European Resuscitation Council Guidelines for Resuscitation ... - CPR

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18 de 0ctubre de 2010 www.elsuapdetodos.com1308 C.D. Deakin et al. / Resuscitation 81 (2010) 1305–1352patient care and prevent futile CPR attempts (see Section 10). 145Medical emergency teams may have an important role in improvingend-of-life and DNAR decision-making. 142,146–148Guidelines for prevention of in-hospital cardiac arrestHospitals should provide a system of care that includes: (a) staffeducation about the signs of patient deterioration, and the rationalefor rapid response to illness, (b) appropriate and regular vitalsigns monitoring of patients, (c) clear guidance (e.g., via calling criteriaor early warning scores) to assist staff in the early detectionof patient deterioration, (d) a clear, uniform system of calling forassistance, and (e) an appropriate and timely clinical response tocalls for assistance. 5 The following strategies may prevent avoidablein-hospital cardiac arrests.1. Provide care for patients who are critically ill or at risk of clinicaldeterioration in appropriate areas, with the level of careprovided matched to the level of patient sickness.2. Critically ill patients need regular observations: each patientshould have a documented plan for vital signs monitoring thatidentifies which variables need to be measured and the frequencyof measurement according to the severity of illness orthe likelihood of clinical deterioration and cardiopulmonaryarrest. Recent guidance suggests monitoring of simple physiologicalvariables including pulse, blood pressure, respiratoryrate, conscious level, temperature and arterial blood oxygensaturation by pulse oximetry (SpO 2 ). 26,1493. Use a track-and-trigger system (either ‘calling criteria’ or earlywarning system) to identify patients who are critically ill and,or at risk of clinical deterioration and cardiopulmonary arrest.4. Use a patient charting system that enables the regular measurementand recording of vital signs and, where used, earlywarning scores.5. Have a clear and specific policy that requires a clinical responseto abnormal physiology, based on the track and trigger systemused. This should include advice on the further clinical managementof the patient and the specific responsibilities of medicaland nursing staff.6. The hospital should have a clearly identified response to criticalillness. This may include a designated outreach service orresuscitation team (e.g., MET, RRT system) capable of respondingin a timely fashion to acute clinical crises identified by thetrack-and-trigger system or other indicators. This service mustbe available 24 h per day. The team must include staff with theappropriate acute or critical care skills.7. Train all clinical staff in the recognition, monitoring and managementof the critically ill patient. Include advice on clinicalmanagement while awaiting the arrival of more experiencedstaff. Ensure that staff know their role(s) in the rapid responsesystem.8. Hospitals must empower staff of all disciplines to call for helpwhen they identify a patient at risk of deterioration or cardiacarrest. Staff should be trained in the use of structured communicationtools to ensure effective handover of informationbetween doctors, nurses and other healthcare professions.9. Identify patients for whom cardiopulmonary arrest is an anticipatedterminal event and in whom CPR is inappropriate, andpatients who do not wish to be treated with CPR. Hospitalsshould have a DNAR policy, based on national guidance, whichis understood by all clinical staff.10. Ensure accurate audit of cardiac arrest, “false arrest”, unexpecteddeaths and unanticipated ICU admissions usingcommon datasets. Audit also the antecedents and clinicalresponse to these events.Prevention of sudden cardiac death (SCD)out-of-hospitalCoronary artery disease is the commonest cause of SCD. Nonischaemiccardiomyopathy and valvular disease account for mostother SCD events. A small percentage of SCDs are caused byinherited abnormalities (e.g., Brugada syndrome, hypertrophic cardiomyopathy)or congenital heart disease.Most SCD victims have a history of cardiac disease and warningsigns, most commonly chest pain, in the hour before cardiacarrest. 150 In patients with a known diagnosis of cardiac disease, syncope(with or without prodrome—particularly recent or recurrent)is as an independent risk factor for increased risk of death. 151–161Chest pain on exertion only, and palpitations associated withsyncope only, are associated with hypertrophic cardiomyopathy,coronary abnormalities, Wolff–Parkinson–White, and arrhythmogenicright ventricular cardiomyopathy.Apparently healthy children and young adults who suffer SCDcan also have signs and symptoms (e.g., syncope/pre-syncope, chestpain and palpitations) that should alert healthcare professionals toseek expert help to prevent cardiac arrest. 162–170Children and young adults presenting with characteristic symptomsof arrhythmic syncope should have a specialist cardiologyassessment, which should include an ECG and in most cases anechocardiogram and exercise test. Characteristics of arrhythmicsyncope include: syncope in the supine position, occurring duringor after exercise, with no or only brief prodromal symptoms,repetitive episodes, or in individuals with a family history ofsudden death. In addition, non-pleuritic chest pain, palpitationsassociated with syncope, seizures (when resistant to treatment,occurring at night or precipitated by exercise, syncope, or loudnoise), and drowning in a competent swimmer should raise suspicionof increased risk. Systematic evaluation in a clinic specializingin the care of those at risk for SCD is recommended in family membersof young victims of SCD or those with a known cardiac disorderresulting in an increased risk of SCD. 151,171–175 A family history ofsyncope or SCD, palpitations as a symptom, supine syncope andsyncope associated with exercise and emotional stress are morecommon in patients with long QT syndrome (LQTS). 176 In olderadults 177,178 the absence of nausea and vomiting before syncopeand ECG abnormalities is an independent predictor of arrhythmicsyncope.Inexplicable drowning and drowning in a strong swimmermay be due to LQTS or catecholaminergic polymorphic ventriculartachycardia (CPVT). 179 There is an association between LQTSand presentation with seizure phenotype. 180,181 Guidance has beenpublished for the screening of competitive athletes to identify thoseat risk of sudden death. 182www.elsuapdetodos.com4b Prehospital resuscitationEMS personnelThere is considerable variation across Europe in the structureand process of EMS systems. Some countries have adopted almostexclusively paramedic/emergency medical technician (EMT)-basedsystems while other incorporate prehospital physicians to a greateror lesser extent. In adult cardiac arrest, physician presence duringresuscitation, compared with paramedics alone, has been reportedto increase compliance with guidelines 183,184 and physicians insome systems can perform advanced resuscitation proceduresmore successfully. 183,185–188 When compared within individualsystems, there are contradictory findings with some studies suggestingimproved survival to hospital discharge when physiciansare part of the resuscitation team 189–192 and other studies suggest-
18 de 0ctubre de 2010 www.elsuapdetodos.comC.D. Deakin et al. / Resuscitation 81 (2010) 1305–1352 1309ing no difference in short- or long-term survival. 183,189,191,193–199in one study, survival of the event was lower when physicianswere part of the resuscitation team. 199 Studies indirectly comparingresuscitation outcomes between physician-staffed and othersystems are difficult to interpret because of the extremely highvariability between systems, independent of physician-staffing. 200Although some studies have documented higher survival ratesafter cardiac arrest in EMS systems that include experiencedphysicians, 186,188,201–203 compared with those that rely on nonphysicianproviders, 201,202,204,205 other comparisons have found nodifference in survival between systems using paramedics or physiciansas part of the response. 206,207 Well-organised non-physiciansystems with highly trained paramedics have also reported highsurvival rates. 200 Given the inconsistent evidence, the inclusion orexclusion of physicians among prehospital personnel respondingto cardiac arrests will depend largely on existing local policy.Termination of resuscitation rulesresuscitation (CPR). For all in-hospital cardiac arrests, ensure that:• cardiorespiratory arrest is recognised immediately;• help is summoned using a standard telephone number;• CPR is started immediately using airway adjuncts, e.g., a pocketmask and, if indicated, defibrillation attempted as rapidly as possibleand certainly within 3 min.The exact sequence of actions after in-hospital cardiac arrestwill depend on many factors, including:• location (clinical/non-clinical area; monitored/unmonitoredarea);• training of the first responders;• number of responders;• equipment available;• hospital response system to cardiac arrest and medical emergencies(e.g., MET, RRT).One high-quality, prospective study has demonstrated thatapplication of a ‘basic life support termination of resuscitation rule’is predictive of death when applied by defibrillation-only emergencymedical technicians. 208 The rule recommends terminationwhen there is no return of spontaneous circulation, no shocks areadministered, and the arrest is not witnessed by EMS personnel. Of776 patients with cardiac arrest for whom the rule recommendedtermination, four survived [0.5% (95% CI 0.2–0.9)]. Implementationof the rule would reduce the transportation rate by almost twothirds. Four studies have shown external generalisability of thisrule. 209–212Additional studies have shown associations with futility of certainvariables such as no ROSC at scene; non-shockable rhythm;unwitnessed arrest; no bystander CPR, call response time andpatient demographics. 213–218Two in-hospital studies and one emergency department studyshowed that the reliability of termination of resuscitation rules islimited in these settings. 219–221Prospectively validated termination of resuscitation rules suchas the ‘basic life support termination of resuscitation rule’ can beused to guide termination of prehospital CPR in adults; however,these must be validated in an emergency medical services systemsimilar to the one in which implementation is proposed. Other rulesfor various provider levels, including in-hospital providers, may behelpful to reduce variability in decision-making; however, rulesshould be prospectively validated prior to implementation.CPR versus defibrillation firstThere is evidence that performing chest compressions whileretrieving and charging a defibrillator improves the probability ofsurvival. 222 EMS personnel should provide good-quality CPR whilea defibrillator is retrieved, applied and charged, but routine deliveryof a pre-specified period of CPR (e.g., 2 or 3 min) before rhythm analysisand a shock is delivered is not recommended. Some emergencymedical services have already fully implemented a pre-specifiedperiod of chest compressions before defibrillation; given the lackof convincing data either supporting or refuting this strategy, it isreasonable for them to continue this practice (see Section 3). 2234c In-hospital resuscitationAfter in-hospital cardiac arrest, the division between basic lifesupport and advanced life support is arbitrary; in practice, theresuscitation process is a continuum and is based on common sense.The public expect that clinical staff can undertake cardiopulmonaryLocationPatients who have monitored arrests are usually diagnosedrapidly. Ward patients may have had a period of deterioration andan unwitnessed arrest. 6,8 Ideally, all patients who are at high riskof cardiac arrest should be cared for in a monitored area wherefacilities for immediate resuscitation are available.Training of first respondersAll healthcare professionals should be able to recognise cardiacarrest, call for help and start CPR. Staff should do what they havebeen trained to do. For example, staff in critical care and emergencymedicine will have more advanced resuscitation skills thanstaff who are not involved regularly in resuscitation in their normalclinical role. Hospital staff who attend a cardiac arrest mayhave different levels of skill to manage the airway, breathing andcirculation. Rescuers must undertake only the skills in which theyare trained and competent.Number of respondersThe single responder must ensure that help is coming. If otherstaff are nearby, several actions can be undertaken simultaneously.www.elsuapdetodos.comEquipment availableAll clinical areas should have immediate access to resuscitationequipment and drugs to facilitate rapid resuscitation of the patientin cardiopulmonary arrest. Ideally, the equipment used for CPR(including defibrillators) and the layout of equipment and drugsshould be standardised throughout the hospital. 224,225Resuscitation teamThe resuscitation team may take the form of a traditional cardiacarrest team, which is called only when cardiac arrest is recognised.Alternatively, hospitals may have strategies to recognise patientsat risk of cardiac arrest and summon a team (e.g., MET or RRT)before cardiac arrest occurs. The term ‘resuscitation team’ reflectsthe range of response teams. In hospital cardiac arrests are rarelysudden or unexpected. A strategy of recognising patients at risk ofcardiac arrest may enable some of these arrests to be prevented, ormay prevent futile resuscitation attempts in those who are unlikelyto benefit from CPR.
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