European Resuscitation Council Guidelines for Resuscitation ... - CPR

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18 de 0ctubre de 2010 www.elsuapdetodos.com1312 C.D. Deakin et al. / Resuscitation 81 (2010) 1305–1352broadly similar, with a total of 2 min of CPR being given beforeassessing the rhythm and where indicated, feeling for a pulse.Adrenaline 1 mg is given every 3–5 min until ROSC is achieved—thetiming of the initial dose of adrenaline is described below. In VF/VT,a single dose of amiodarone is indicated after three unsuccessfulshocks.Shockable rhythms (ventricular fibrillation/pulselessventricular tachycardia)The first monitored rhythm is VF/VT in approximately 25% ofcardiac arrests, both in- 4 or out-of-hospital. 248–250 VF/VT will alsooccur at some stage during resuscitation in about 25% of cardiacwww.elsuapdetodos.comFig. 4.2. Advanced life support cardiac arrest algorithm. © 2010 ERC.
arrests with an initial documented rhythm of asystole or PEA. 4 Havingconfirmed cardiac arrest, summon help (including the requestfor a defibrillator) and start CPR, beginning with chest compressions,with a compression:ventilation (CV) ratio of 30:2. When thedefibrillator arrives, continue chest compressions while applyingthe paddles or self-adhesive pads. Identify the rhythm and treataccording to the ALS algorithm.• If VF/VT is confirmed, charge the defibrillator while anotherrescuer continues chest compressions. Once the defibrillator ischarged, pause the chest compressions, quickly ensure that allrescuers are clear of the patient and then give one shock (360-Jmonophasic or 150–200 J biphasic).• Minimise the delay between stopping chest compressions anddelivery of the shock (the preshock pause); even 5–10 s delaywill reduce the chances of the shock being successful. 251,252• Without reassessing the rhythm or feeling for a pulse, resume CPR(CV ratio 30:2) immediately after the shock, starting with chestcompressions. Even if the defibrillation attempt is successful inrestoring a perfusing rhythm, it takes time until the post-shockcirculation is established 253 and it is very rare for a pulse tobe palpable immediately after defibrillation. 254 Furthermore, thedelay in trying to palpate a pulse will further compromise themyocardium if a perfusing rhythm has not been restored. 255• Continue CPR for 2 min, then pause briefly to assess the rhythm; ifstill VF/VT, give a second shock (360-J monophasic or 150–360-Jbiphasic). Without reassessing the rhythm or feeling for a pulse,resume CPR (CV ratio 30:2) immediately after the shock, startingwith chest compressions.• Continue CPR for 2 min, then pause briefly to assess the rhythm;if still VF/VT, give a third shock (360-J monophasic or 150–360-Jbiphasic). Without reassessing the rhythm or feeling for a pulse,resume CPR (CV ratio 30:2) immediately after the shock, startingwith chest compressions. If IV/IO access has been obtained, giveadrenaline 1 mg and amiodarone 300 mg once compressions haveresumed. If ROSC has not been achieved with this 3rd shock theadrenaline will improve myocardial blood flow and may increasethe chance of successful defibrillation with the next shock. Inanimal studies, peak plasma concentrations of adrenaline occurat about 90 s after a peripheral injection. 256 If ROSC has beenachieved after the 3rd shock it is possible that the bolus dose ofadrenaline will cause tachycardia and hypertension and precipitaterecurrence of VF. However, naturally occurring adrenalineplasma concentrations are high immediately after ROSC, 257 andany additional harm caused by exogenous adrenaline has notbeen studied. Interrupting chest compressions to check for a perfusingrhythm midway in the cycle of compressions is also likelyto be harmful. The use of waveform capnography may enableROSC to be detected without pausing chect compressions andmay be a way of avoiding a bolus injection of adenaline afterROSC has been achieved. Two prospective human studies haveshown that a significant increase in end-tidal CO 2 occurs whenreturn of spontaneous circulation occurs. 258,259• After each 2-min cycle of CPR, if the rhythm changes to asystoleor PEA, see ‘non-shockable rhythms’ below. If a non-shockablerhythm is present and the rhythm is organised (complexes appearregular or narrow), try to palpate a pulse. Rhythm checks shouldbe brief, and pulse checks should be undertaken only if an organisedrhythm is observed. If there is any doubt about the presenceof a pulse in the presence of an organised rhythm, resume CPR. IfROSC has been achieved, begin post-resuscitation care18 de 0ctubre de 2010 www.elsuapdetodos.comC.D. Deakin et al. / Resuscitation 81 (2010) 1305–1352 1313depleted of oxygen and metabolic substrates. A brief period ofchest compressions will deliver oxygen and energy substrates andincrease the probability of restoring a perfusing rhythm after shockdelivery. 260 Analyses of VF waveform characteristics predictive ofshock success indicate that the shorter the time between chestcompression and shock delivery, the more likely the shock willbe successful. 260,261 Reduction in the interval from compression toshock delivery by even a few seconds can increase the probabilityof shock success. 251,252Regardless of the arrest rhythm, give adrenaline 1 mg every3–5 min until ROSC is achieved; in practice, this will be once everytwo cycles of the algorithm. If signs of life return during CPR(purposeful movement, normal breathing, or coughing), check themonitor; if an organised rhythm is present, check for a pulse. Ifa pulse is palpable, continue post-resuscitation care and/or treatmentof peri-arrest arrhythmia. If no pulse is present, continue CPR.Providing CPR with a CV ratio of 30:2 is tiring; change the individualundertaking compressions every 2 min, while minimising theinterruption in compressions.Witnessed, monitored VF/VT in the cardiac catheter lab or aftercardiac surgeryIf a patient has a monitored and witnessed cardiac arrest in thecatheter laboratory or early after cardiac surgery:• Confirm cardiac arrest and shout for help.• If the initial rhythm is VF/VT, give up to three quick successive(stacked) shocks. Start chest compressions immediately after thethird shock and continue CPR for 2 min.This three-shock strategy may also be considered for an initial,witnessed VF/VT cardiac arrest if the patient is already connectedto a manual defibrillator. Although there are no data supporting athree-shock strategy in any of these circumstances, it is unlikelythat chest compressions will improve the already very high chanceof return of spontaneous circulation when defibrillation occursearly in the electrical phase, immediately after onset of VF (seeSection 3). 223Precordial thumpA single precordial thump has a very low success rate forcardioversion of a shockable rhythm 262–264 and is only likely tosucceed if given within the first few seconds of the onset of ashockable rhythm. 265 There is more success with pulseless VT thanwith VF. Delivery of a precordial thump must not delay calling forhelp or accessing a defibrillator. It is therefore appropriate therapyonly when several clinicians are present at a witnessed, monitoredarrest, and when a defibrillator is not immediately to hand (see Section3). 223,266 In practice, this is only likely to be in a critical careenvironment such as the emergency department or ICU. 264A precordial thump should be undertaken immediately afterconfirmation of cardiac arrest and only by healthcare professionalstrained in the technique. Using the ulnar edge of a tightly clenchedfist, deliver a sharp impact to the lower half of the sternum from aheight of about 20 cm, then retract the fist immediately to create animpulse-like stimulus. There are very rare reports of a precordialthump converting a perfusing to a non-perfusing rhythm. 267www.elsuapdetodos.comAirway and ventilationDuring treatment of VF/VT, healthcare providers must practiceefficient coordination between CPR and shock delivery. WhenVF is present for more than a few minutes, the myocardium isDuring the treatment of persistent VF, ensure good-quality chestcompressions between defibrillation attempts. Consider reversiblecauses (4 Hs and 4 Ts) and, if identified, correct them. Check the
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European Resuscitation Council Guidelines for Resuscitation ... - CPR

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