European Resuscitation Council Guidelines for Resuscitation ... - CPR

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18 de 0ctubre de 2010 www.elsuapdetodos.com1282 R.W. Koster et al. / Resuscitation 81 (2010) 1277–1292Fig. 2.12. Take your mouth away from the victim and watch for his chest to fall asair comes out.professionals, as well as lay rescuers, have difficulty determiningthe presence or absence of adequate or normal breathing inunresponsive victims. 53,54 This may be because the airway is notopen or because the victim is making occasional (agonal) gasps.When bystanders are asked by ambulance dispatchers over thetelephone if breathing is present, they often misinterpret agonalgasps as normal breathing. This incorrect information can resultin the bystander withholding CPR from a cardiac arrest victim. 55Agonal gasps are present in up to 40% of cardiac arrest victimsin the first minutes after onset, and are associated with highersurvival if recognised as a sign of cardiac arrest. 56 Bystandersdescribe agonal gasps as barely breathing, heavy or labouredbreathing, or noisy or gasping breathing. 57 Laypeople should,therefore, be taught to begin CPR if the victim is unconscious(unresponsive) and not breathing normally. It should be emphasisedduring training that agonal gasps occur commonly in thefirst few minutes after SCA, and that they are an indication tostart CPR immediately; they should not be confused with normalbreathing.Adequate description of the victim is also of critical importanceduring communication with the ambulance dispatch centre. It isimportant for the dispatcher that the caller can see the victim,but in a small minority of cases the caller is not at the scene. 58Information about a victim’s breathing is most important, but thedescription of breathing by callers varies considerably. If the natureof the victim’s breathing is not described or actively asked forby the dispatcher, recognition that the victim has had a cardiacarrest is much less likely than if the breathing is described asabnormal or absent. 59 If, when a caller describes an unconsciousvictim with absent or abnormal breathing, the dispatcher alwaysresponded as for cardiac arrest, cases of cardiac arrest would not bemissed. 60Confirming the absence of a past medical history of seizurescan increase the likelihood of recognizing cardiac arrest among victimspresenting with seizure activity. 59,61 Asking about regularityof breathing can also help to recognise cardiac arrest among callersreporting seizure activity.An experienced dispatcher can improve the survival rate significantly:if the dispatcher takes very few cardiac arrest calls peryear, the survival rate is much lower than if he takes more than ninecalls a year (22% versus 39%). 58 The accuracy of identification of cardiacarrest by dispatchers varies from approximately 50% to over80%. If the dispatcher recognises cardiac arrest, survival is morelikely because appropriate measures can be taken (e.g. telephoneinstructedCPR or appropriate ambulance response). 25,60Initial rescue breathsIn primary (non-asphyxial) cardiac arrest the arterial bloodis not moving and remains saturated with oxygen for severalminutes. 62 If CPR is initiated within a few minutes, the blood oxygencontent remains adequate, and myocardial and cerebral oxygendelivery is limited more by the reduced cardiac output than by alack of oxygen in the lungs and arterial blood. Initially, therefore,ventilation is less important than chest compressions. 63,64In adults needing CPR, there is a high a-priori probability of aprimary cardiac cause. To emphasise the priority of chest compressions,it is recommended that CPR should start with chestcompression rather than initial ventilations. Time should not bespent checking the mouth for foreign bodies unless attempted rescuebreathing fails to make the chest rise.VentilationDuring CPR, the purpose of ventilation is to maintain adequateoxygenation and to remove CO 2 . The optimal tidal volume, respiratoryrate and inspired oxygen concentration to achieve this,however, are not fully known. The current recommendations arebased on the following evidence:1. During CPR, blood flow to the lungs is substantially reduced, soan adequate ventilation–perfusion ratio can be maintained withlower tidal volumes and respiratory rates than normal. 652. Hyperventilation is harmful because it increases intrathoracicpressure, which decreases venous return to the heart andreduces cardiac output. Survival is consequently reduced. 663. Interruptions in chest compression (for example, to check theheart rhythm or for a pulse check) have a detrimental effect onsurvival. 674. When the airway is unprotected, a tidal volume of 1 l producessignificantly more gastric distension than a tidal volumeof 500 ml. 685. Low minute-ventilation (lower than normal tidal volume andrespiratory rate) can maintain effective oxygenation and ventilationduring CPR. 69–72 During adult CPR, tidal volumes ofapproximately 500–600 ml (6–7 ml kg −1 ) are recommended.The current recommendations are, therefore, for rescuers to giveeach rescue breath over about 1 s, with enough volume to makethe victim’s chest rise, but to avoid rapid or forceful breaths. Thetime taken to give two breaths should not exceed 5 s. These recommendationsapply to all forms of ventilation during CPR, includingmouth-to-mouth and bag-mask ventilation with and without supplementaryoxygen.Mouth-to-nose ventilation is an acceptable alternative tomouth-to-mouth ventilation. 73 It may be considered if the victim’smouth is seriously injured or cannot be opened, the rescuer isassisting a victim in the water, or a mouth-to-mouth seal is difficultto achieve.There is no published evidence on the safety, effectiveness orfeasibility of mouth-to-tracheostomy ventilation, but it may beused for a victim with a tracheostomy tube or tracheal stoma whorequires rescue breathing.To use bag-mask ventilation requires considerable practice andskill. 74,75 It can be used by properly trained and experienced rescuerswho perform two-rescuer CPR.www.elsuapdetodos.comChest compressionChest compressions produce blood flow by increasing theintrathoracic pressure and by directly compressing the heart.Although chest compressions, performed properly, can produce
systolic arterial pressure peaks of 60–80 mm Hg, diastolic pressureremains low and mean arterial pressure in the carotid artery seldomexceeds 40 mm Hg. 76 Chest compressions generate a small butcritical amount of blood flow to the brain and myocardium andincrease the likelihood that defibrillation will be successful.Since the 2005 Guidelines were published, chest compressionprompt/feedback devices have generated new data from victims incardiac arrest that supplement animal and manikin studies. 77–81Recommendations based on this evidence are:1. Each time compressions are resumed, place your hands withoutdelay ‘in the centre of the chest’.2. Compress the chest at a rate of at least 100 min −1 .3. Ensure that the full compression depth of at least 5 cm (for anadult) is achieved.4. Allow the chest to recoil completely after each compression, i.e.do not lean on the chest during the relaxation phase of the chestcompression.5. Take approximately the same amount of time for compressionas relaxation.6. Minimise interruptions in chest compression in order to ensurethe victim receives at least 60 compressions in each minute.7. Do not rely on feeling the carotid or other pulse as a gauge ofeffective arterial flow during chest compressions. 50,82Hand positionFor adults receiving chest compressions, rescuers should placetheir hands on the lower half of the sternum. It is recommendedthat this location be taught in a simplified way, such as, “place theheel of your hand in the centre of the chest with the other handon top.” This instruction should be accompanied by demonstratingplacing the hands on the lower half of the sternum on a manikin.Use of the internipple line as a landmark for hand placement is notreliable. 83,84Compression rateThere is a positive relationship between the number of compressionsactually delivered per minute and the chance of successfulresuscitation. 81 While the compression rate (the speed at whichthe 30 consecutive compressions are given) should be at least100 min −1 , the actual number of compressions delivered duringeach minute of CPR will be lower due to interruptions to deliverrescue breaths and allow AED analysis, etc. In one out-of-hospitalstudy, rescuers recorded compression rates of 100–120 min −1 butthe mean number of compressions was reduced to 64 min −1 by frequentinterruptions. 79 At least 60 compressions should be deliveredeach minute.Compression depthFear of doing harm, fatigue and limited muscle strength frequentlyresult in rescuers compressing the chest less deeply thanrecommended. There is evidence that a compression depth of 5 cmand over results in a higher rate of return of spontaneous circulation(ROSC), and a higher percentage of victims admitted alive tohospital, than a compression depth of 4 cm or below. 77,78 There isno direct evidence that damage from chest compression is relatedto compression depth, nor has an upper limit of compression depthbeen established in studies. Nevertheless, it is recommended that,even in large adults, chest compression depth should not exceed6cm.CPR should be performed on a firm surface when possible. Airfilledmattresses should be routinely deflated during CPR. 85 Thereis no evidence for or against the use of backboards, 86,87 but if one18 de 0ctubre de 2010 www.elsuapdetodos.comR.W. Koster et al. / Resuscitation 81 (2010) 1277–1292 1283is used, care should be taken to avoid interruption in CPR and dislodgingintravenous lines or other tubes during board placement.Chest decompressionAllowing complete recoil of the chest after each compressionresults in better venous return to the chest and may improvethe effectiveness of CPR. 88,89 The optimal method of achievingthis goal, without compromising other aspects of chest compressiontechnique such as compression depth, has not, however, beenestablished.Feedback on compression techniqueRescuers can be assisted to achieve the recommended compressionrate and depth by prompt/feedback devices that are either builtinto the AED or manual defibrillator, or are stand-alone devices. Theuse of such prompt/feedback devices, as part of an overall strategyto improve the quality of CPR, may be beneficial. Rescuers should beaware that the accuracy of devices that measure compression depthvaries according to the stiffness of the support surface upon whichCPR is being performed (e.g. floor/mattress), and may overestimatecompression depth. 87 Further studies are needed to determine ifthese devices improve victim outcomes.Compression–ventilation ratioAnimal data supported an increase in the ratio of compressionto ventilation to >15:2. 90–92 A mathematical model suggests thata ratio of 30:2 provides the best compromise between blood flowand oxygen delivery. 93,94 A ratio of 30 compressions to 2 ventilationswas recommended in the Guidelines 2005 for the singlerescuer attempting resuscitation of an adult or child out of hospital,an exception being that a trained healthcare professional shoulduse a ratio of 15:2 for a child. This decreased the number of interruptionsin compression and the no-flow fraction, 95,96 and reducedthe likelihood of hyperventilation. 66,97 Direct evidence that survivalrates have increased from this change, however, is lacking.Likewise, there is no new evidence that would suggest a change inthe recommended compression to ventilation ratio of 30:2.Compression-only CPRSome healthcare professionals as well as lay rescuers indicatethat they would be reluctant to perform mouth-to-mouth ventilation,especially in unknown victims of cardiac arrest. 98,99 Animalstudies have shown that chest-compression-only CPR may be aseffective as combined ventilation and compression in the first fewminutes after non-asphyxial arrest. 63,100 If the airway is open,occasional gasps and passive chest recoil may provide some airexchange, but this may result in ventilation of the dead spaceonly. 56,101–103 Animal and mathematical model studies of chestcompression-onlyCPR have shown that arterial oxygen storesdeplete in 2–4 min. 92,104In adults, the outcome of chest compression without ventilationis significantly better than the outcome of giving no CPRat all in non-asphyxial arrest. 22,23 Several studies of human cardiacarrest have suggested equivalence of chest-compression-onlyCPR and chest compressions combined with rescue breaths, butnone excluded the possibility that chest-compression-only is inferiorto chest compressions combined with ventilations. 23,105 Onestudy suggested superiority of chest-compression-only CPR. 22 Allthese studies have significant limitations because they were basedon retrospective database analyses, where the type of BLS wasnot controlled and did not include CPR according to Guidelineswww.elsuapdetodos.com
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European Resuscitation Council Guidelines for Resuscitation ... - CPR

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