European Resuscitation Council Guidelines for Resuscitation 2010 ...

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1232 J.P. Nolan et al. / Resuscitation 81 (2010) 1219–1276 Fig. 1.6. ALS cardiac arrest algorithm. © 2010 ERC. • The quality of chest compressions during in-hospital CPR is frequently sub-optimal. 224,225 The importance of uninterrupted chest compressions cannot be over emphasised. Even short interruptions to chest compressions are disastrous for outcome and every effort must be made to ensure that continuous, effective chest compression is maintained throughout the resuscitation attempt. The team leader should monitor the quality of CPR and alternate CPR providers if the quality of CPR is poor. Continuous ETCO 2 monitoring can be used to indicate the quality of CPR: although an optimal target for ETCO 2 during CPR has not been established, a value of less than 10 mm Hg (1.4 kPa) is associated with failure to achieve ROSC and may indicate that the quality of chest compressions should be improved. If possible, the person providing chest compressions should be changed every 2 min, but without causing long pauses in chest compressions. ALS treatment algorithm Although the ALS cardiac arrest algorithm (Fig. 1.6) is applicable to all cardiac arrests, additional interventions may be indicated for cardiac arrest caused by special circumstances (see Section 8). 10 The interventions that unquestionably contribute to improved survival after cardiac arrest are prompt and effective bystander BLS, uninterrupted, high-quality chest compressions and early defibrillation for VF/VT. The use of adrenaline has been shown to increase ROSC, but no resuscitation drugs or advanced airway interventions have been shown to increase survival to hospital discharge after cardiac arrest. 226–229 Thus, although drugs and advanced airways are still included among ALS interventions, they are of secondary importance to early defibrillation and high-quality, uninterrupted chest compressions.
J.P. Nolan et al. / Resuscitation 81 (2010) 1219–1276 1233 As with previous guidelines, the ALS algorithm distinguishes between shockable and non-shockable rhythms. Each cycle is broadly similar, with a total of 2 min of CPR being given before assessing the rhythm and where indicated, feeling for a pulse. Adrenaline 1 mg is given every 3–5 min until ROSC is achieved – the timing of the initial dose of adrenaline is described below. Shockable rhythms (ventricular fibrillation/pulseless ventricular tachycardia) The first monitored rhythm is VF/VT in approximately 25% of cardiac arrests, both in- 36 or out-of-hospital. 24,25,146 VF/VT will also occur at some stage during resuscitation in about 25% of cardiac arrests with an initial documented rhythm of asystole or PEA. 36 Having confirmed cardiac arrest, summon help (including the request for a defibrillator) and start CPR, beginning with chest compressions, with a CV ratio of 30:2. When the defibrillator arrives, continue chest compressions while applying the paddles or self-adhesive pads. Identify the rhythm and treat according to the ALS algorithm. • If VF/VT is confirmed, charge the defibrillator while another rescuer continues chest compressions. Once the defibrillator is charged, pause the chest compressions, quickly ensure that all rescuers are clear of the patient and then give one shock (360-J monophasic or 150–200 J biphasic). • Minimise the delay between stopping chest compressions and delivery of the shock (the preshock pause); even 5–10 s delay will reduce the chances of the shock being successful. 71,110 • Without reassessing the rhythm or feeling for a pulse, resume CPR (CV ratio 30:2) immediately after the shock, starting with chest compressions. Even if the defibrillation attempt is successful in restoring a perfusing rhythm, it takes time until the post-shock circulation is established 230 and it is very rare for a pulse to be palpable immediately after defibrillation. 231 Furthermore, the delay in trying to palpate a pulse will further compromise the myocardium if a perfusing rhythm has not been restored. 232 • Continue CPR for 2 min, then pause briefly to assess the rhythm; if still VF/VT, give a second shock (360-J monophasic or 150–360-J biphasic). Without reassessing the rhythm or feeling for a pulse, resume CPR (CV ratio 30:2) immediately after the shock, starting with 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-J biphasic). Without reassessing the rhythm or feeling for a pulse, resume CPR (CV ratio 30:2) immediately after the shock, starting with chest compressions. If IV/IO access has been obtained, give adrenaline 1 mg and amiodarone 300 mg once compressions have resumed. If ROSC has not been achieved with this 3rd shock the adrenaline will improve myocardial blood flow and may increase the chance of successful defibrillation with the next shock. In animal studies, peak plasma concentrations of adrenaline occur at about 90 s after a peripheral injection. 233 If ROSC has been achieved after the 3rd shock it is possible that the bolus dose of adrenaline will cause tachycardia and hypertension and precipitate recurrence of VF. However, naturally occurring adrenaline plasma concentrations are high immediately after ROSC, 234 and any additional harm caused by exogenous adrenaline has not been studied. Interrupting chest compressions to check for a perfusing rhythm midway in the cycle of compressions is also likely to be harmful. The use of waveform capnography may enable ROSC to be detected without pausing chest compressions and may be a way of avoiding a bolus injection of adrenaline after ROSC has been achieved. Two prospective human studies have shown that a significant increase in end-tidal CO 2 occurs when return of spontaneous circulation occurs. 235,236 • After each 2-min cycle of CPR, if the rhythm changes to asystole or PEA, see ‘non-shockable rhythms’ below. If a non-shockable rhythm is present and the rhythm is organised (complexes appear regular or narrow), try to palpate a pulse. Rhythm checks should be brief, and pulse checks should be undertaken only if an organised rhythm is observed. If there is any doubt about the presence of a pulse in the presence of an organised rhythm, resume CPR. If ROSC has been achieved, begin post-resuscitation care. Regardless of the arrest rhythm, give further doses of adrenaline 1 mg every 3–5 min until ROSC is achieved; in practice, this will be once every two cycles of the algorithm. If signs of life return during CPR (purposeful movement, normal breathing, or coughing), check the monitor; if an organised rhythm is present, check for a pulse. If a pulse is palpable, continue post-resuscitation care and/or treatment of peri-arrest arrhythmia. If no pulse is present, continue CPR. Providing CPR with a CV ratio of 30:2 is tiring; change the individual undertaking compressions every 2 min, while minimising the interruption in compressions. Precordial thump A single precordial thump has a very low success rate for cardioversion of a shockable rhythm 237–239 and is likely to succeed only if given within the first few seconds of the onset of a shockable rhythm. 240 There is more success with pulseless VT than with VF. Delivery of a precordial thump must not delay calling for help or accessing a defibrillator. It is therefore appropriate therapy only when several clinicians are present at a witnessed, monitored arrest, and when a defibrillator is not immediately to hand. 241 In practice, this is only likely to be in a critical care environment such as the emergency department or ICU. 239 Airway and ventilation During the treatment of persistent VF, ensure good-quality chest compressions between defibrillation attempts. Consider reversible causes (4 Hs and 4 Ts) and, if identified, correct them. Check the electrode/defibrillating paddle positions and contacts, and the adequacy of the coupling medium, e.g., gel pads. Tracheal intubation provides the most reliable airway, but should be attempted only if the healthcare provider is properly trained and has regular, ongoing experience with the technique. Personnel skilled in advanced airway management should attempt laryngoscopy and intubation without stopping chest compressions; a brief pause in chest compressions may be required as the tube is passed through the vocal cords, but this pause should not exceed 10 s. Alternatively, to avoid any interruptions in chest compressions, the intubation attempt may be deferred until return of spontaneous circulation. No studies have shown that tracheal intubation increases survival after cardiac arrest. After intubation, confirm correct tube position and secure it adequately. Ventilate the lungs at 10 breaths min −1 ; do not hyperventilate the patient. Once the patient’s trachea has been intubated, continue chest compressions, at a rate of 100 min −1 without pausing during ventilation. In the absence of personnel skilled in tracheal intubation, a supraglottic airway device (e.g., laryngeal mask airway) is an acceptable alternative (Section 4e). Once a supraglottic airway device has been inserted, attempt to deliver continuous chest compressions, uninterrupted during ventilation. If excessive gas leakage causes inadequate ventilation of the patient’s lungs, chest compressions will have to be interrupted to enable ventilation (using a CV ratio of 30:2).
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