidence of significant fetalcompromise, babies delivering before 35 weeks gestation, babiesdelivering vaginally by the breech, and multiple pregnancies.Although it is often possible to predict the need for resuscitationor stabilisation before a baby is born, this is not always the case.Therefore, personnel trained in newborn life support should be easilyavailable at every delivery and, should there be any need forintervention, the care of the baby should be their sole responsibility.One person experienced in tracheal intubation of the newbornshould ideally be in attendance for deliveries associated with a highrisk of requiring neonatal resuscitation. Local guidelines indicatingwho should attend deliveries should be developed, based oncurrent practice and clinical audit.An organised educational programme in the standards and skillsrequired for resuscitation of the newborn is therefore essential forany institution in which deliveries occur.18 de 0ctubre de 2010 www.elsuapdetodos.comJ.P. Nolan et al. / Resuscitation 81 (2010) 1219–1276 1251Planned home deliveriesRecommendations as to who should attend a planned homedelivery vary from country to country, but the decision to undergoa planned home delivery, once agreed with medical and midwiferystaff, should not compromise the standard of initial resuscitationat birth. There will inevitably be some limitations to resuscitationof a newborn baby in the home, because of the distance from furtherassistance, and this must be made clear to the mother at thetime plans for home delivery are made. Ideally, two trained professionalsshould be present at all home deliveries; one of these mustbe fully trained and experienced in providing mask ventilation andchest compressions in the newborn.Equipment and environmentUnlike adult cardiopulmonary resuscitation (CPR), resuscitationat birth is often a predictable event. It is therefore possible to preparethe environment and the equipment before delivery of thebaby. Resuscitation should ideally take place in a warm, well-lit,draught free area with a flat resuscitation surface placed below aradiant heater, with other resuscitation equipment immediatelyavailable. All equipment must be checked frequently.When a birth takes place in a non-designated delivery area, therecommended minimum set of equipment includes a device forsafe assisted lung aeration of an appropriate size for the newborn,warm dry towels and blankets, a sterile instrument for cutting theumbilical cord and clean gloves for the attendant and assistants. Itmay also be helpful to have a suction device with a suitably sizedsuction catheter and a tongue depressor (or laryngoscope) to enablethe oropharynx to be examined. Unexpected deliveries outside hospitalare most likely to involve emergency services who should planfor such events.Temperature controlNaked, wet, newborn babies cannot maintain their body temperaturein a room that feels comfortably warm for adults.Compromised babies are particularly vulnerable. 572 Exposure ofthe newborn to cold stress will lower arterial oxygen tension 573and increase metabolic acidosis. 574 Prevent heat loss:• Protect the baby from draughts.• Keep the delivery room warm. For babies less than 28 weeksgestation the delivery room temperature should be 26 ◦ C. 575,576• Dry the term baby immediately after delivery. Cover the headand body of the baby, apart from the face, with a warm towelto prevent further heat loss. Alternatively, place the baby skin toskin with mother and cover both with a towel.• If the baby needs resuscitation then place the baby on a warmsurface under a preheated radiant warmer.• In very preterm babies (especially below 28 weeks) drying andwrapping may not be sufficient. A more effective method of keepingthese babies warm is to cover the head and body of the baby(apart from the face) with plastic wrapping, without drying thebaby beforehand, and then to place the baby so covered underradiant heat.www.elsuapdetodos.comInitial assessmentThe Apgar score was proposed as a “simple, common, clear classificationor grading of newborn infants” to be used “as a basisfor discussion and comparison of the results of obstetric practices,types of maternal pain relief and the effects of resuscitation” (ouremphasis). 577 It was not designed to be assembled and ascribedin order to then identify babies in need of resuscitation. 578 However,individual components of the score, namely respiratory rate,
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