European Resuscitation Council Guidelines for Resuscitation 2010 ...

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