European Resuscitation Council Guidelines for Resuscitation 2010 ...

1328 C.D. Deakin et al. / Resuscitation 81 (2010) 1305–1352
4g Peri-arrest arrhythmias
The correct identification and treatment of arrhythmias in the
critically ill patient may prevent cardiac arrest from occurring or
from reoccurring after successful initial resuscitation. The treatment
algorithms described in this section have been designed to
enable the non-specialist ALS provider to treat the patient effectively
and safely in an emergency; for this reason, they have been
kept as simple as possible. If patients are not acutely ill there may
be several other treatment options, including the use of drugs (oral
or parenteral) that will be less familiar to the non-expert. In this situation
there will be time to seek advice from cardiologists or other
senior doctors with the appropriate expertise.
More comprehensive information on the management of
arrhythmias can be found at www.escardio.org.
Principles of treatment
The initial assessment and treatment of a patient with an
arrhythmia should follow the ABCDE approach. Key elements in
this process include assessing for adverse signs; administration of
high flow oxygen; obtaining intravenous access, and establishing
monitoring (ECG, blood pressure, SpO 2 ). Whenever possible, record
a 12-lead ECG; this will help determine the precise rhythm, either
before treatment or retrospectively. Correct any electrolyte abnormalities
(e.g., K + ,Mg 2+ ,Ca 2+ ). Consider the cause and context of
arrhythmias when planning treatment.
The assessment and treatment of all arrhythmias addresses two
factors: the condition of the patient (stable versus unstable), and
the nature of the arrhythmia. Anti-arrhythmic drugs are slower in
onset and less reliable than electrical cardioversion in converting a
tachycardia to sinus rhythm; thus, drugs tend to be reserved for stable
patients without adverse signs, and electrical cardioversion is
usually the preferred treatment for the unstable patient displaying
adverse signs.
Adverse signs
The presence or absence of adverse signs or symptoms will dictate
the appropriate treatment for most arrhythmias. The following
adverse factors indicate a patient who is unstable because of the
arrhythmia.
1. Shock—this is seen as pallor, sweating, cold and clammy extremities
(increased sympathetic activity), impaired consciousness
(reduced cerebral blood flow), and hypotension (e.g., systolic
blood pressure < 90 mm Hg).
2. Syncope—loss of consciousness, which occurs as a consequence
of reduced cerebral blood flow.
3. Heart failure—arrhythmias compromise myocardial performance
by reducing coronary artery blood flow. In acute
situations this is manifested by pulmonary oedema (failure of the
left ventricle) and/or raised jugular venous pressure, and hepatic
engorgement (failure of the right ventricle).
4. Myocardial ischaemia—this occurs when myocardial oxygen
consumption exceeds delivery. Myocardial ischaemia may
present with chest pain (angina) or may occur without pain as
an isolated finding on the 12 lead ECG (silent ischaemia). The
presence of myocardial ischaemia is especially important if there
is underlying coronary artery disease or structural heart disease
because it may cause further life-threatening complications
including cardiac arrest.
Treatment options
Having determined the rhythm and the presence or absence of
adverse signs, the options for immediate treatment are categorised
as:
1. Electrical (cardioversion, pacing).
2. Pharmacological (anti-arrhythmic (and other) drugs).
Tachycardias
If the patient is unstable
If the patient is unstable and deteriorating, with any of the
adverse signs and symptoms described above being caused by
the tachycardia, attempt synchronised cardioversion immediately
(Fig. 4.11). In patients with otherwise normal hearts, serious
signs and symptoms are uncommon if the ventricular rate is