synchronisation of compression and ventilation is abandoned and the two operations are performed independently.
Ventilation
Five initial ‘rescue breaths’ are recommended for children whereas, for adults, the 2 first breaths are given only after the first 30 chest compressions.
Each breath should only take 1 second so as to main-tain constant chest compressions. Mouth to mouth-and-nose ventilation is required for infants. A pocket mask may be used by occasional resuscitators to avoid direct patient contact; professional rescuers should use bag, valve and mask units initially but aim for endotracheal intubation as soon as practi-cally possible. Airway adjuncts such as the oesopha-geal obturator airway and Combitube are not recommended – there are more disadvantages to their use than advantages. However, the laryngeal mask airway (LMA) is increasingly used by first responders.
Precordial thump
This supplies energy that may abort VT or even VF but in the unstable heart it may also possibly convert sinus rhythm into VF. Therefore, its use is most survivable by far. The only effective treatment
for it – defibrillation – was introduced into clinical practice by Zoll and colleagues in 1956. In almost all circumstances, no other intervention must take prec-edence over defibrillation.
Figure 11.3 Advanced life support for adults. Reproduced with the kind permission of the Resuscitation Council (UK).
Adult Advanced Life Support
CPR 30:2
Attach defibrillator / monitor Minimise interruptions
Shockable (VF / Pulseless VT)
1 Shock
During CPR
• Ensure high-quality CPR: rate, depth, recoil
• Plan actions before interrupting CPR
• Give oxygen
• Consider advanced airway and capnography
• Continuous chest compressions when advanced airway in place
• Vascular access (intravenous, intraosseous)
• Give adrenaline every 3-5 min
• Correct reversible causes
Reversible Causes
• Hypoxia
• Hypovolaemia
• Hypo-/hyperkalaemia/metabolic
• Hypothermia
• Thrombosis - coronary or pulmonary
• Tamponade - cardiac
• Toxins
• Tension pneumothorax
Non-Shockable (PEA/Asystole) Call
resuscitation team Unresponsive?
Not breathing or only occasional gasps
Return of spontaneous
circulation
Immediately resume CPR for 2 min Minimise interruptions
Immediately resume CPR for 2 min Minimise interruptions Immediate post
cardiac arrest treatment
• Use ABCDE approach
• Controlled oxygenation and ventilation
• 12-lead ECG
• Treat precipitating cause
• Temperature control/
therapeutic hypothermia
Assess rhythm
2010
ResuscitationGuidelines Resuscitation Council (UK)
Figure 11.4 Advanced life support for children. Reproduced with the kind permission of the Resuscitation Council (UK).
Paediatric Advanced Life Support
CPR
(5 initial breaths then 15:2) Attach defibrillator / monitor
Minimise interruptions
Shockable (VF / Pulseless VT)
1 Shock 4J / kg
During CPR
• Ensure high-quality CPR: rate, depth, recoil
• Plan actions before interrupting CPR
• Give oxygen
• Vascular access (intravenous, intraosseous)
• Give adrenaline every 3-5 min
• Consider advanced airway and capnography
• Continuous chest compressions when advanced airway in place
• Correct reversible causes
Reversible Causes
• Hypoxia
• Hypovolaemia
• Hypo-/hyperkalaemia/metabolic
• Hypothermia
• Tension pneumothorax
• Toxins
• Tamponade - cardiac
• Thromboembolism
Non-Shockable (PEA / Asystole)
Call resuscitation team
(1 min CPR first, if alone) Unresponsive?
Not breathing or only occasional gasps
Return of spontaneous
circulation
Immediately resume CPR for 2 min Minimise interruptions
Immediately resume CPR for 2 min Minimise interruptions Immediate post cardiac
arrest treatment
• Use ABCDE approach
• Controlled oxygenation and ventilation
• Investigations
• Treat precipitating cause
• Temperature control
• Therapeutic hypothermia?
Assess rhythm
2010
ResuscitationGuidelines Resuscitation Council (UK)
resumed). It stabilises cell membranes and thus increases the duration of the action potential and refractory period in both atrial and ventricular myo-cardial cells. As an antiarrhythmic agent, it prolongs the Q–T interval and slows conduction through both the atrioventricular (AV) node and any accessory pathways. Amiodarone has less negative inotropic effects and fewer proarrhythmic actions than most similar drugs. An initial IV bolus of 300 mg should be given in adults; the equivalent IV/IO dose for children is 5 mg/kg. A further dose of 150 mg may be given for persistent or recurrent VF/VT, followed by an infusion of 900 mg over 24 h.
Atropine
Atropine is no longer recommended in cardiac arrest. Pulseless patients with extreme bradycardia or isolated P waves may benefit from pacing (→
p. 160).
Bicarbonate
Bicarbonate therapy is contraindicated in early re -suscitation. Acidosis develops but aids oxyhaemo-globin dissociation; temporary buffering of pH is achieved by hyperventilation. Sodium bicarbonate is reserved for cardiac arrests that are associated with the following:
1 Hyperkalaemia (→ p. 248)
2 Poisoning with tricyclic antidepressants (→ p. 278).
The initial dose is 50–100 mmol (or 1–2 mmol/kg).
Further information about bicarbonate therapy → Box 14.24 on p. 252. Prolonged arrest (i.e. over 20–
25 min) causes profound intracellular acidosis and so recommended only in witnessed arrests when ALS
skills are available.
Gastric decompression
Inflation of the stomach is inevitable during BLS.
It causes splinting of the diaphragm and may impair cardiac output. For this reason, it is helpful to decompress the stomach with a large-bore orogastric (lavage-type) tube as soon as possible during all resuscitations. This should not be attempted until the airway is protected by intubation. The stomach may be emptied of both air and fluids in order to decrease the risk of aspiration. At postmortem examination, almost half of all patients who have died after attempted resuscitation are found to have full stom-achs. Contamination of the respiratory tract is evident in 30%. Airway protection is ensured by early endotra-cheal intubation; the LMA is an effective alternative for first responders.
Relatives
Honest, accurate and frequent communication with relatives is essential throughout all resuscitations.
Increasingly, relatives are being encouraged to come into the resuscitation room, even if it is only for a very short period. Staff may feel threatened by their pres-ence but relatives are reassured by the experipres-ence;
however cluttered and confusing the resuscitation area may appear, the reality is often less frightening than their imaginings. A dedicated member of staff should accompany relatives in the resuscitation room at all times.