European Resuscitation Council Guidelines for Resuscitation 2010 ...

C.D. Deakin et al. / Resuscitation 81 (2010) 1305–1352 1311
◦ Those experienced in clinical assessment should assess the
carotid pulse whilst simultaneously looking for signs of life for
not more than 10 s.
◦ If the patient appears to have no signs of life, or if there is
doubt, start CPR immediately. Delivering chest compressions
to a patient with a beating heart is unlikely to cause harm. 240
However, delays in diagnosis of cardiac arrest and starting CPR
will adversely effect survival and must be avoided.
If there is a pulse or signs of life, urgent medical assessment
is required. Depending on the local protocols, this may take
the form of a resuscitation team. While awaiting this team, give
the patient oxygen, attach monitoring, and insert an intravenous
cannula. When a reliable measurement of oxygen saturation
of arterial blood (e.g., pulse oximetry (SpO 2 )) can be achieved,
titrate the inspired oxygen concentration to achieve a SpO 2 of
94–98%.
If there is no breathing, but there is a pulse (respiratory arrest),
ventilate the patient’s lungs and check for a circulation every 10
breaths.
Starting in-hospital CPR
• One person starts CPR as others call the resuscitation team and
collect the resuscitation equipment and a defibrillator. If only one
member of staff is present, this will mean leaving the patient.
• Give 30 chest compressions followed by 2 ventilations.
• Minimise interruptions and ensure high-quality compressions.
• Undertaking good-quality chest compressions for a prolonged
time is tiring; with minimal interruption, try to change the person
doing chest compressions every 2 min.
• Maintain the airway and ventilate the lungs with the most appropriate
equipment immediately to hand. A pocket mask, which
may be supplemented with an oral airway, is usually readily available.
Alternatively, use a supraglottic airway device (SAD) and
self-inflating bag, or bag-mask, according to local policy. Tracheal
intubation should be attempted only by those who are trained,
competent and experienced in this skill. Waveform capnography
should be routinely available for confirming tracheal tube
placement (in the presence of a cardiac output) and subsequent
monitoring of an intubated patient.
• Use an inspiratory time of 1 s and give enough volume to produce
a normal chest rise. Add supplemental oxygen as soon as possible.
• Once the patient’s trachea has been intubated or a SAD has been
inserted, continue chest compressions uninterrupted (except
for defibrillation or pulse checks when indicated), at a rate of
at least 100 min −1 , and ventilate the lungs at approximately
10 breaths min −1 . Avoid hyperventilation (both excessive rate
and tidal volume), which may worsen outcome. Mechanical ventilators
may free up a rescuer and ensure appropriate ventilation
rates and volumes.
• If there is no airway and ventilation equipment available, consider
giving mouth-to-mouth ventilation. If there are clinical
reasons to avoid mouth-to-mouth contact, or you are unwilling
or unable to do this, do chest compressions until help or airway
equipment arrives.
• When the defibrillator arrives, apply the paddles to the patient
and analyse the rhythm. If self-adhesive defibrillation pads are
available, apply these without interrupting chest compressions.
The use of adhesive electrode pads or a ‘quick-look’ paddles technique
will enable rapid assessment of heart rhythm compared
with attaching ECG electrodes. 241 Pause briefly to assess the
heart rhythm. With a manual defibrillator, if the rhythm is VF/VT
charge the defibrillator while another rescuer continues chest
compressions. Once the defibrillator is charged, pause the chest
compressions, ensure that all rescuers are clear of the patient and
then give one shock. If using an automated external defibrillation
(AED) follow the AED’s audio-visual prompts.
• Restart chest compressions immediately after the defibrillation
attempt. Minimise interruptions to chest compressions. Using a
manual defibrillator it is possible to reduce the pause between
stopping and restarting of chest compressions to less than 5 s.
• Continue resuscitation until the resuscitation team arrives or the
patient shows signs of life. Follow the voice prompts if using an
AED. If using a manual defibrillator, follow the universal algorithm
for advanced life support (Section 4d).
• Once resuscitation is underway, and if there are sufficient staff
present, prepare intravenous cannulae and drugs likely to be used
by the resuscitation team (e.g., adrenaline).
• Identify one person to be responsible for handover to the resuscitation
team leader. Use a structured communication tool for
handover (e.g., SBAR, RSVP). 97,98 Locate the patient’s records.
• The quality of chest compressions during in-hospital CPR is
frequently sub-optimal. 242,243 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. Chest compressions should commence at the beginning
of a resuscitation attempt and continue uninterrupted unless
they are briefly paused for a specific intervention (e.g., pulse
check). 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 alternated every 2 min,
but without causing long pauses in chest compressions.
4d ALS treatment algorithm
Introduction
Heart rhythms associated with cardiac arrest are divided into
two groups: shockable rhythms (ventricular fibrillation/pulseless
ventricular tachycardia (VF/VT)) and non-shockable rhythms (asystole
and pulseless electrical activity (PEA)). The principal difference
in the treatment of these two groups of arrhythmias is the need for
attempted defibrillation in those patients with VF/VT. Subsequent
actions, including high-quality chest compressions with minimal
interruptions, airway management and ventilation, venous access,
administration of adrenaline and the identification and correction
of reversible factors, are common to both groups.
Although the ALS cardiac arrest algorithm (Fig. 4.2) is applicable
to all cardiac arrests, additional interventions may be indicated for
cardiac arrest caused by special circumstances (see Section 8).
The interventions that unquestionably contribute to improved
survival after cardiac arrest are prompt and effective bystander
basic life support (BLS), uninterrupted, high-quality chest compressions
and early defibrillation for VF/VT. The use of adrenaline has
been shown to increase return of spontaneous circulation (ROSC),
but no resuscitation drugs or advanced airway interventions have
been shown to increase survival to hospital discharge after cardiac
arrest. 244–247 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.
As with previous guidelines, the ALS algorithm distinguishes
between shockable and non-shockable rhythms. Each cycle is