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18 de 0ctubre de 2010 www.elsuapdetodos.com1304 C.D. Deakin et al. / Resuscitation 81 (2010) 1293–1304181. Rodriguez-Nunez A, Lopez-Herce J, Garcia C, Dominguez P, Carrillo A, BellonJM. Pediatric defibrillation after cardiac arrest: initial response and outcome.Crit Care 2006;10:R113.182. Samson RA, Nadkarni VM, Meaney PA, Carey SM, Berg MD, Berg RA. Outcomesof in-hospital ventricular fibrillation in children. N Engl J Med2006;354:2328–39.183. Lown B. Electrical reversion of cardiac arrhythmias. Br Heart J 1967;29:469–89.184. Ambler JJ, Deakin CD. A randomised controlled trial of the effect of biphasic ormonophasic waveform on the incidence and severity of cutaneous burns followingexternal direct current cardioversion. Resuscitation 2006;71:293–300.185. Joglar JA, Hamdan MH, Ramaswamy K, et al. Initial energy for elective externalcardioversion of persistent atrial fibrillation. Am J Cardiol 2000;86:348–50.186. Boodhoo L, Mitchell AR, Bordoli G, Lloyd G, Patel N, Sulke N. DC cardioversionof persistent atrial fibrillation: a comparison of two protocols. Int J Cardiol2007;114:16–21.187. Boos C, Thomas MD, Jones A, Clarke E, Wilbourne G, More RS. Higher energymonophasic DC cardioversion for persistent atrial fibrillation: is it time to startat 360 joules? Ann Noninvasive Electrocardiol 2003;8:121–6.188. Glover BM, Walsh SJ, McCann CJ, et al. Biphasic energy selection fortransthoracic cardioversion of atrial fibrillation. The BEST AF Trial. Heart2008;94:884–7.189. Rashba EJ, Gold MR, Crawford FA, Leman RB, Peters RW, Shorofsky SR. Efficacyof transthoracic cardioversion of atrial fibrillation using a biphasic, truncatedexponential shock waveform at variable initial shock energies. Am J Cardiol2004;94:1572–4.190. Pinski SL, Sgarbossa EB, Ching E, Trohman RG. A comparison of 50-J versus100-J shocks for direct-current cardioversion of atrial flutter. Am HeartJ 1999;137:439–42.191. Alatawi F, Gurevitz O, White R. Prospective, randomized comparison of twobiphasic waveforms for the efficacy and safety of transthoracic biphasic cardioversionof atrial fibrillation. Heart Rhythm 2005;2:382–7.192. Kerber RE, Kienzle MG, Olshansky B, et al. Ventricular tachycardia rate andmorphology determine energy and current requirements for transthoracic cardioversion.Circulation 1992;85:158–63.193. Hedges JR, Syverud SA, Dalsey WC, Feero S, Easter R, Shultz B. Prehospital trialof emergency transcutaneous cardiac pacing. Circulation 1987;76:1337–43.194. Barthell E, Troiano P, Olson D, Stueven HA, Hendley G. Prehospital externalcardiac pacing: a prospective, controlled clinical trial. Ann Emerg Med1988;17:1221–6.195. Cummins RO, Graves JR, Larsen MP, et al. Out-of-hospital transcutaneous pacingby emergency medical technicians in patients with asystolic cardiac arrest.N Engl J Med 1993;328:1377–82.196. Ornato JP, Peberdy MA. The mystery of bradyasystole during cardiac arrest.Ann Emerg Med 1996;27:576–87.197. Niemann JT, Adomian GE, Garner D, Rosborough JP. Endocardial and transcutaneouscardiac pacing, calcium chloride, and epinephrine in postcountershockasystole and bradycardias. Crit Care Med 1985;13:699–704.198. Quan L, Graves JR, Kinder DR, Horan S, Cummins RO. Transcutaneous cardiacpacing in the treatment of out-of-hospital pediatric cardiac arrests. Ann EmergMed 1992;21:905–9.199. Dalsey WC, Syverud SA, Hedges JR. Emergency department use of transcutaneouspacing for cardiac arrests. Crit Care Med 1985;13:399–401.200. Knowlton AA, Falk RH. External cardiac pacing during in-hospital cardiac arrest.Am J Cardiol 1986;57:1295–8.201. Ornato JP, Carveth WL, Windle JR. Pacemaker insertion for prehospitalbradyasystolic cardiac arrest. Ann Emerg Med 1984;13:101–3.202. Stockwell B, Bellis G, Morton G, et al. Electrical injury during “hands on”defibrillation-A potential risk of internal cardioverter defibrillators? Resuscitation2009;80:832–4.203. Monsieurs KG, Conraads VM, Goethals MP, Snoeck JP, Bossaert LL. Semiautomaticexternal defibrillation and implanted cardiac pacemakers: understandingthe interactions during resuscitation. Resuscitation 1995;30:127–31.www.elsuapdetodos.com
Resuscitation 81 (2010) 1305–135218 de 0ctubre de 2010 www.elsuapdetodos.comContents lists available at ScienceDirectResuscitationjournal homepage: www.elsevier.com/locate/resuscitationEuropean Resuscitation Council Guidelines for Resuscitation 2010Section 4. Adult advanced life supportCharles D. Deakin a,1 , Jerry P. Nolan b,∗,1 , Jasmeet Soar c , Kjetil Sunde d , Rudolph W. Koster e ,Gary B. Smith f , Gavin D. Perkins fa Cardiothoracic Anaesthesia, Southampton General Hospital, Southampton, UKb Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UKc Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UKd Surgical Intensive Care Unit, Oslo University Hospital Ulleval, Oslo, Norwaye Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlandsf Critical Care and Resuscitation, University of Warwick, Warwick Medical School, Warwick, UKSummary of changes since 2005 GuidelinesThe most important changes in the 2010 European ResuscitationCouncil Advanced Life Support (ALS) Guidelines include:• Increased emphasis on the importance of minimally interruptedhigh-quality chest compressions throughout any ALS intervention:chest compressions are paused briefly only to enable specificinterventions.• Increased emphasis on the use of ‘track and trigger systems’ todetect the deteriorating patient and enable treatment to preventin-hospital cardiac arrest.• Increased awareness of the warning signs associated with thepotential risk of sudden cardiac death out of hospital.• Removal of the recommendation for a pre-specified periodof cardiopulmonary resuscitation (CPR) before out-of-hospitaldefibrillation following cardiac arrest unwitnessed by the emergencymedical services (EMS).• Continuation of chest compressions while a defibrillator ischarged—this will minimise the preshock pause.• The role of the precordial thump is de-emphasised.• The use of up to three quick successive (stacked) shocks forventricular fibrillation/pulseless ventricular tachycardia (VF/VT)occurring in the cardiac catheterisation laboratory or in theimmediate post-operative period following cardiac surgery.• Delivery of drugs via a tracheal tube is no longerrecommended—if intravenous access cannot be achieved,drugs should be given by the intraosseous route.• When treating VF/VT cardiac arrest, adrenaline 1 mg is givenafter the third shock once chest compressions have restarted and∗ Corresponding author.E-mail address: jerry.nolan@btinternet.com (J.P. Nolan).1 These individuals contributed equally to this manuscript and are equal firstco-authors.0300-9572/$ – see front matter © 2010 European Resuscitation Council. Published by Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.resuscitation.2010.08.017then every 3–5 min (during alternate cycles of CPR). Amiodarone300 mg is also given after the third shock.• Atropine is no longer recommended for routine use in asystole orpulseless electrical activity.• Reduced emphasis on early tracheal intubation unless achievedby highly skilled individuals with minimal interruption to chestcompressions.• Increased emphasis on the use of capnography to confirm andcontinually monitor tracheal tube placement, quality of CPR andto provide an early indication of return of spontaneous circulation(ROSC).• The potential role of ultrasound imaging during ALS is recognised.• Recognition of the potential harm caused by hyperoxaemia afterROSC is achieved: once ROSC has been established and the oxygensaturation of arterial blood (SaO 2 ) can be monitored reliably(by pulse oximetry and/or arterial blood gas analysis), inspiredoxygen is titrated to achieve a SaO 2 of 94–98%.• Much greater detail and emphasis on the treatment of the postcardiacarrest syndrome.• Recognition that implementation of a comprehensive, structuredpost-resuscitation treatment protocol may improve survival incardiac arrest victims after ROSC.• Increased emphasis on the use of primary percutaneous coronaryintervention in appropriate, but comatose, patients withsustained ROSC after cardiac arrest.• Revision of the recommendation for glucose control: in adultswith sustained ROSC after cardiac arrest, blood glucose values>10 mmol l −1 (>180 mg dl −1 ) should be treated but hypoglycaemiamust be avoided.• Use of therapeutic hypothermia to include comatose survivorsof cardiac arrest associated initially with non-shockablerhythms as well shockable rhythms. The lower level of evidencefor use after cardiac arrest from non-shockable rhythms isacknowledged.• Recognition that many of the accepted predictors of poor outcomein comatose survivors of cardiac arrest are unreliable,www.elsuapdetodos.com
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