European Resuscitation Council Guidelines for Resuscitation ... - CPR

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18 de 0ctubre de 2010 www.elsuapdetodos.com1286 R.W. Koster et al. / Resuscitation 81 (2010) 1277–1292Adult foreign-body airway obstruction (choking) sequence (thissequence is also suitable for use in children over the age of 1 year)(Fig. 2.17)1. If the victim shows signs of mild airway obstruction:• Encourage continued coughing but do nothing else.2. If the victim shows signs of severe airway obstruction and isconscious:• Apply five back blows as follows:◦ stand to the side and slightly behind the victim;◦ support the chest with one hand and lean the victim wellforwards so that when the obstructing object is dislodged itcomes out of the mouth rather than goes further down theairway;◦ give five sharp blows between the shoulder blades with theheel of your other hand.• If five back blows fail to relieve the airway obstruction, givefive abdominal thrusts as follows:◦ stand behind the victim and put both arms round the upperpart of the abdomen;◦ lean the victim forwards;◦ clench your fist and place it between the umbilicus (navel)and the ribcage;◦ grasp this hand with your other hand and pull sharplyinwards and upwards;◦ repeat five times.• If the obstruction is still not relieved, continue alternating fiveback blows with five abdominal thrusts.3. If the victim at any time becomes unconscious:• support the victim carefully to the ground;• immediately activate the ambulance service;• begin CPR with chest compressions.Foreign-body airway obstruction causing mild airway obstructionCoughing generates high and sustained airway pressures andmay expel the foreign body. Aggressive treatment, with back blows,abdominal thrusts and chest compression, may cause potentiallyserious complications and could worsen the airway obstruction. Itshould be reserved for victims who have signs of severe airwayobstruction. Victims with mild airway obstruction should remainFig. 2.17. Adult foreign body airway obstruction treatment algorithm.under continuous observation until they improve, as severe airwayobstruction may subsequently develop.Foreign-body airway obstruction with severe airway obstructionThe clinical data on choking are largely retrospective and anecdotal.For conscious adults and children over 1 year with a completeFBAO, case reports demonstrate the effectiveness of back blowsor “slaps”, abdominal thrusts and chest thrusts. 126 Approximately50% of episodes of airway obstruction are not relieved by a singletechnique. 127 The likelihood of success is increased when combinationsof back blows or slaps, and abdominal and chest thrusts areused. 126A randomised trial in cadavers 128 and two prospective studiesin anaesthetised volunteers 129,130 showed that higher airway pressurescan be generated using chest thrusts compared with abdominalthrusts. Since chest thrusts are virtually identical to chestcompressions, rescuers should be taught to start CPR if a victimof known or suspected FBAO becomes unconscious. The purpose ofthe chest compressions is primarily to attempt to remove the airwayobstruction in the unconscious and supine victim, and only secondarilyto promote circulation. Therefore, chest compressions arerequired even when a professional rescuer still feels a pulse. If theobstruction is not relieved, progressive bradycardia and asystolewill occur. During CPR for choking, each time the airway is openedthe victim’s mouth should be quickly checked for any foreign bodythat has been partly expelled. During CPR in other cases, therefore,a routine check of the mouth for foreign bodies is not necessary.www.elsuapdetodos.comThe finger sweepNo studies have evaluated the routine use of a finger sweep toclear the airway in the absence of visible airway obstruction, 131–133and four case reports have documented harm to the victim 131,134or rescuer 126 during this manoeuvre. Blind finger sweeps should,therefore, be avoided, and solid material in the airway removedmanually only if it can be seen.Aftercare and referral for medical reviewFollowing successful treatment for FBAO, foreign material maynevertheless remain in the upper or lower respiratory tract and
cause complications later. Victims with a persistent cough, difficultyswallowing or the sensation of an object being still stuckin the throat should, therefore, be referred for a medical opinion.Abdominal thrusts and chest compressions can potentially causeserious internal injuries, and all victims successfully treated withthese measures should be examined afterwards for injury.Resuscitation of children (see also Section 6) 134a andvictims of drowning (see also Section 8c) 134bFor victims of primary cardiac arrest who receive chestcompression-onlyCPR, oxygen stores become depleted about2–4 min after initiation of CPR. 92,104 The combination of chest compressionswith ventilation then becomes critically important. Aftercollapse from asphyxial arrest, a combination of chest compressionswith ventilations is important immediately after the start ofresuscitation. Previous guidelines have tried to address this differencein pathophysiology, and have recommended that victims ofidentifiable asphyxia (drowning, intoxication) and children shouldreceive 1 min of CPR before the lone rescuer leaves the victim to get18 de 0ctubre de 2010 www.elsuapdetodos.comR.W. Koster et al. / Resuscitation 81 (2010) 1277–1292 1287help. The majority of cases of SCA out of hospital, however, occur inadults, and although the rate of VF as the first recorded rhythm hasdeclined over recent years, the cause of adult cardiac arrest remainsVF in most cases (59%) when documented in the earliest phase by anAED. 13 In children, VF is much less common as the primary cardiacarrest rhythm (approximately 7%). 135 These additional recommendations,therefore, added to the complexity of the guidelines whileaffecting only a minority of victims.It is important to be aware that many children do not receiveresuscitation because potential rescuers fear causing harm if theyare not specifically trained in resuscitation for children. This fearis unfounded; it is far better to use the adult BLS sequence forresuscitation of a child than to do nothing. For ease of teaching andretention laypeople should be taught that the adult sequence mayalso be used for children who are not responsive and not breathingor not breathing normally.The following minor modifications to the adult sequence willmake it even more suitable for use in children.• Give 5 initial rescue breaths before starting chest compressions(adult sequence of actions, 5b).www.elsuapdetodos.comFig. 2.18. Algorithm for use of an automated external defibrillator. © 2010 ERC.
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