European Resuscitation Council Guidelines for Resuscitation 2010 ...

1236 J.P. Nolan et al. / Resuscitation 81 (2010) 1219–1276
rescuers are well-trained and that if a circulatory adjunct is used, a
program of continuous surveillance be in place to ensure that use
of the adjunct does not adversely affect survival. Although manual
chest compressions are often performed very poorly, 287–289 no
adjunct has consistently been shown to be superior to conventional
manual CPR.
Impedance threshold device (ITD)
The impedance threshold device (ITD) is a valve that limits air
entry into the lungs during chest recoil between chest compressions;
this decreases intrathoracic pressure and increases venous
return to the heart. A recent meta-analysis demonstrated improved
ROSC and short-term survival but no significant improvement in
either survival to discharge or neurologically intact survival to discharge
associated with the use of an ITD in the management of
adult OHCA patients. 290 In the absence of data showing that the ITD
increases survival to hospital discharge, its routine use in cardiac
arrest is not recommended.
Lund University cardiac arrest system (LUCAS) CPR
The Lund University cardiac arrest system (LUCAS) is a gasdriven
sternal compression device that incorporates a suction cup
for active decompression. Although animal studies showed that
LUCAS-CPR improves haemodynamic and short-term survival compared
with standard CPR. 291,292 there are no published randomised
human studies comparing LUCAS-CPR with standard CPR.
Load-distributing band CPR (AutoPulse)
The load-distributing band (LDB) is a circumferential chest compression
device comprising a pneumatically actuated constricting
band and backboard. Although the use of LDB-CPR improves
haemodynamics, 293–295 results of clinical trials have been conflicting.
Evidence from one multicentre randomised control trial
in over 1000 adults documented no improvement in 4-h survival
and worse neurological outcome when LDB-CPR was used
by EMS providers for patients with primary out-of-hospital cardiac
arrest. 296 A non-randomised human study reported increased
survival to discharge following OHCA. 297
The current status of LUCAS and AutoPulse
Two large prospective randomised multicentre studies are currently
underway to evaluate the LDB (AutoPulse) and the Lund
University Cardiac Arrest System (LUCAS). The results of these
studies are awaited with interest. In hospital, mechanical devices
have been used effectively to support patients undergoing primary
coronary intervention (PCI) 298,299 and CT scans 300 and also for
prolonged resuscitation attempts (e.g., hypothermia, 301,302 poisoning,
thrombolysis for pulmonary embolism, prolonged transport
etc) where rescuer fatigue may impair the effectiveness of manual
chest compression. In the prehospital environment where extrication
of patients, resuscitation in confined spaces and movement of
patients on a trolley often preclude effective manual chest compressions,
mechanical devices may also have an important role.
During transport to hospital, manual CPR is often performed poorly;
mechanical CPR can maintain good quality CPR during an ambulance
transfer. 303,304 Mechanical devices also have the advantage of
allowing defibrillation without interruption in external chest compression.
The role of mechanical devices in all situations requires
further evaluation.
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. These treatment
algorithms should enable the non-specialist ALS provider to
treat the patient effectively and safely in an emergency. 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.
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