European Resuscitation Council Guidelines for Resuscitation ... - CPR

18 de 0ctubre de 2010 www.elsuapdetodos.comJ.P. Nolan et al. / Resuscitation 81 (2010) 1219–1276 1253ToneBreathingA very floppy baby is likely to be unconscious and will needventilatory support.Tactile stimulationDrying the baby usually produces enough stimulation to induceeffective breathing. Avoid more vigorous methods of stimulation. Ifthe baby fails to establish spontaneous and effective breaths followinga brief period of stimulation, further support will be required.Classification according to initial assessmentOn the basis of the initial assessment, the baby can be placedinto one of three groups:1. Vigorous breathing or cryingGood toneHeart rate higher than 100 min −1This baby requires no intervention other than drying, wrappingin a warm towel and, where appropriate, handing to the mother.The baby will remain warm through skin-to-skin contact withmother under a cover, and may be put to the breast at this stage.2. Breathing inadequately or apnoeicNormal or reduced toneHeart rate less than 100 min −1Dry and wrap. This baby may improve with mask inflation but ifthis does not increase the heart rate adequately, may also requirechest compressions.3. Breathing inadequately or apnoeicFloppyLow or undetectable heart rateOften pale suggesting poor perfusionDry and wrap. This baby will then require immediate airwaycontrol, lung inflation and ventilation. Once this has been successfullyaccomplished the baby may also need chest compressions, andperhaps drugs.There remains a very rare group of babies who, though breathingadequately and with a good heart rate, remain hypoxaemic. Thisgroup includes a range of possible diagnoses such as diaphragmatichernia, surfactant deficiency, congenital pneumonia, pneumothorax,or cyanotic congenital heart disease.Newborn life supportCommence newborn life support if assessment shows that thebaby has failed to establish adequate regular normal breathing, orhas a heart rate of less than 100 min −1 . Opening the airway andaerating the lungs is usually all that is necessary. Furthermore, morecomplex interventions will be futile unless these two first stepshave been successfully completed.After initial steps at birth, if breathing efforts are absent orinadequate, lung aeration is the priority. In term babies, beginresuscitation with air. The primary measure of adequate initial lunginflation is a prompt improvement in heart rate; assess chest wallmovement if heart rate does not improve.For the first few breaths maintain the initial inflation pressurefor 2–3 s. This will help lung expansion. Most babies needingresuscitation at birth will respond with a rapid increase in heartrate within 30 s of lung inflation. If the heart rate increases butthe baby is not breathing adequately, ventilate at a rate of about30 breaths min −1 allowing approximately one second for eachinflation, until there is adequate spontaneous breathing.Adequate passive ventilation is usually indicated by either arapidly increasing heart rate or a heart rate that is maintained fasterthan 100 beats min −1 . If the baby does not respond in this way themost likely cause is inadequate airway control or inadequate ventilation.Without adequate lung aeration, chest compressions will beineffective; therefore, confirm lung aeration before progressing tocirculatory support. Some practitioners will ensure airway controlby tracheal intubation, but this requires training and experience. Ifthis skill is not available and the heart rate is decreasing, re-evaluatethe airway position and deliver inflation breaths while summoninga colleague with intubation skills. Continue ventilatory supportuntil the baby has established normal regular breathing.Circulatory supportCirculatory support with chest compressions is effective only ifthe lungs have first been successfully inflated. Give chest compressionsif the heart rate is less than 60 beats min −1 despite adequateventilation. The most effective technique for providing chest compressionsis to place the two thumbs side by side over the lowerthird of the sternum just below an imaginary line joining thenipples, with the fingers encircling the torso and supporting theback. 583–586 An alternative way to find the correct position ofthe thumbs is to identify the xiphisternum and then to place thethumbs on the sternum one finger’s breadth above this point. Thesternum is compressed to a depth of approximately one-third of theanterior–posterior diameter of the chest allowing the chest wall toreturn to its relaxed position between compressions. 587Use a CV ratio of 3:1, aiming to achieve approximately120 events min −1 , i.e., approximately 90 compressions and 30breaths. Check the heart rate after about 30 s and periodically thereafter.Discontinue chest compressions when the spontaneous heartrate is faster than 60 beats min −1 .www.elsuapdetodos.comDrugsAirwayPlace the baby on his back with the head in a neutral position.A 2 cm thickness of the blanket or towel placed under the baby’sshoulders may be helpful in maintaining proper head position. Infloppy babies application of jaw thrust or the use of an appropriatelysized oropharyngeal airway may be helpful in opening theairway.Suction is needed only if the airway is obstructed and is bestdone under direct vision. Aggressive pharyngeal suction can delaythe onset of spontaneous breathing and cause laryngeal spasm andvagal bradycardia. 582 The presence of thick meconium in a nonvigorousbaby is the only indication for considering immediatesuction of the oropharynx. Connect a 12–14 FG suction catheter,or a Yankauer sucker, to a suction source not exceeding minus100 mm Hg.Drugs are rarely indicated in resuscitation of the newly borninfant. Bradycardia in the newborn infant is usually caused byinadequate lung inflation or profound hypoxia, and establishingadequate ventilation is the most important step to correct it. However,if the heart rate remains less than 60 beats min −1 despiteadequate ventilation and chest compressions, it is reasonable toconsider the use of drugs. These are best given via an umbilicalvenous catheter.AdrenalineDespite the lack of human data it is reasonable to use adrenalinewhen adequate ventilation and chest compressions have failed toincrease the heart rate above 60 beats min −1 . If adrenaline is used,give 10–30 gkg −1 intravenously as soon as possible. The trachealroute is not recommended but if it is used, it is highly likely thatdoses of 50–100 gkg −1 will be required. Neither the safety nor