European Resuscitation Council Guidelines for Resuscitation 2010 ...

More documents

Recommendations

Info

1418 J. Soar et al. / Resuscitation 81 (2010) 1400–1433 surgery setting should trigger the need for emergency resternotomy. Further defibrillation is attempted as indicated in the universal algorithm and should be performed with internal paddles at 20 J if resternotomy has been performed. Emergency drugs Use adrenaline very cautiously and titrate to effect (intravenous doses of 100 or less micrograms in adults). In order to exclude a medication error as the cause of the arrest, stop all drug infusions and check if they are correct. If there is concern about patient awareness, restart the anaesthetic drugs. Atropine is no longer recommended for the treatment of cardiac arrest as there is little evidence to show it is effective in patients who have been given adrenaline. Individual clinicians may use atropine at their discretion in post-cardiac surgery cardiac arrest if they feel it is indicated. Treat bradycardia with atropine, according to the bradycardia algorithm (see Section 4 Advanced Life Support). 24a Give amiodarone 300 mg after the 3rd failed defibrillation attempt but do not delay resternotomy. An irritable myocardium following cardiac surgery is caused most commonly by myocardial ischaemia and correction of this, rather than giving amiodarone, is more likely to achieve myocardial stability. Emergency resternotomy This is an integral part of resuscitation after cardiac surgery, once all other reversible causes have been excluded. Once adequate an airway and ventilation has been established, and if three attempts at defibrillation have failed in VF/VT, undertake resternotomy without delay. Emergency resternotomy is also indicated in asystole or PEA, when other treatments have failed. Resuscitation teams should be well rehearsed in this technique so that it can be performed safely within 5 min of the onset of cardiac arrest. Resternotomy equipment should be prepared as soon as an arrest is identified. Simplification of the resternotomy tray and regular manikin rehearsals are key measures to ensure a prompt resternotomy. 407,408 All medical members of the patient care team should be trained to perform resternotomy if a surgeon is not available within 5 min. Improved survival and better quality of life is well documented with rapid resternotomy. 394,395,409 Resternotomy should be a standard part of resuscitation within 10 days after cardiac surgery. The overall survival to discharge following internal cardiac massage is 17% 394 to 25% 395 although survival rates are much lower when chest opening is performed outside the specialised environment of the post-cardiac surgery ICU. 395 Patients with non-sternotomy cardiac surgery These guidelines are appropriate for patients following nonsternotomy cardiac surgery, but surgeons performing these operations should have already given clear instructions for chest reopening. Patients undergoing port-access mitral procedures or minimally invasive coronary bypass graft surgery are likely to require an emergency sternotomy, as very poor access is obtained by opening or extending a mini-thoracotomy incision. Equipment and guidelines should be kept close to the patient. Children The incidence of cardiac arrest after cardiac surgery in children is 4% 411 and survival rates are similar to those of adults. The causes are also similar, although one case-series documented primary respiratory arrest in 11%. The guidance given in this section is equally applicable to children, with appropriate modification of defibrillation energy and drug doses (see Section 6 Paediatric Life Support). 411a Use extreme caution and check doses carefully when giving intravenous adrenaline doses to children in cardiac arrest after cardiac surgery. Use smaller doses of adrenaline in this setting (e.g., 1 gkg −1 ) under the guidance of experienced clinicians. Internal defibrillation Internal defibrillation using paddles applied directly across the ventricles requires considerably less energy than that used for external defibrillation. Biphasic shocks are more effective than monophasic shocks for direct defibrillation. 412 For biphasic shocks, starting at 5 J creates the optimum conditions for lowest threshold and cumulative energy, whereas 10–20 J offers optimum conditions for more rapid defibrillation and fewer shocks, 412 thus 20 J is the most applicable energy in an arrest situation, whereas 5 J would be adequate if the patient has been placed on cardiopulmonary bypass. Continuing cardiac compressions using the internal paddles whilst charging the defibrillator and delivering the shock during the decompression phase of compressions may improve shock success. 413,414 It is acceptable to perform external defibrillation after emergency resternotomy. Apply external pads preoperatively to all patients undergoing resternotomy surgery. 415 Use the defibrillation energy level indicated in the universal algorithm. If the sternum is widely open the impedence may be significantly increased – if external defibrillation is chosen over internal defibrillation close the sternal retractor before shock delivery. Reinstitution of emergency cardiopulmonary bypass The need for emergency cardiopulmonary bypass (CPB) occurs in approximately 0.8% patients at a mean of 7 h post-operatively 396 and is usually indicated to correct surgical bleeding or graft occlusion and rest the myocardium. Emergency institution of CPB should be available on all units undertaking cardiac surgery. Survival to discharge rates of 32%, 395 42% 396 and 56.3% 410 have been reported when CPB is reinstituted on the ICU. Survival rates decline rapidly when this procedure is undertaken more than 24 h after surgery and when performed on the ward rather than the ICU. Emergency CPB should probably be restricted to patients who arrest within 72 h of surgery, as surgically remediable problems are unlikely after this time. 395 Ensuring adequate anticoagulation before starting CPB, or the use of a heparin-bonded circuit, is important. The need for a further period of cross-clamping does not preclude a favourable outcome. 396 8i. Traumatic cardiorespiratory arrest Introduction Cardiac arrest caused by trauma has a very high mortality, with an overall survival of just 5.6% (range 0–17%) (Table 8.4). 416–422 For reasons that are unclear, reported survival rates in the last 5 years are better than reported previously (Table 8.4) In those who survive (and where data are available) neurological outcome is good in only 1.6% of those sustaining traumatic cardiorespiratory arrest (TCRA). Diagnosis of traumatic cardiorespiratory arrest The diagnosis of TCRA is made clinically: the trauma patient is unresponsive, apnoeic and pulseless. Both asystole and organised cardiac activity without cardiac output are regarded as TCRA.
J. Soar et al. / Resuscitation 81 (2010) 1400–1433 1419 Table 8.4 Survival after out of hospital traumatic cardiac arrest. Source Entry criteria: children or adults requiring CPR before or on hospital admission Number of patients/survivors/ good neurological outcome Penetrating/ survivors/good neurological outcome Blunt/survivors/ good neurological outcome Shimazu and Shatney 417 TCRA on admission 267 7 4 Rosemurgy et al. 416 CPR before admission 138 42 96 0 0 0 0 0 0 Bouillon et al. 429 CPR on scene 224 4 3 Battistella et al. 418 CPR at scene, en route or in the ED 604 300 304 16 12 4 9 9 0 Fisher and Worthen 430 Hazinski et al. 431 Children requiring CPR before or on admission after blunt trauma Children requiring CPR or being severely hypotensive on admission after blunt trauma 65 65 1 1 0 0 38 38 1 1 0 0 Stratton et al. 422 Unconscious, pulseless at scene 879 497 382 9 4 5 3 3 0 Calkins et al. 432 Children requiring CPR after blunt trauma 25 25 2 2 2 2 Yanagawa et al. 433 OHCA in blunt trauma 332 332 6 6 0 0 Pickens et al. 434 CPR on scene 184 94 90 14 9 5 9 5 4 Di Bartolomeo et al. 435 CPR on scene 129 2 0 Willis et al. 436 CPR on scene 89 18 71 4 2 2 4 2 2 David et al. 437 CPR on scene 268 5 1 Crewdson et al. 438 80 children who required CPR on scene after trauma 80 7 73 7 0 7 3 0 3 Huber-Wagner et al. 439 CPR on scene or after arrival 757 43 714 130 ? ? 28 ? ? Pasquale et al. 421 CPR before or on hospital admission 106 21 85 3 1 2 Lockey et al. 440 CPR on scene 871 114 757 68 9 59 Cera et al. 441 CPR on admission 161 15 Totals 5217 1136 3032 293 (5.6%) 37 (3.3%) 94 (3.1%) Commotio cordis Commotio cordis is actual or near cardiac arrest caused by a blunt impact to the chest wall over the heart. 423–427 A blow to the chest during the vulnerable phase of the cardiac cycle may cause malignant arrhythmias (usually ventricular fibrillation). Syncope after chest wall impact may be caused by non-sustained arrhythmic events. Commotio cordis occurs mostly during sports (most commonly baseball) and recreational activities and victims are usually young males (mean age 14 years). In a series of 1866 cardiac arrests
Page 1 and 2:
Resuscitation 81 (2010) 1219-1276 C
Page 3 and 4:
J.P. Nolan et al. / Resuscitation 8
Page 5 and 6:
Page 7 and 8:
Page 9 and 10:
Page 11 and 12:
Page 13 and 14:
Page 15 and 16:
Page 17 and 18:
Page 19 and 20:
Page 21 and 22:
Page 23 and 24:
Page 25 and 26:
Page 27 and 28:
Page 29 and 30:
Page 31 and 32:
Page 33 and 34:
Page 35 and 36:
Page 37 and 38:
Page 39 and 40:
Page 41 and 42:
Page 43 and 44:
Page 45 and 46:
Page 47 and 48:
Page 49 and 50:
Page 51 and 52:
Page 53 and 54:
Page 55 and 56:
Page 57 and 58:
Page 59 and 60:
Page 61 and 62:
R.W. Koster et al. / Resuscitation
Page 63 and 64:
Page 65 and 66:
Page 67 and 68:
Page 69 and 70:
Page 71 and 72:
Page 73 and 74:
Page 75 and 76:
Page 77 and 78:
C.D. Deakin et al. / Resuscitation
Page 79 and 80:
Page 81 and 82:
Page 83 and 84:
Page 85 and 86:
Page 87 and 88:
Page 89 and 90:
Page 91 and 92:
Page 93 and 94:
Page 95 and 96:
Page 97 and 98:
Page 99 and 100:
Page 101 and 102:
Page 103 and 104:
Page 105 and 106:
Page 107 and 108:
Page 109 and 110:
Page 111 and 112:
Page 113 and 114:
Page 115 and 116:
Page 117 and 118:
Page 119 and 120:
Page 121 and 122:
Page 123 and 124:
Page 125 and 126:
Page 127 and 128:
Page 129 and 130:
Page 131 and 132:
Page 133 and 134:
Page 135 and 136:
Page 137 and 138:
H.-R. Arntz et al. / Resuscitation
Page 139 and 140:
Page 141 and 142:
Page 143 and 144:
Page 145 and 146:
Page 147 and 148:
D. Biarent et al. / Resuscitation 8
Page 149 and 150: D. Biarent et al. / Resuscitation 8
Page 171 and 172: Resuscitation 81 (2010) 1389-1399 C
Page 173 and 174: S. Richmond, J. Wyllie / Resuscitat
Page 183 and 184: J. Soar et al. / Resuscitation 81 (
Page 199: J. Soar et al. / Resuscitation 81 (
Page 227 and 228: Resuscitation 81 (2010) 1445-1451 C
Page 229 and 230: F.K. Lippert et al. / Resuscitation
Page 231 and 232: F.K. Lippert et al. / Resuscitation
Page 233: F.K. Lippert et al. / Resuscitation
show all

European Resuscitation Council Guidelines for Resuscitation 2010 ...

Create successful ePaper yourself

Delete template?

Save as template?