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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C.D. Deakin et al. / <strong>Resuscitation</strong> 81 (<strong>2010</strong>) 1305–1352 1311<br />
◦ Those experienced in clinical assessment should assess the<br />
carotid pulse whilst simultaneously looking <strong>for</strong> signs of life <strong>for</strong><br />
not more than 10 s.<br />
◦ If the patient appears to have no signs of life, or if there is<br />
doubt, start CPR immediately. Delivering chest compressions<br />
to a patient with a beating heart is unlikely to cause harm. 240<br />
However, delays in diagnosis of cardiac arrest and starting CPR<br />
will adversely effect survival and must be avoided.<br />
If there is a pulse or signs of life, urgent medical assessment<br />
is required. Depending on the local protocols, this may take<br />
the <strong>for</strong>m of a resuscitation team. While awaiting this team, give<br />
the patient oxygen, attach monitoring, and insert an intravenous<br />
cannula. When a reliable measurement of oxygen saturation<br />
of arterial blood (e.g., pulse oximetry (SpO 2 )) can be achieved,<br />
titrate the inspired oxygen concentration to achieve a SpO 2 of<br />
94–98%.<br />
If there is no breathing, but there is a pulse (respiratory arrest),<br />
ventilate the patient’s lungs and check <strong>for</strong> a circulation every 10<br />
breaths.<br />
Starting in-hospital CPR<br />
• One person starts CPR as others call the resuscitation team and<br />
collect the resuscitation equipment and a defibrillator. If only one<br />
member of staff is present, this will mean leaving the patient.<br />
• Give 30 chest compressions followed by 2 ventilations.<br />
• Minimise interruptions and ensure high-quality compressions.<br />
• Undertaking good-quality chest compressions <strong>for</strong> a prolonged<br />
time is tiring; with minimal interruption, try to change the person<br />
doing chest compressions every 2 min.<br />
• Maintain the airway and ventilate the lungs with the most appropriate<br />
equipment immediately to hand. A pocket mask, which<br />
may be supplemented with an oral airway, is usually readily available.<br />
Alternatively, use a supraglottic airway device (SAD) and<br />
self-inflating bag, or bag-mask, according to local policy. Tracheal<br />
intubation should be attempted only by those who are trained,<br />
competent and experienced in this skill. Wave<strong>for</strong>m capnography<br />
should be routinely available <strong>for</strong> confirming tracheal tube<br />
placement (in the presence of a cardiac output) and subsequent<br />
monitoring of an intubated patient.<br />
• Use an inspiratory time of 1 s and give enough volume to produce<br />
a normal chest rise. Add supplemental oxygen as soon as possible.<br />
• Once the patient’s trachea has been intubated or a SAD has been<br />
inserted, continue chest compressions uninterrupted (except<br />
<strong>for</strong> defibrillation or pulse checks when indicated), at a rate of<br />
at least 100 min −1 , and ventilate the lungs at approximately<br />
10 breaths min −1 . Avoid hyperventilation (both excessive rate<br />
and tidal volume), which may worsen outcome. Mechanical ventilators<br />
may free up a rescuer and ensure appropriate ventilation<br />
rates and volumes.<br />
• If there is no airway and ventilation equipment available, consider<br />
giving mouth-to-mouth ventilation. If there are clinical<br />
reasons to avoid mouth-to-mouth contact, or you are unwilling<br />
or unable to do this, do chest compressions until help or airway<br />
equipment arrives.<br />
• When the defibrillator arrives, apply the paddles to the patient<br />
and analyse the rhythm. If self-adhesive defibrillation pads are<br />
available, apply these without interrupting chest compressions.<br />
The use of adhesive electrode pads or a ‘quick-look’ paddles technique<br />
will enable rapid assessment of heart rhythm compared<br />
with attaching ECG electrodes. 241 Pause briefly to assess the<br />
heart rhythm. With a manual defibrillator, if the rhythm is VF/VT<br />
charge the defibrillator while another rescuer continues chest<br />
compressions. Once the defibrillator is charged, pause the chest<br />
compressions, ensure that all rescuers are clear of the patient and<br />
then give one shock. If using an automated external defibrillation<br />
(AED) follow the AED’s audio-visual prompts.<br />
• Restart chest compressions immediately after the defibrillation<br />
attempt. Minimise interruptions to chest compressions. Using a<br />
manual defibrillator it is possible to reduce the pause between<br />
stopping and restarting of chest compressions to less than 5 s.<br />
• Continue resuscitation until the resuscitation team arrives or the<br />
patient shows signs of life. Follow the voice prompts if using an<br />
AED. If using a manual defibrillator, follow the universal algorithm<br />
<strong>for</strong> advanced life support (Section 4d).<br />
• Once resuscitation is underway, and if there are sufficient staff<br />
present, prepare intravenous cannulae and drugs likely to be used<br />
by the resuscitation team (e.g., adrenaline).<br />
• Identify one person to be responsible <strong>for</strong> handover to the resuscitation<br />
team leader. Use a structured communication tool <strong>for</strong><br />
handover (e.g., SBAR, RSVP). 97,98 Locate the patient’s records.<br />
• The quality of chest compressions during in-hospital CPR is<br />
frequently sub-optimal. 242,243 The importance of uninterrupted<br />
chest compressions cannot be over emphasised. Even short interruptions<br />
to chest compressions are disastrous <strong>for</strong> outcome and<br />
every ef<strong>for</strong>t must be made to ensure that continuous, effective<br />
chest compression is maintained throughout the resuscitation<br />
attempt. Chest compressions should commence at the beginning<br />
of a resuscitation attempt and continue uninterrupted unless<br />
they are briefly paused <strong>for</strong> a specific intervention (e.g., pulse<br />
check). The team leader should monitor the quality of CPR and<br />
alternate CPR providers if the quality of CPR is poor. Continuous<br />
ETCO 2 monitoring can be used to indicate the quality of CPR:<br />
although an optimal target <strong>for</strong> ETCO 2 during CPR has not been<br />
established, a value of less than 10 mm Hg (1.4 kPa) is associated<br />
with failure to achieve ROSC and may indicate that the quality of<br />
chest compressions should be improved. If possible, the person<br />
providing chest compressions should be alternated every 2 min,<br />
but without causing long pauses in chest compressions.<br />
4d ALS treatment algorithm<br />
Introduction<br />
Heart rhythms associated with cardiac arrest are divided into<br />
two groups: shockable rhythms (ventricular fibrillation/pulseless<br />
ventricular tachycardia (VF/VT)) and non-shockable rhythms (asystole<br />
and pulseless electrical activity (PEA)). The principal difference<br />
in the treatment of these two groups of arrhythmias is the need <strong>for</strong><br />
attempted defibrillation in those patients with VF/VT. Subsequent<br />
actions, including high-quality chest compressions with minimal<br />
interruptions, airway management and ventilation, venous access,<br />
administration of adrenaline and the identification and correction<br />
of reversible factors, are common to both groups.<br />
Although the ALS cardiac arrest algorithm (Fig. 4.2) is applicable<br />
to all cardiac arrests, additional interventions may be indicated <strong>for</strong><br />
cardiac arrest caused by special circumstances (see Section 8).<br />
The interventions that unquestionably contribute to improved<br />
survival after cardiac arrest are prompt and effective bystander<br />
basic life support (BLS), uninterrupted, high-quality chest compressions<br />
and early defibrillation <strong>for</strong> VF/VT. The use of adrenaline has<br />
been shown to increase return of spontaneous circulation (ROSC),<br />
but no resuscitation drugs or advanced airway interventions have<br />
been shown to increase survival to hospital discharge after cardiac<br />
arrest. 244–247 Thus, although drugs and advanced airways are still<br />
included among ALS interventions, they are of secondary importance<br />
to early defibrillation and high-quality, uninterrupted chest<br />
compressions.<br />
As with previous guidelines, the ALS algorithm distinguishes<br />
between shockable and non-shockable rhythms. Each cycle is