European Resuscitation Council Guidelines for Resuscitation ... - CPR

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