European Resuscitation Council Guidelines for Resuscitation 2010 ...
European Resuscitation Council Guidelines for Resuscitation 2010 ...
European Resuscitation Council Guidelines for Resuscitation 2010 ...
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1254 J.P. Nolan et al. / <strong>Resuscitation</strong> 81 (<strong>2010</strong>) 1219–1276<br />
the efficacy of these higher tracheal doses has been studied. Do not<br />
give these high doses intravenously.<br />
Bicarbonate<br />
There are insufficient data to recommend routine use of bicarbonate<br />
in resuscitation of the newly born. The hyperosmolarity and<br />
carbon dioxide-generating properties of sodium bicarbonate may<br />
impair myocardial and cerebral function. Use of sodium bicarbonate<br />
is discouraged during brief CPR. If it is used during prolonged<br />
arrests unresponsive to other therapy, it should be given only after<br />
adequate ventilation and circulation is established with CPR. A dose<br />
of 1–2 mmol kg −1 may be given by slow intravenous injection after<br />
adequate ventilation and perfusion have been established.<br />
Fluids<br />
If there has been suspected blood loss or the infant appears to be<br />
in shock (pale, poor perfusion, weak pulse) and has not responded<br />
adequately to other resuscitative measures then consider giving<br />
fluid. 588 This is a rare event. In the absence of suitable blood (i.e.,<br />
irradiated and leucocyte-depleted group O Rh-negative blood),<br />
isotonic crystalloid rather than albumin is the solution of choice<br />
<strong>for</strong> restoring intravascular volume. Give a bolus of 10 ml kg −1<br />
initially. If successful it may need to be repeated to maintain an<br />
improvement.<br />
Stopping resuscitation<br />
Local and national committees will determine the indications<br />
<strong>for</strong> stopping resuscitation. If the heart rate of a newly born baby<br />
is not detectable and remains undetectable <strong>for</strong> 10 min, it is then<br />
appropriate to consider stopping resuscitation. In cases where the<br />
heart rate is less than 60 min −1 at birth and does not improve after<br />
10 or 15 min of continuous and apparently adequate resuscitative<br />
ef<strong>for</strong>ts, the choice is much less clear. In this situation there is insufficient<br />
evidence about outcome to enable firm guidance on whether<br />
to withhold or to continue resuscitation.<br />
Communication with the parents<br />
It is important that the team caring <strong>for</strong> the newborn baby<br />
in<strong>for</strong>ms the parents of the baby’s progress. At delivery, adhere<br />
to local plans <strong>for</strong> routine care and, if possible, hand the baby to<br />
the mother at the earliest opportunity. If resuscitation is required<br />
in<strong>for</strong>m the parents of the procedures undertaken and why they<br />
were required. Record carefully all discussions and decisions in the<br />
mother’s notes prior to delivery and in the baby’s records after birth.<br />
Cardiac arrest in special circumstances<br />
Electrolyte abnormalities<br />
Life-threatening arrhythmias are associated most commonly<br />
with potassium disorders, particularly hyperkalaemia, and less<br />
commonly with disorders of serum calcium and magnesium.<br />
In some cases therapy <strong>for</strong> life-threatening electrolyte disorders<br />
should start be<strong>for</strong>e laboratory results become available. There is<br />
little or no evidence <strong>for</strong> the treatment of electrolyte abnormalities<br />
during cardiac arrest. Guidance during cardiac arrest is based on<br />
the strategies used in the non-arrest patient. There are no major<br />
changes in the treatment of these disorders since the International<br />
<strong>Guidelines</strong> 2005. 589<br />
Poisoning<br />
Poisoning rarely causes cardiac arrest, but is a leading cause of<br />
death in victims younger than 40 years of age. 590 Poisoning by<br />
therapeutic or recreational drugs and by household products are<br />
the main reasons <strong>for</strong> hospital admission and poison centre calls.<br />
Inappropriate drug dosing, drug interactions and other medication<br />
errors can also cause harm. Accidental poisoning is commonest in<br />
children. Homicidal poisoning is uncommon. Industrial accidents,<br />
warfare or terrorism can also cause exposure to harmful substances.<br />
Prevention of cardiac arrest<br />
Assess and treat the victim using the ABCDE (Airway, Breathing,<br />
Circulation, Disability, Exposure) approach. Airway obstruction<br />
and respiratory arrest secondary to a decreased conscious level is<br />
a common cause of death after self-poisoning. 591 Pulmonary aspiration<br />
of gastric contents can occur after poisoning with central<br />
nervous system depressants. Early tracheal intubation of unconscious<br />
patients by a trained person decreases the risk of aspiration.<br />
Drug-induced hypotension usually responds to fluid infusion, but<br />
occasionally vasopressor support (e.g., noradrenaline infusion) is<br />
required. A long period of coma in a single position can cause pressure<br />
sores and rhabdomyolysis. Measure electrolytes (particularly<br />
potassium), blood glucose and arterial blood gases. Monitor temperature<br />
because thermoregulation is impaired. Both hypothermia<br />
and hyperthermia (hyperpyrexia) can occur after overdose of some<br />
drugs. Retain samples of blood and urine <strong>for</strong> analysis. Patients<br />
with severe poisoning should be cared <strong>for</strong> in a critical care<br />
setting. Interventions such as decontamination, enhanced elimination<br />
and antidotes may be indicated and are usually second<br />
line interventions. 592 Alcohol excess is often associated with selfpoisoning.<br />
Modifications to basic and advanced life support<br />
• Have a high index of personal safety where there is a suspicious<br />
cause or unexpected cardiac arrest. This is especially so when<br />
more than one casualty collapses simultaneously.<br />
• Avoid mouth-to-mouth ventilation in the presence of chemicals<br />
such as cyanide, hydrogen sulphide, corrosives and organophosphates.<br />
• Treat life-threatening tachyarrhythmias with cardioversion<br />
according to the peri-arrest arrhythmia guidelines (see Advanced<br />
life support). 6 This includes correction of electrolyte and acid-base<br />
abnormalities.<br />
• Try to identify the poison(s). Relatives, friends and ambulance<br />
crews can provide useful in<strong>for</strong>mation. Examination of<br />
the patient may reveal diagnostic clues such as odours, needle<br />
marks, pupil abnormalities, and signs of corrosion in the<br />
mouth.<br />
• Measure the patient’s temperature because hypo- or hyperthermia<br />
may occur after drug overdose (see Sections 8d and 8e).<br />
• Be prepared to continue resuscitation <strong>for</strong> a prolonged period, particularly<br />
in young patients, as the poison may be metabolized or<br />
excreted during extended life support measures.<br />
• Alternative approaches that may be effective in severely poisoned<br />
patients include: higher doses of medication than in standard<br />
protocols; non-standard drug therapies; prolonged CPR.<br />
• Consult regional or national poisons centres <strong>for</strong> in<strong>for</strong>mation on<br />
treatment of the poisoned patient. The International Programme<br />
on Chemical Safety (IPCS) lists poison centres on its website:<br />
http://www.who.int/ipcs/poisons/centre/en/<br />
• On-line databases <strong>for</strong> in<strong>for</strong>mation on toxicology and hazardous<br />
chemicals: (http://toxnet.nlm.nih.gov/)