European Resuscitation Council Guidelines for Resuscitation 2010 ...

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1244 J.P. Nolan et al. / Resuscitation 81 (2010) 1219–1276 (2) Bypassing a closer but non-PCI capable hospital and taking measures to shorten the delay to intervention if PPCI is the chosen strategy. (3) Procedures in special situations e.g., for patients successfully resuscitated from non-traumatic cardiac arrest, patients with shock or patients with non-STEMI-ACS who are unstable or have signs of very high risk. Reperfusion strategy in patients presenting with STEMI For patients presenting with STEMI within 12 h of symptom onset, reperfusion should be initiated as soon as possible independent of the method chosen. 414,442–444 Reperfusion may be achieved with fibrinolysis, with PPCI, or a combination of both. Efficacy of reperfusion therapy is profoundly dependent on the duration of symptoms. Fibrinolysis is effective specifically in the first 2–3 h after symptom onset; PPCI is less time sensitive. 445 Giving fibrinolytics out-of-hospital to patients with STEMI or signs and symptoms of an ACS with presumed new LBBB is beneficial. Fibrinolytic therapy can be given safely by trained paramedics, nurses or physicians using an established protocol. 446–451 The efficacy is greatest within the first 3 h of the onset of symptoms. 452 Patients with symptoms of ACS and ECG evidence of STEMI (or presumably new LBBB or true posterior infarction) presenting directly to the ED should be given fibrinolytic therapy as soon as possible unless there is timely access to PPCI. Healthcare professionals who give fibrinolytic therapy must be aware of its contraindications and risks. Primary percutaneous intervention Coronary angioplasty with or without stent placement has become the first-line treatment for patients with STEMI, because it has been shown to be superior to fibrinolysis in the combined endpoints of death, stroke and reinfarction in several studies and meta-analyses. 453,454 Fibrinolysis versus primary PCI Several reports and registries comparing fibrinolytic (including pre-hospital administration) therapy with PPCI showed a trend of improved survival if fibrinolytic therapy was initiated within 2 h of onset of symptoms and was combined with rescue or delayed PCI. 455–457 If PPCI cannot be accomplished within an adequate timeframe, independent of the need for emergent transfer, then immediate fibrinolysis should be considered unless there is a contraindication. For those STEMI patients presenting in shock, primary PCI (or coronary artery bypass surgery) is the preferred reperfusion treatment. Fibrinolysis should be considered only if there is a substantial delay to PCI. Triage and inter-facility transfer for primary PCI The risk of death, reinfarction or stroke is reduced if patients with STEMI are transferred promptly from community hospitals to tertiary care facilities for PPCI. 383,454,458 It is less clear whether immediate fibrinolytic therapy (in- or out-of-hospital) or transfer for PPCI is superior for younger patients presenting with anterior infarction and within a short duration of
J.P. Nolan et al. / Resuscitation 81 (2010) 1219–1276 1245 ◦ At the same time, with your fingertip(s) under the point of the child’s chin, lift the chin. Do not push on the soft tissues under the chin as this may obstruct the airway. ◦ If you still have difficulty in opening the airway, try a jaw thrust: place the first two fingers of each hand behind each side of the child’s mandible and push the jaw forward. 4. Keeping the airway open, look, listen and feel for normal breathing by putting your face close to the child’s face and looking along the chest: • Look for chest movements. • Listen at the child’s nose and mouth for breath sounds. • Feel for air movement on your cheek. In the first few minutes after a cardiac arrest a child may be taking slow infrequent gasps. Look, listen and feel for no more than 10 s before deciding—if you have any doubt whether breathing is normal, act as if it is not normal: 5A. If the child is breathing normally: • Turn the child on his side into the recovery position (see below) • Send or go for help—call the local emergency number for an ambulance. • Check for continued breathing. 5B. If breathing is not normal or absent: • Remove carefully any obvious airway obstruction. • Give five initial rescue breaths. • While performing the rescue breaths note any gag or cough response to your action. These responses or their absence will form part of your assessment of ‘signs of life’, which will be described later. Rescue breaths for a child over 1 year of age: Fig. 1.11. Paediatric basic life support algorithm for those with a duty to respond. • Ensure head tilt and chin lift. • Pinch the soft part of the nose closed with the index finger and thumb of your hand on his forehead. • Allow the mouth to open, but maintain chin lift. • Take a breath and place your lips around the mouth, making sure that you have a good seal. • Blow steadily into the mouth over about 1–1.5 s watching for chest rise. • Maintain head tilt and chin lift, take your mouth away from the victim and watch for his chest to fall as air comes out. • Take another breath and repeat this sequence five times. Identify effectiveness by seeing that the child’s chest has risen and fallen in a similar fashion to the movement produced by a normal breath. Rescue breaths for an infant: The following sequence is to be followed by those with a duty to respond to paediatric emergencies (usually health professional teams) (Fig. 1.11). 1. Ensure the safety of rescuer and child. 2. Check the child’s responsiveness. • Gently stimulate the child and ask loudly: Are you all right? 3A. If the child responds by answering or moving: • Leave the child in the position in which you find him (provided he is not in further danger). • Check his condition and get help if needed. • Reassess him regularly. 3B. If the child does not respond: • Shout for help. • Turn carefully the child on his back. • Open the child’s airway by tilting the head and lifting the chin. ◦ Place your hand on his forehead and gently tilt his head back. • Ensure a neutral position of the head and a chin lift. • Take a breath and cover the mouth and nose of the infant with your mouth, making sure you have a good seal. If the nose and mouth cannot be covered in the older infant, the rescuer may attempt to seal only the infant’s nose or mouth with his mouth (if the nose is used, close the lips to prevent air escape). • Blow steadily into the infant’s mouth and nose over 1–1.5 s, sufficient to make the chest visibly rise. • Maintain head position and chin lift, take your mouth away from the victim and watch for his chest to fall as air comes out. • Take another breath and repeat this sequence five times. For both infants and children, if you have difficulty achieving an effective breath, the airway may be obstructed: • Open the child’s mouth and remove any visible obstruction. Do not perform a blind finger sweep.
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