European Resuscitation Council Guidelines for Resuscitation ... - CPR

More documents

Recommendations

Info

18 de 0ctubre de 2010 www.elsuapdetodos.com1256 J.P. Nolan et al. / Resuscitation 81 (2010) 1219–1276• severe bronchospasm and mucous plugging leading to asphyxia(this condition causes the vast majority of asthma-relateddeaths);• cardiac arrhythmias caused by hypoxia, which is the commonestcause of asthma-related arrhythmia. 610 Arrhythmias can also becaused by stimulant drugs (e.g., beta-adrenergic agonists, aminophylline)or electrolyte abnormalities;• dynamic hyperinflation, i.e., auto-positive end-expiratory pressure(auto-PEEP), can occur in mechanically ventilated asthmatics.Auto-PEEP is caused by air trapping and ‘breath stacking’ (airentering the lungs and being unable to escape). Gradual build-upof pressure occurs and reduces venous return and blood pressure;• tension pneumothorax (often bilateral).Key interventions to prevent arrestThe patient with severe asthma requires aggressive medicalmanagement to prevent deterioration. Base assessment and treatmenton an ABCDE approach. Patients with SaO 2 < 92% or withfeatures of life-threatening asthma are at risk of hypercapnicrespiratory failure and require arterial blood gas measurement.Experienced clinicians should treat these high-risk patients in acritical-care area. The specific drugs and the treatment sequencewill vary according to local practice but are described in detail inSection 8f of the ERC Guidelines. 10Treatment of cardiac arrest caused by asthmaGive basic life support according to standard guidelines. Ventilationwill be difficult because of increased airway resistance; tryto avoid gastric inflation. Modifications to standard ALS guidelinesinclude considering the need for early tracheal intubation. The veryhigh airways resistance means that there is a significant risk of gastricinflation and hypoventilation of the lungs when attempting toventilate a severe asthmatic without a tracheal tube. During cardiacarrest this risk is even higher, because the lower oesophagealsphincter pressure is substantially less than normal. 611Respiratory rates of 8–10 breaths min −1 and tidal volumerequired for a normal chest rise during CPR should not causedynamic hyperinflation of the lungs (gas trapping). Tidal volumedepends on inspiratory time and inspiratory flow. Lung emptyingdepends on expiratory time and expiratory flow. In mechanicallyventilated severe asthmatics, increasing the expiratory time(achieved by reducing the respiratory rate) provides only moderategains in terms of reduced gas trapping when a minute volume ofless than 10 l min −1 is used. 612There is limited evidence from case reports of unexpected ROSCin patients with suspected gas trapping when the tracheal tube isdisconnected. 613–617 If dynamic hyperinflation of the lungs is suspectedduring CPR, compression of the chest wall and/or a periodof apnoea (disconnection from the tracheal tube) may relieve gastrapping if dynamic hyperinflation occurs. Although this procedureis supported by limited evidence, it is unlikely to be harmful in anotherwise desperate situation. 15 Dynamic hyperinflation increasestransthoracic impedance. 618 Consider higher shock energies fordefibrillation if initial defibrillation attempts fail. 14There is no good evidence for the use of open-chest cardiaccompressions in patients with asthma-associated cardiac arrest.Working through the four Hs and four Ts will identify potentiallyreversible causes of asthma-related cardiac arrest. Tension pneumothoraxcan be difficult to diagnose in cardiac arrest; it maybe indicated by unilateral expansion of the chest wall, shiftingof the trachea and subcutaneous emphysema. Pleural ultrasoundin skilled hands is faster and more sensitive than chest X-ray forthe detection of pneumothorax. 619 Always consider bilateral pneumothoracesin asthma-related cardiac arrest.Extracorporeal life support (ECLS) can ensure both organperfusion and gas exchange in case of otherwise untreatable respiratoryand circulatory failure. Cases of successful treatment ofasthma-related cardiac arrest in adults using ECLS have beenreported 620,621 ; however, the role of ECLS in cardiac arrest causedby asthma has never been investigated in controlled studies.AnaphylaxisAnaphylaxis is a severe, life-threatening, generalised or systemichypersensitivity reaction. This is characterised by rapidlydeveloping life-threatening airway and/or breathing and/or circulationproblems usually associated with skin and mucosalchanges. 622,623 Anaphylaxis usually involves the release of inflammatorymediators from mast cells and, or basophils triggered byan allergen interacting with cell-bound immunoglobulin E (IgE).Non-IgE-mediated or non-immune release of mediators can alsooccur. Histamine and other inflammatory mediator release areresponsible for the vasodilatation, oedema and increased capillarypermeability.Anaphylaxis is the likely diagnosis if a patient who is exposedto a trigger (allergen) develops a sudden illness (usually withinminutes) with rapidly developing life-threatening airway and/orbreathing and/or circulation problems usually associated with skinand mucosal changes.Use an ABCDE approach to recognise and treat anaphylaxis.Adrenaline should be given to all patients with life-threateningfeatures. The intramuscular (IM) route is the best for most rescuerswho have to give adrenaline to treat anaphylaxis. Use the followingdoses:>12 years and adults 500 g IM>6–12 years 300 g IM>6 months–6 years 150 g IM
if treated promptly cardiac arrest after cardiac surgery has a relativelyhigh survival rate. Key to the successful resuscitation ofcardiac arrest in these patients is recognition of the need the needto perform emergency resternotomy early, especially in the contextof tamponade or haemorrhage, where external chest compressionsmay be ineffective.Starting CPRStart external chest compressions immediately in all patientswho collapse without an output. Consider reversible causes:hypoxia – check tube position, ventilate with 100% oxygen; tensionpneumothorax – clinical examination, thoracic ultrasound;hypovolaemia, pacing failure. In asystole, secondary to a loss ofcardiac pacing, chest compressions may be delayed momentarilyas long as the surgically inserted temporary pacing wires can beconnected rapidly and pacing re-established (DDD at 100 min −1 atmaximum amplitude). The effectiveness of compressions may beverified by looking at the arterial trace, aiming to achieve a systolicblood pressure of at least 80 mm Hg at a rate of 100 min −1 .DefibrillationThere is concern that external chest compressions can causesternal disruption or cardiac damage. 634–637 In the post-cardiacsurgery ICU, a witnessed and monitored VF/VT cardiac arrest shouldbe treated immediately with up to three quick successive (stacked)defibrillation attempts. Three failed shocks in the post-cardiacsurgery setting should trigger the need for emergency resternotomy.Further defibrillation is attempted as indicated in theuniversal algorithm and should be performed with internal paddlesat 20 J if resternotomy has been performed.Emergency drugsUse adrenaline very cautiously and titrate to effect (intravenousdoses of up to 100 g in adults). Give amiodarone 300 mg after the3rd failed defibrillation attempt but do not delay resternotomy.Emergency resternotomyThis is an integral part of resuscitation after cardiac surgery, onceall other reversible causes have been excluded. Once adequate airwayand ventilation has been established, and if three attempts atdefibrillation have failed in VF/VT, undertake resternotomy withoutdelay. Emergency resternotomy is also indicated in asystole orPEA, when other treatments have failed.18 de 0ctubre de 2010 www.elsuapdetodos.comJ.P. Nolan et al. / Resuscitation 81 (2010) 1219–1276 1257data are available) neurological outcome is good in only 1.6% ofthose sustaining traumatic cardiorespiratory arrest (TCRA).Commotio cordisCommotio cordis is actual or near cardiac arrest caused by ablunt impact to the chest wall over the heart. 647–651 A blow to thechest during the vulnerable phase of the cardiac cycle may causemalignant arrhythmias (usually ventricular fibrillation). Commotiocordis occurs mostly during sports (most commonly baseball) andrecreational activities and victims are usually young males (meanage 14 years). The overall survival rate from commotio cordis is15%, but 25% if resuscitation is started within 3 min. 651Signs of life and initial ECG activityThere are no reliable predictors of survival for TCRA. One studyreported that the presence of reactive pupils and sinus rhythmcorrelate significantly with survival. 652 In a study of penetratingtrauma, pupil reactivity, respiratory activity and sinus rhythmwere correlated with survival but were unreliable. 646 Three studiesreported no survivors in patients presenting with asystole oragonal rhythms. 642,646,653 Another reported no survivors amongthose with PEA after blunt trauma. 654 Based on these studies,the American College of Surgeons and the National Association ofEMS physicians produced pre-hospital guidelines on withholdingresuscitation. 655TreatmentSurvival from TCRA is correlated with duration of CPR andpre-hospital time. 644,656–660 Undertake only essential lifesavinginterventions on scene and, if the patient has signs of life,transfer rapidly to the nearest appropriate hospital. Consider onscene thoracotomy for appropriate patients. 661,662 Do not delayfor unproven interventions such as spinal immobilization. 663Treat reversible causes: hypoxaemia (oxygenation, ventilation);compressible haemorrhage (pressure, pressure dressings, tourniquets,novel haemostatic agents); non-compressible haemorrhage(splints, intravenous fluid); tension pneumothorax (chest decompression);cardiac tamponade (immediate thoracotomy). Chestcompressions may not be effective in hypovolaemic cardiac arrest,but most survivors do not have hypovolaemia and in this subgroupstandard advanced life support may be lifesaving. Standard CPRshould not delay the treatment of reversible causes (e.g., thoracotomyfor cardiac tamponade).www.elsuapdetodos.comResuscitative thoracotomyInternal defibrillationInternal defibrillation using paddles applied directly acrossthe ventricles requires considerably less energy than that usedfor external defibrillation. Use 20 J in cardiac arrest, but 5 J if thepatient has been placed on cardiopulmonary bypass. Continuingcardiac compressions using the internal paddles while charging thedefibrillator and delivering the shock during the decompressionphase of compressions may improve shock success. 638,639Traumatic cardiorespiratory arrestCardiac arrest caused by trauma has a very high mortality, withan overall survival of just 5.6% (range 0–17%). 640–646 For reasonsthat are unclear, reported survival rates in the last 5 years arebetter than reported previously. In those who survive (and whereIf physicians with appropriate skills are on scene, prehospitalresuscitative thoracotomy may be indicated for selected patientswith cardiac arrest associated with penetrating chest injury.Emergency department thoracotomy (EDT) is best applied topatients with penetrating cardiac injuries who arrive at a traumacentre after a short on scene and transport time with witnessedsigns of life or ECG activity (estimated survival rate 31%). 664 Afterblunt trauma, EDT should be limited to those with vital signs onarrival and a witnessed cardiac arrest (estimated survival rate 1.6%).UltrasoundUltrasound is a valuable tool for the evaluation of thecompromised trauma patient. Haemoperitoneum, haemo-or pneumothoraxand cardiac tamponade can be diagnosed reliably inminutes even in the pre-hospital phase. 665 Pre-hospital ultrasoundis now available, although its benefits are yet to be proven. 666
Page 1: Resuscitation 81 (2010) 1219-127618
Page 4 and 5: 18 de 0ctubre de 2010 www.elsuapdet
Page 7: If there is more than one rescuer p
Page 88 and 89:
18 de 0ctubre de 2010 www.elsuapdet
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Resuscitation 81 (2010) 1364-138818
Page 148 and 149:
Page 150 and 151:
Page 152 and 153:
Page 154 and 155:
Page 156 and 157:
Page 158 and 159:
Page 160 and 161:
Page 162 and 163:
Page 164 and 165:
Page 166 and 167:
Page 168 and 169:
Page 170 and 171:
Page 172 and 173:
Page 174 and 175:
Page 176 and 177:
Page 178 and 179:
Page 180 and 181:
Page 182 and 183:
Resuscitation 81 (2010) 1400-143318
Page 184 and 185:
Page 186 and 187:
Page 188 and 189:
Page 190 and 191:
Page 192 and 193:
Page 194 and 195:
Page 196 and 197:
Page 198 and 199:
Page 202 and 203:
Page 204 and 205:
Page 206 and 207:
Page 208 and 209:
Page 210 and 211:
Page 212 and 213:
Page 214 and 215:
Page 216 and 217:
Resuscitation 81 (2010) 1434-144418
Page 218 and 219:
Page 220 and 221:
Page 222 and 223:
Page 224 and 225:
Page 226 and 227:
Page 228 and 229:
Page 230 and 231:
Page 232 and 233:
show all

European Resuscitation Council Guidelines for Resuscitation ... - CPR

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?