European Resuscitation Council Guidelines for Resuscitation 2010 ...

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1312 C.D. Deakin et al. / Resuscitation 81 (2010) 1305–1352 broadly similar, with a total of 2 min of CPR being given before assessing the rhythm and where indicated, feeling for a pulse. Adrenaline 1 mg is given every 3–5 min until ROSC is achieved—the timing of the initial dose of adrenaline is described below. In VF/VT, a single dose of amiodarone is indicated after three unsuccessful shocks. Shockable rhythms (ventricular fibrillation/pulseless ventricular tachycardia) The first monitored rhythm is VF/VT in approximately 25% of cardiac arrests, both in- 4 or out-of-hospital. 248–250 VF/VT will also occur at some stage during resuscitation in about 25% of cardiac Fig. 4.2. Advanced life support cardiac arrest algorithm. © 2010 ERC.
C.D. Deakin et al. / Resuscitation 81 (2010) 1305–1352 1313 arrests with an initial documented rhythm of asystole or PEA. 4 Having confirmed cardiac arrest, summon help (including the request for a defibrillator) and start CPR, beginning with chest compressions, with a compression:ventilation (CV) ratio of 30:2. When the defibrillator arrives, continue chest compressions while applying the paddles or self-adhesive pads. Identify the rhythm and treat according to the ALS algorithm. • If VF/VT is confirmed, charge the defibrillator while another rescuer continues chest compressions. Once the defibrillator is charged, pause the chest compressions, quickly ensure that all rescuers are clear of the patient and then give one shock (360-J monophasic or 150–200 J biphasic). • Minimise the delay between stopping chest compressions and delivery of the shock (the preshock pause); even 5–10 s delay will reduce the chances of the shock being successful. 251,252 • Without reassessing the rhythm or feeling for a pulse, resume CPR (CV ratio 30:2) immediately after the shock, starting with chest compressions. Even if the defibrillation attempt is successful in restoring a perfusing rhythm, it takes time until the post-shock circulation is established 253 and it is very rare for a pulse to be palpable immediately after defibrillation. 254 Furthermore, the delay in trying to palpate a pulse will further compromise the myocardium if a perfusing rhythm has not been restored. 255 • Continue CPR for 2 min, then pause briefly to assess the rhythm; if still VF/VT, give a second shock (360-J monophasic or 150–360-J biphasic). Without reassessing the rhythm or feeling for a pulse, resume CPR (CV ratio 30:2) immediately after the shock, starting with chest compressions. • Continue CPR for 2 min, then pause briefly to assess the rhythm; if still VF/VT, give a third shock (360-J monophasic or 150–360-J biphasic). Without reassessing the rhythm or feeling for a pulse, resume CPR (CV ratio 30:2) immediately after the shock, starting with chest compressions. If IV/IO access has been obtained, give adrenaline 1 mg and amiodarone 300 mg once compressions have resumed. If ROSC has not been achieved with this 3rd shock the adrenaline will improve myocardial blood flow and may increase the chance of successful defibrillation with the next shock. In animal studies, peak plasma concentrations of adrenaline occur at about 90 s after a peripheral injection. 256 If ROSC has been achieved after the 3rd shock it is possible that the bolus dose of adrenaline will cause tachycardia and hypertension and precipitate recurrence of VF. However, naturally occurring adrenaline plasma concentrations are high immediately after ROSC, 257 and any additional harm caused by exogenous adrenaline has not been studied. Interrupting chest compressions to check for a perfusing rhythm midway in the cycle of compressions is also likely to be harmful. The use of waveform capnography may enable ROSC to be detected without pausing chect compressions and may be a way of avoiding a bolus injection of adenaline after ROSC has been achieved. Two prospective human studies have shown that a significant increase in end-tidal CO 2 occurs when return of spontaneous circulation occurs. 258,259 • After each 2-min cycle of CPR, if the rhythm changes to asystole or PEA, see ‘non-shockable rhythms’ below. If a non-shockable rhythm is present and the rhythm is organised (complexes appear regular or narrow), try to palpate a pulse. Rhythm checks should be brief, and pulse checks should be undertaken only if an organised rhythm is observed. If there is any doubt about the presence of a pulse in the presence of an organised rhythm, resume CPR. If ROSC has been achieved, begin post-resuscitation care During treatment of VF/VT, healthcare providers must practice efficient coordination between CPR and shock delivery. When VF is present for more than a few minutes, the myocardium is depleted of oxygen and metabolic substrates. A brief period of chest compressions will deliver oxygen and energy substrates and increase the probability of restoring a perfusing rhythm after shock delivery. 260 Analyses of VF waveform characteristics predictive of shock success indicate that the shorter the time between chest compression and shock delivery, the more likely the shock will be successful. 260,261 Reduction in the interval from compression to shock delivery by even a few seconds can increase the probability of shock success. 251,252 Regardless of the arrest rhythm, give adrenaline 1 mg every 3–5 min until ROSC is achieved; in practice, this will be once every two cycles of the algorithm. If signs of life return during CPR (purposeful movement, normal breathing, or coughing), check the monitor; if an organised rhythm is present, check for a pulse. If a pulse is palpable, continue post-resuscitation care and/or treatment of peri-arrest arrhythmia. If no pulse is present, continue CPR. Providing CPR with a CV ratio of 30:2 is tiring; change the individual undertaking compressions every 2 min, while minimising the interruption in compressions. Witnessed, monitored VF/VT in the cardiac catheter lab or after cardiac surgery If a patient has a monitored and witnessed cardiac arrest in the catheter laboratory or early after cardiac surgery: • Confirm cardiac arrest and shout for help. • If the initial rhythm is VF/VT, give up to three quick successive (stacked) shocks. Start chest compressions immediately after the third shock and continue CPR for 2 min. This three-shock strategy may also be considered for an initial, witnessed VF/VT cardiac arrest if the patient is already connected to a manual defibrillator. Although there are no data supporting a three-shock strategy in any of these circumstances, it is unlikely that chest compressions will improve the already very high chance of return of spontaneous circulation when defibrillation occurs early in the electrical phase, immediately after onset of VF (see Section 3). 223 Precordial thump A single precordial thump has a very low success rate for cardioversion of a shockable rhythm 262–264 and is only likely to succeed if given within the first few seconds of the onset of a shockable rhythm. 265 There is more success with pulseless VT than with VF. Delivery of a precordial thump must not delay calling for help or accessing a defibrillator. It is therefore appropriate therapy only when several clinicians are present at a witnessed, monitored arrest, and when a defibrillator is not immediately to hand (see Section 3). 223,266 In practice, this is only likely to be in a critical care environment such as the emergency department or ICU. 264 A precordial thump should be undertaken immediately after confirmation of cardiac arrest and only by healthcare professionals trained in the technique. Using the ulnar edge of a tightly clenched fist, deliver a sharp impact to the lower half of the sternum from a height of about 20 cm, then retract the fist immediately to create an impulse-like stimulus. There are very rare reports of a precordial thump converting a perfusing to a non-perfusing rhythm. 267 Airway and ventilation During the treatment of persistent VF, ensure good-quality chest compressions between defibrillation attempts. Consider reversible causes (4 Hs and 4 Ts) and, if identified, correct them. Check the
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