European Resuscitation Council Guidelines for Resuscitation ... - CPR

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18 de 0ctubre de 2010 www.elsuapdetodos.com1254 J.P. Nolan et al. / Resuscitation 81 (2010) 1219–1276the efficacy of these higher tracheal doses has been studied. Do notgive these high doses intravenously.BicarbonateThere are insufficient data to recommend routine use of bicarbonatein resuscitation of the newly born. The hyperosmolarity andcarbon dioxide-generating properties of sodium bicarbonate mayimpair myocardial and cerebral function. Use of sodium bicarbonateis discouraged during brief CPR. If it is used during prolongedarrests unresponsive to other therapy, it should be given only afteradequate ventilation and circulation is established with CPR. A doseof 1–2 mmol kg −1 may be given by slow intravenous injection afteradequate ventilation and perfusion have been established.FluidsIf there has been suspected blood loss or the infant appears to bein shock (pale, poor perfusion, weak pulse) and has not respondedadequately to other resuscitative measures then consider givingfluid. 588 This is a rare event. In the absence of suitable blood (i.e.,irradiated and leucocyte-depleted group O Rh-negative blood),isotonic crystalloid rather than albumin is the solution of choicefor restoring intravascular volume. Give a bolus of 10 ml kg −1initially. If successful it may need to be repeated to maintain animprovement.Stopping resuscitationLocal and national committees will determine the indicationsfor stopping resuscitation. If the heart rate of a newly born babyis not detectable and remains undetectable for 10 min, it is thenappropriate to consider stopping resuscitation. In cases where theheart rate is less than 60 min −1 at birth and does not improve after10 or 15 min of continuous and apparently adequate resuscitativeefforts, the choice is much less clear. In this situation there is insufficientevidence about outcome to enable firm guidance on whetherto withhold or to continue resuscitation.Communication with the parentsIt is important that the team caring for the newborn babyinforms the parents of the baby’s progress. At delivery, adhereto local plans for routine care and, if possible, hand the baby tothe mother at the earliest opportunity. If resuscitation is requiredinform the parents of the procedures undertaken and why theywere required. Record carefully all discussions and decisions in themother’s notes prior to delivery and in the baby’s records after birth.Cardiac arrest in special circumstancesElectrolyte abnormalitiesLife-threatening arrhythmias are associated most commonlywith potassium disorders, particularly hyperkalaemia, and lesscommonly with disorders of serum calcium and magnesium.In some cases therapy for life-threatening electrolyte disordersshould start before laboratory results become available. There islittle or no evidence for the treatment of electrolyte abnormalitiesduring cardiac arrest. Guidance during cardiac arrest is based onthe strategies used in the non-arrest patient. There are no majorchanges in the treatment of these disorders since the InternationalGuidelines 2005. 589PoisoningPoisoning rarely causes cardiac arrest, but is a leading cause ofdeath in victims younger than 40 years of age. 590 Poisoning bytherapeutic or recreational drugs and by household products arethe main reasons for hospital admission and poison centre calls.Inappropriate drug dosing, drug interactions and other medicationerrors can also cause harm. Accidental poisoning is commonest inchildren. Homicidal poisoning is uncommon. Industrial accidents,warfare or terrorism can also cause exposure to harmful substances.Prevention of cardiac arrestAssess and treat the victim using the ABCDE (Airway, Breathing,Circulation, Disability, Exposure) approach. Airway obstructionand respiratory arrest secondary to a decreased conscious level isa common cause of death after self-poisoning. 591 Pulmonary aspirationof gastric contents can occur after poisoning with centralnervous system depressants. Early tracheal intubation of unconsciouspatients by a trained person decreases the risk of aspiration.Drug-induced hypotension usually responds to fluid infusion, butoccasionally vasopressor support (e.g., noradrenaline infusion) isrequired. A long period of coma in a single position can cause pressuresores and rhabdomyolysis. Measure electrolytes (particularlypotassium), blood glucose and arterial blood gases. Monitor temperaturebecause thermoregulation is impaired. Both hypothermiaand hyperthermia (hyperpyrexia) can occur after overdose of somedrugs. Retain samples of blood and urine for analysis. Patientswith severe poisoning should be cared for in a critical caresetting. Interventions such as decontamination, enhanced eliminationand antidotes may be indicated and are usually secondline interventions. 592 Alcohol excess is often associated with selfpoisoning.Modifications to basic and advanced life support• Have a high index of personal safety where there is a suspiciouscause or unexpected cardiac arrest. This is especially so whenmore than one casualty collapses simultaneously.• Avoid mouth-to-mouth ventilation in the presence of chemicalssuch as cyanide, hydrogen sulphide, corrosives and organophosphates.• Treat life-threatening tachyarrhythmias with cardioversionaccording to the peri-arrest arrhythmia guidelines (see Advancedlife support). 6 This includes correction of electrolyte and acid-baseabnormalities.• Try to identify the poison(s). Relatives, friends and ambulancecrews can provide useful information. Examination ofthe patient may reveal diagnostic clues such as odours, needlemarks, pupil abnormalities, and signs of corrosion in themouth.• Measure the patient’s temperature because hypo- or hyperthermiamay occur after drug overdose (see Sections 8d and 8e).• Be prepared to continue resuscitation for a prolonged period, particularlyin young patients, as the poison may be metabolized orexcreted during extended life support measures.• Alternative approaches that may be effective in severely poisonedpatients include: higher doses of medication than in standardprotocols; non-standard drug therapies; prolonged CPR.• Consult regional or national poisons centres for information ontreatment of the poisoned patient. The International Programmeon Chemical Safety (IPCS) lists poison centres on its website:http://www.who.int/ipcs/poisons/centre/en/• On-line databases for information on toxicology and hazardouschemicals: (http://toxnet.nlm.nih.gov/)www.elsuapdetodos.com
DrowningThe World Health Organisation (WHO) estimates that, worldwide,drowning accounts for approximately 450,000 deaths eachyear and drowning is a common cause of accidental death in Europe.After drowning the duration of hypoxia is the most critical factorin determining the victim’s outcome; therefore, oxygenation, ventilation,and perfusion should be restored as rapidly as possible.Immediate resuscitation at the scene is essential for survival andneurological recovery after a drowning incident. This will requireprovision of CPR by a bystander and immediate activation of theEMS system. Victims who have spontaneous circulation and breathingwhen they reach hospital usually recover with good outcomes.Research into drowning is limited in comparison with primary cardiacarrest and there is a need for further research in this area. 593The guidelines described in detail in Section 8 of the ERC Guidelinesare intended for healthcare professionals and certain groups of layresponders that have a special interest in the care of the drowningvictim e.g., lifeguards. 10Accidental hypothermiaAccidental hypothermia exists when the body core temperatureunintentionally drops below 35 ◦ C. Hypothermia can be classifiedarbitrarily as mild (35–32 ◦ C), moderate (32–28 ◦ C) or severe (lessthan 28 ◦ C). 594 In a hypothermic patient, no signs of life alone isunreliable for declaring death. In the pre-hospital setting, resuscitationshould be withheld only if the cause of a cardiac arrest is clearlyattributable to a lethal injury, fatal illness, prolonged asphyxia, or ifthe chest is incompressible. All the principles of prevention, basicand advanced life support apply to the hypothermic patient. Use thesame ventilation and chest compression rates as for a normothermicpatient. Hypothermia can cause stiffness of the chest wall,making ventilation and chest compressions more difficult.The hypothermic heart may be unresponsive to cardioactivedrugs, attempted electrical pacing and defibrillation. Drugmetabolism is slowed, leading to potentially toxic plasma concentrationsof any drugs given repeatedly. 595 Withold adrenaline andother CPR drugs until the patient has been warmed to a temperaturehigher than approximately 30 ◦ C. Once 30 ◦ C has been reached, theintervals between drug doses should be doubled when comparedwith normothermia intervals. As normothermia is approached(over 35 ◦ C), standard drug protocols should be used.As the body core temperature decreases, sinus bradycardiatends to give way to atrial fibrillation followed by VF and finallyasystole. 596 Once in hospital, severely hypothermic victims in cardiacarrest should be rewarmed with active internal methods.Arrhythmias other than VF tend to revert spontaneously as the coretemperature increases, and usually do not require immediate treatment.Bradycardia may be physiological in severe hypothermia, andcardiac pacing is not indicated unless bradycardia associated withhaemodynamic compromise persists after re-warming. The temperatureat which defibrillation should first be attempted and howoften it should be tried in the severely hypothermic patient hasnot been established. AEDs may be used on these patients. If VF isdetected, give a shock at the maximum energy setting; if VF/VT persistsafter three shocks, delay further defibrillation attempts untilthe core temperature is above 30 ◦ C. 597 If an AED is used, follow theAED prompts while rewarming the patient. CPR and rewarmingmay have to be continued for several hours to facilitate successfuldefibrillation. 597Rewarming may be passive, active external, or active internal.Passive rewarming is appropriate in conscious victims with mildhypothermia who are still able to shiver. Hypothermic victims withan altered consciousness should be taken to a hospital capable ofactive external and internal rewarming. In a hypothermic patient18 de 0ctubre de 2010 www.elsuapdetodos.comJ.P. Nolan et al. / Resuscitation 81 (2010) 1219–1276 1255with apnoea and cardiac arrest, extracorporeal rewarming is thepreferred method of active internal rewarming because it providessufficient circulation and oxygenation while the core body temperatureis increased by 8–12 ◦ Ch −1 . 598During rewarming, patients will require large volumes of fluidsas vasodilation causes expansion of the intravascular space. Continuoushaemodynamic monitoring and warm IV fluids are essential.Avoid hyperthermia during and after re-warming. Although thereare no formal studies, once ROSC has been achieved use standardstrategies for post-resuscitation care, including mild hypothermiaif appropriate.HyperthermiaHyperthermia occurs when the body’s ability to thermoregulatefails and core temperature exceeds that normally maintainedby homeostatic mechanisms. Hyperthermia may be exogenous,caused by environmental conditions, or secondary to endogenousheat production.Environment-related hyperthermia occurs where heat, usuallyin the form of radiant energy, is absorbed by the body at a rate fasterthan can be lost by thermoregulatory mechanisms. Hyperthermiaoccurs along a continuum of heat-related conditions, startingwith heat stress, progressing to heat exhaustion, to heat stroke(HS) and finally multiorgan dysfunction and cardiac arrest in someinstances. 599Heat stroke is a systemic inflammatory response with a coretemperature above 40.6 ◦ C, accompanied by mental state changeand varying levels of organ dysfunction. There are two forms ofHS: classic non-exertional heat stroke (CHS) occurs during highenvironmental temperatures and often effects the elderly duringheat waves 600 ; Exertional heat stroke (EHS) occurs during strenuousphysical exercise in high environmental temperatures and/orhigh humidity usually effects healthy young adults. 601 Mortalityfrom heat stroke ranges between 10% and 50%. 602The mainstay of treatment is supportive therapy based on optimizingthe ABCDEs and rapidly cooling the patient. 603–605 Startcooling before the patient reaches hospital. Aim to reduce the coretemperature rapidly to approximately 39 ◦ C. Patients with severeheat stroke need to be managed in a critical-care setting.There are no specific studies on cardiac arrest in hyperthermia.If cardiac arrest occurs, follow standard procedures for basic andadvanced life support and cool the patient. Cooling techniques similarto those used to induce therapeutic hypothermia should beused. There are no data on the effects of hyperthermia on defibrillationthreshold; therefore, attempt defibrillation according tocurrent guidelines, while continuing to cool the patient. Animalstudies suggest the prognosis is poor compared with normothermiccardiac arrest. 606,607 The risk of unfavourable neurological outcomeincreases for each degree of body temperature >37 ◦ C. 349www.elsuapdetodos.comAsthmaThe worldwide prevalence of asthma symptoms ranges from 1%to 18% of the population with a high prevalence in some Europeancountries (United Kingdom, Ireland and Scandinavia). 608 Annualworldwide deaths from asthma have been estimated at 250,000.National and international guidance for the management of asthmaalready exists. 608,609 This guidance focuses on the treatment ofpatients with near-fatal asthma and cardiac arrest.Causes of asthma-related cardiac arrestCardiac arrest in a person with asthma is often a terminal eventafter a period of hypoxaemia; occasionally, it may be sudden. Cardiacarrest in those with asthma has been linked to:
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European Resuscitation Council Guidelines for Resuscitation ... - CPR

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