europeanresuscitationcouncil                Summary                of the main                changes in the              ...
2                         European                         Resuscitation                         Council    To p r e s e r...
3Summary of main changes since 2005 GuidelinesBasic life support                             improve the quality of CPR pe...
4    Adult Basic Life Support            UNRESPONSIVE?              Shout for help              Open airway       NOT BREA...
5Automated External Defibrillation                              Unresponsive?                                             ...
In Hospital Resuscitation                                                Collapsed/sick patient                           ...
7these guidelines that the risk of harm      Adult advanced lifeto a rescuer from a defibrillator is very   supportsmall, ...
8                                 Advanced Life Support                                                       Unresponsive...
Tachycardia (with pulse)                                                                                   •	 Assess using...
10                                                 Bradycardia                                  •	Assess using the ABCDE a...
11♦♦ The use of up to three quick suc-cessive (stacked) shocks for ventricular    ♦♦ The potential role of ultrasoundfibri...
12                                                                                                      ACS               ...
13 ♦♦ Use of therapeutic hypothermia to        ♦♦ The role of chest pain observation include comatose survivors of cardiac...
14     ♦♦ Gp IIb/IIIa inhibitors before angiog-        - Angiography and, if necessary, PCI     raphy/percutaneous coronar...
15infants or children. Healthcare provid-     minimise no-flow time. Compressers should look for signs of life and if    t...
16      Paediatric Basic Life Support     Health professionals with a duty to respond                        UNRESPONSIVE?...
17                 Paediatric Advanced Life Support                                                   Unresponsive?       ...
18                                            Newborn Life Support     At all stages ask: Do you need HELP?               ...
19self-adhesive pads (if the size of the       ♦♦ Implementation      of a rapidchild’s chest allows this). Chest com-    ...
20     ♦♦ Preterm babies less than 32 weeks       start mask ventilation, particularly if     gestation may not reach the ...
21Principles of education in                   ♦♦ Basic and advanced life supportresuscitation                            ...
22                          Edited by Jerry Nolan                                     Authors     Jerry P. Nolan          ...
23Become a member of the ERCYou can choose between  * Full membership on paper and electronic  * Full membership electroni...
www.erc.eduwww.CPRguidelines.eu
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Executive summary vf20101018

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Executive summary vf20101018

  1. 1. europeanresuscitationcouncil Summary of the main changes in the Resuscitation Guidelines ERC Guidelines 2010
  2. 2. 2 European Resuscitation Council To p r e s e r v e h u m a n l i f e b y m a k i n g high quality resuscitation available to all The Network of National Resuscitation Councils Published by: European Resuscitation Council Secretariat vzw, Drie Eikenstraat 661 - BE 2650 Edegem - Belgium Website: www.erc.edu Email: info@erc.edu Tel: +32 3 826 93 21 © European Resuscitation Council 2010. All rights reserved. We encourage you to send this document to other persons as a whole in order to disseminate the ERC Guidelines. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise for commercial purposes, without the prior written permission of the ERC. Version1.2 Disclaimer: No responsibility is assumed by the authors and the publisher for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions or ideas contained in the material herein.
  3. 3. 3Summary of main changes since 2005 GuidelinesBasic life support improve the quality of CPR perform- ance and provide feedback to pro-Changes in basic life support (BLS) since fessional rescuers during debriefingthe 2005 guidelines include: sessions. ♦♦ Dispatchers should be trained to interrogate callers with strict protocols Electrical therapies: to elicit information. This information automated external defi- should focus on the recognition of brillators, defibrillation, unresponsiveness and the quality of cardioversion and pacing breathing. In combination with unre- sponsiveness, absence of breathing or The most important changes in the 2010 any abnormality of breathing should ERC Guidelines for electrical therapies start a dispatch protocol for suspect- include: ed cardiac arrest. The importance of gasping as sign of cardiac arrest is emphasised. ♦♦ The importance of early, uninter- rupted chest compressions is empha- sised throughout these guidelines. ♦♦ All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. A strong empha- ♦♦ Much greater emphasis on mini- sis on delivering high quality chest mising the duration of the pre-shock compressions remains essential. The and post-shock pauses; the continua- aim should be to push to a depth of tion of compressions during charging at least 5 cm at a rate of at least 100 of the defibrillator is recommended. compressions min-1, to allow full chest recoil, and to minimise interruptions in chest compressions. Trained rescu- ♦♦ Immediate resumption of chest ers should also provide ventilations compressions following defibrillation with a compression–ventilation (CV) is also emphasised; in combination ratio of 30:2. Telephone-guided chest with continuation of compressions compression-only CPR is encouraged during defibrillator charging, the for untrained rescuers. delivery of defibrillation should be achievable with an interruption in chest compressions of no more than 5 ♦♦ The use of prompt/feedback devic- seconds. es during CPR will enable immediate feedback to rescuers and is encour- aged. The data stored in rescue equip- ♦♦ Safety of the rescuer remains par- ment can be used to monitor and amount, but there is recognition in
  4. 4. 4 Adult Basic Life Support UNRESPONSIVE? Shout for help Open airway NOT BREATHING NORMALLY? Call 112* 30 chest compressions 2 rescue breaths 30 compressions *or national emergency number
  5. 5. 5Automated External Defibrillation Unresponsive? Call for help Open airway Not breathing normally Send or go for AED Call 112* * or national emergency number CPR 30:2 Until AED is attached AED assesses rhythm Shock No shock advised advised 1 ShockImmediately resume: Immediately resume: CPR 30:2 CPR 30:2 for 2 min for 2 min Continue until the victim starts to wake up: to move, opens eyes and to breathe normally
  6. 6. In Hospital Resuscitation Collapsed/sick patient Shout for HELP & assess patient No Signs of life? Yes Call resuscitation team Assess ABCDE Recognise & treat Oxygen, monitoring, iv access CPR 30:2 with oxygen and airway adjuncts Call resuscitation team Apply pads/monitor If appropriate Attempt defibrillation if appropriate Advanced Life Support Handover to resuscitation team when resuscitation team arrives6
  7. 7. 7these guidelines that the risk of harm Adult advanced lifeto a rescuer from a defibrillator is very supportsmall, particularly if the rescuer is The most important changes in the 2010wearing gloves. The focus is now on a ERC Advanced Life Support (ALS) Guide-rapid safety check to minimise the pre- lines include:shock pause. ♦♦ Increased emphasis on the♦♦ When treating out-of-hospital car- importance of minimally interrupt-diac arrest, emergency medical serv- ed high-quality chest compressionsices (EMS) personnel should provide throughout any ALS intervention:good-quality CPR while a defibrillator chest compressions are paused brieflyis retrieved, applied and charged, but only to enable specific interventions.routine delivery of a pre-specified peri-od of CPR (e.g., two or three minutes)before rhythm analysis and a shock is ♦♦ Increased emphasis on the use ofdelivered is no longer recommended. ‘track and trigger systems’ to detectFor some EMS that have already fully the deteriorating patient and enableimplemented a pre-specified period of treatment to prevent in-hospital car-chest compressions before defibrilla- diac arrest.tion, given the lack of convincing dataeither supporting or refuting this strat-egy, it is reasonable for them to con- ♦♦ Increased awareness of the warn-tinue this practice. ing signs associated with the poten- tial risk of sudden cardiac death out of hospital.♦♦ The use of up to three-stackedshocks may be considered if VF/VToccurs during cardiac catheterisation ♦♦ Removal of the recommendationor in the early post-operative period for a pre-specified period of cardiop-following cardiac surgery. This three- ulmonary resuscitation (CPR) beforeshock strategy may also be considered out-of-hospital defibrillation followingfor an initial, witnessed VF/VT cardiac cardiac arrest unwitnessed by the EMS.arrest when the patient is already con-nected to a manual defibrillator. ♦♦ Continuation of chest compres- sions while a defibrillator is charged -♦♦ Further development of AED pro- this will minimise the pre-shock pause.grammes is encouraged – there is aneed for further deployment of AEDsin both public and residential areas. ♦♦ The role of the precordial thump is de-emphasised.
  8. 8. 8 Advanced Life Support Unresponsive? Not breathing or only occasional gasps Call Resuscitation Team CPR 30:2 Attach defibrillator/monitor Minimise interruptions Assess rhythm Shockable Non-shockable (VF/Pulseless VT) (PEA/Asystole) Return of 1 Shock spontaneous circulation Immediately resume: Immediate post cardiac Immediately resume: CPR for 2 min arrest treatment CPR for 2 min • Use ABCDE approach Minimise interruptions Minimise interruptions • Controlled oxygenation and ventilation • 12-lead ECG • Treat precipitating cause •Temperature control / therapeu- tic hypothermia During CPR Reversible causes• Ensure high-quality CPR: rate, depth, recoil • Hypoxia• Plan actions before interrupting CPR • Hypovolaemia• Give oxygen • Hypo-/hyperkalaemia/metabolic• Consider advanced airway and capnography • Hypothermia• Continuous chest compressions when advanced airway in place • Thrombosis• Vascular access (intravenous, intraosseous) • Tamponade - cardiac• Give adrenaline every 3-5 min • Toxins• Correct reversible causes • Tension pneumothorax
  9. 9. Tachycardia (with pulse) • Assess using the ABCDE approach • Ensure oxygen given and obtain IV access • Monitor ECG, BP, SpO2 ,record 12 lead ECG • Identify and treat reversible causes (e.g. electrolyte abnormalities) Assess for evidence of adverse signs Synchronised DC Shock* Unstable 1. Shock 2. Syncope Stable Is QRS narrow (< 0.12 sec)? Up to 3 attempts 3. Myocardial ischaemia 4. Heart failure Broad Narrow • Amiodarone 300 mg IV over 10-20 min and repeat shock; followed by: • Amiodarone 900 mg over 24 h Irregular Broad QRS Regular Regular Narrow QRS Irregular Is QRS regular? Is rhythm regular? Seek expert help Irregular Narrow Complex • Use vagal manoeuvres Tachycardia • Adenosine 6 mg rapid IV bolus; Probable atrial fibrillation if unsuccessful give 12 mg; Control rate with: if unsuccessful give further 12 mg. • ß-Blocker or diltiazem • Monitor ECG continuously • Consider digoxin or amiodarone if evidence of heart failure Anticoagulate if duration > 48h If Ventricular Tachycardia Normal sinus rhythm restored? Seek expert help Possibilities include: No (or uncertain rhythm): • AF with bundle branch block • Amiodarone 300 mg IV over 20-60 treat as for narrow complex min; then 900 mg over 24 h • Pre-excited AF Yes consider amiodarone If previously confirmed • Polymorphic VT SVT with bundle branch block: (e.g. torsades de pointes - • Give adenosine as for regular give magnesium 2 g over 10 min) narrow complex tachycardia Probable re-entry PSVT: Possible atrial flutter • Record 12-lead ECG in sinus rhythm • Control rate (e.g. ß-Blocker) • If recurs, give adenosine again &*Attempted electrical cardioversion is always undertaken under sedation or general anaesthesia consider choice of anti-arrhythmic 9 prophylaxis
  10. 10. 10 Bradycardia • Assess using the ABCDE approach • Ensure oxygen given and obtain IV access • Monitor ECG, BP, SpO2 ,record 12 lead ECG • Identify and treat reversible causes (e.g. electrolyte abnormalities) Assess for evidence of adverse signs: 1 Shock Yes 2 Syncope No 3 Myocardial ischaemia 4 Heart failure Atropine 500 mcg IV Satisfactory Yes Response? No Risk of asystole? • Recent asystole Yes • Möbitz II AV block • Complete heart block with broad QRS • Ventricular pause > 3s Interim measures: • Atropine 500 mcg IV repeat to maximum of 3 mg • Isoprenaline 5 mcg min-1 • Adrenaline 2-10 mcg min-1 • Alternative drugs* No OR • Transcutaneous pacing Seek expert help Observe Arrange transvenous pacing * Alternatives include: • Aminophylline • Dopamine • Glucagon (if beta-blocker or calcium channel blocker overdose) • Glycopyrrolate can be used instead of atropine
  11. 11. 11♦♦ The use of up to three quick suc-cessive (stacked) shocks for ventricular ♦♦ The potential role of ultrasoundfibrillation/pulseless ventricular tachy- imaging during ALS is recognised.cardia (VF/VT) occurring in the cardiaccatheterisation laboratory or in theimmediate post-operative period fol- ♦♦ Recognition of the potential harmlowing cardiac surgery. caused by hyperoxaemia after ROSC is achieved: once ROSC has been estab- lished and the oxygen saturation of♦♦ Delivery of drugs via a tracheal tube arterial blood (SaO2) can be moni-is no longer recommended – if intrave- tored reliably (by pulse oximetry and/nous access cannot be achieved, drugs or arterial blood gas analysis), inspiredshould be given by the intraosseous oxygen is titrated to achieve a SaO2 of(IO) route. 94 – 98%.♦♦ When treating VF/VT cardiac arrest, ♦♦ Much greater detail and emphasisadrenaline 1 mg is given after the third on the treatment of the post-cardiacshock once chest compressions have arrest syndrome.restarted and then every 3-5 min-utes (during alternate cycles of CPR).Amiodarone 300 mg is also given after ♦♦ Recognition that implementationthe third shock. of a comprehensive, structured post resuscitation treatment protocol may improve survival in cardiac arrest vic-♦♦ Atropine is no longer recommend- tims after ROSC.ed for routine use in asystole or pulse-less electrical activity (PEA). ♦♦ Increased emphasis on the use of primary percutaneous coronary♦♦ Reduced emphasis on early tra- intervention in appropriate (includ-cheal intubation unless achieved by ing comatose) patients with sustainedhighly skilled individuals with minimal ROSC after cardiac arrest.interruption to chest compressions. ♦♦ Revision of the recommendation♦♦ Increased emphasis on the use of for glucose control: in adults with sus-capnography to confirm and continu- tained ROSC after cardiac arrest, bloodally monitor tracheal tube placement, glucose values >10 mmol l-1 (>180 mgquality of CPR and to provide an early dl-1) should be treated but hypoglycae-indication of return of spontaneous mia must be avoided.circulation (ROSC).
  12. 12. 12 ACS Patient with clinical signs and symptoms of ACS 12 lead ECG ST elevation ≥ 0.1 mV in ≥ 2 adjacent limb leads and/ Other ECG alterations or ≥ 0.2 mV in ≥ adjacent chest leads (or normal ECG) or (presumably) new LBBB = NSTEMI if troponins = UAP if troponins (T or I) positive remain negative STEMI non-STEMI-ACS High risk • dynamic ECG changes • ST depression • haemodynamic/rhythm instability • diabetes mellitus ECG ECG Pain relief Nitroglycerin sl if systolic BP > 90 mmHg ± Morphine (repeated doses) of 3-5 mg until pain free Antiplatelet treatment 160-325mg Acetylsalicylic acid chewed tablet (or iv) 75 – 600 mg Clopidogrel according to strategy* STEMI Non-STEMI-ACS Thrombolysis preferred if PCI preferred if Early invasive strategy# Conservative no contraindications and • timely and available in a high UFH or delayed invasive strategy# inappropriate delay to PCI volume center Enoxaparin or bivalirudin may be UFH (fondaparinux or bivalirudin • contraindications for fibrinolysis cardiogenic shock (or severe left considered may be considered in pts with high Adjunctive therapy: ventricular failure) bleeding risk) UFH, enoxaparin or fondaparinux Adjunctive therapy: UFH, enoxaparin or bivalirudin may be considered # According to risk stratification
  13. 13. 13 ♦♦ Use of therapeutic hypothermia to ♦♦ The role of chest pain observation include comatose survivors of cardiac units (CPUs) is to identify, by using arrest associated initially with non- repeated clinical examinations, ECG shockable rhythms as well shockable and biomarker testing, those patients rhythms. The lower level of evidence who require admission for invasive for use after cardiac arrest from non- procedures. This may include provoca- shockable rhythms is acknowledged. tive testing and, in selected patients, imaging procedures such as cardiac computed tomography, magnetic res- ♦♦ Recognition that many of the onance imaging etc. accepted predictors of poor outcome in comatose survivors of cardiac arrest are unreliable, especially if the patient ♦♦ Non-steroidal anti-inflammatory has been treated with therapeutic drugs (NSAIDs) should be avoided. hypothermia. ♦♦ Nitrates should not be used forInitial management of diagnostic purposes.acute coronary syndromesChanges in the management of acute ♦♦ Supplementary oxygen is to be giv-coronary syndrome since the 2005 en only to those patients with hypox-guidelines include: aemia, breathlessness or pulmonary congestion. Hyperoxaemia may be ♦♦ The term non-ST-elevation myo- harmful in uncomplicated infarction. cardial infarction-acute coronary syn- drome (non-STEMI-ACS) has been introduced for both NSTEMI and ♦♦ Guidelines for treatment with unstable angina pectoris because the acetyl salicylic acid (ASA) have been differential diagnosis is dependent on made more liberal: ASA may now be biomarkers that may be detectable given by bystanders with or without only after several hours, whereas deci- EMS dispatcher assistance. sions on treatment are dependent on the clinical signs at presentation. ♦♦ Revised guidance for new anti- platelet and anti-thrombin treatment ♦♦ History, clinical examinations, for patients with STEMI and non-STE- biomarkers, ECG criteria and risk scores MI-ACS based on therapeutic strategy. are unreliable for the identification of patients who may be safely discharged early.
  14. 14. 14 ♦♦ Gp IIb/IIIa inhibitors before angiog- - Angiography and, if necessary, PCI raphy/percutaneous coronary inter- may be reasonable in patients with vention (PCI) are discouraged. return of spontaneous circulation (ROSC) after cardiac arrest and may be part of a standardised post-cardi- ♦♦ The reperfusion strategy in ac arrest protocol. ST-elevation myocardial infarction has been updated: - To achieve these goals, the creation of networks including EMS, non PCI - Primary PCI (PPCI) is the preferred capable hospitals and PCI hospitals reperfusion strategy provided it is is useful. performed in a timely manner by an experienced team. ♦♦ Recommendations for the use - A nearby hospital may be bypassed of beta-blockers are more restrict- by emergency medical services ed: there is no evidence for routine (EMS) provided PPCI can be achieved intravenous beta-blockers except in without too much delay. specific circumstances such as for the treatment of tachyarrhythmias. - The acceptable delay between start Otherwise, beta-blockers should be of fibrinolysis and first balloon infla- started in low doses only after the tion varies widely between about 45 patient is stabilised. and 180 minutes depending on inf- arct localisation, age of the patient, and duration of symptoms. ♦♦ Guidelines on the use of prophy- lactic anti-arrhythmics angiotensin, - ‘Rescue PCI’ should be undertaken converting enzyme (ACE) inhibitors/ if fibrinolysis fails. angiotensin receptor blockers (ARBs) and statins are unchanged. - The strategy of routine PCI imme- diately after fibrinolysis (‘facilitated PCI’) is discouraged. Paediatric life support - Patients with successful fibrinolysis but not in a PCI-capable hospital Major changes in these new guidelines should be transferred for angiog- for paediatric life support include: raphy and eventual PCI, performed optimally 6 – 24 hours after fibri- ♦♦ Recognition of cardiac arrest - nolysis (the ‘pharmaco-invasive’ Healthcare providers cannot reliably approach). determine the presence or absence of a pulse in less than 10 seconds in
  15. 15. 15infants or children. Healthcare provid- minimise no-flow time. Compressers should look for signs of life and if the chest to at least 1/3 of the ante-they are confident in the technique, rior-posterior chest diameter in allthey may add pulse palpation for children (i.e., approximately 4 cm indiagnosing cardiac arrest and decide infants and approximately 5 cm in chil-whether they should begin chest com- dren). Subsequent complete release ispressions or not. The decision to begin emphasised. For both infants and chil-CPR must be taken in less than 10 dren, the compression rate should beseconds. According to the child’s age, at least 100 but not greater than 120carotid (children), brachial (infants) or min-1. The compression technique forfemoral pulse (children and infants) infants includes two-finger compres-checks may be used. sion for single rescuers and the two- thumb encircling technique for two or more rescuers. For older children,♦♦ The compression ventilation (CV) a one- or two-hand technique can beratio used for children should be based used, according to rescuer preference.on whether one, or more than onerescuer is present. Lay rescuers, whousually learn only single-rescuer tech- ♦♦ Automated external defibrillatorsniques, should be taught to use a ratio (AEDs) are safe and successful whenof 30 compressions to 2 ventilations, used in children older than one yearwhich is the same as the adult guide- of age. Purpose-made paediatric padslines and enables anyone trained in or software attenuate the output ofBLS to resuscitate children with mini- the machine to 50–75 J and these aremal additional information. Rescuers recommended for children aged 1-8with a duty to respond should learn years. If an attenuated shock or a man-and use a 15:2 CV ratio; however, they ually adjustable machine is not avail-can use the 30:2 ratio if they are alone, able, an unmodified adult AED mayparticularly if they are not achieving be used in children older than 1 year.an adequate number of compressions. There are case reports of successfulVentilation remains a very important use of AEDs in children aged less thancomponent of CPR in asphyxial arrests. 1 year; in the rare case of a shockableRescuers who are unable or unwilling rhythm occurring in a child less thanto provide mouth-to-mouth ventila- 1 year, it is reasonable to use an AEDtion should be encouraged to perform (preferably with dose attenuator).at least compression-only CPR. ♦♦ To reduce the no flow time, when♦♦ The emphasis is on achieving using a manual defibrillator, chestquality compressions of an adequate compressions are continued whiledepth with minimal interruptions to applying and charging the paddles or
  16. 16. 16 Paediatric Basic Life Support Health professionals with a duty to respond UNRESPONSIVE? Shout for help Open airway NOT BREATHING NORMALLY? 5 rescue breaths NO SIGNS OF LIFE? 15 chest compressions 2 rescue breaths 15 compressions Call cardiac arrest team or Paediatric ALS team
  17. 17. 17 Paediatric Advanced Life Support Unresponsive? Not breathing or only occasional gasps CPR (5 initial breaths then 15:2) Call Resuscitation Attach defibrillator/monitor Team Minimise interruptions (1 min CPR first, if alone) Assess rhythm Shockable Non-shockable (VF/Pulseless VT) (PEA/Asystole) Return of 1 Shock 4 J/Kg spontaneous circulation Immediately resume: Immediate post cardiac Immediately resume: CPR for 2 min arrest treatment CPR for 2 min Minimise interruptions • Use ABCDE approach Minimise interruptions • Controlled oxygenation and ventilation • Investigations • Treat precipitating cause • Temperature control • Therapeutic hypothermia? During CPR Reversible causes • Hypoxia• Ensure high-quality CPR: rate, depth, recoil• Plan actions before interrupting CPR • Hypovolaemia• Give oxygen • Hypo-/hyperkalaemia/metabolic• Vascular access (intravenous, intraosseous) • Hypothermia• Give adrenaline every 3-5 min• Consider advanced airway and capnography • Tension pneumothorax• Continuous chevvst compressions when advanced airway • Toxins in place • Tamponade - cardiac• Correct reversible causes • Thromboembolism
  18. 18. 18 Newborn Life Support At all stages ask: Do you need HELP? Dry the baby Birth Remove any wet towels and cover Start the clock or note the time Assess (tone), 30 sec breathing and heart rate If gasping or not breathing Open the airway Give 5 inflation breaths Consider SpO2 monitoring 60 sec Re-assess If no increase in heart rate Look for chest movement Acceptable* If chest not moving pre-ductal SpO2 Recheck head position Consider two-person airway control 2 min : 60% or other airway manoeuvres 3 min : 70% Repeat inflation breaths 4 min : 80% Consider SpO2 monitoring 5 min : 85% Look for a response 10 min : 90% If no increase in heart rate Look for chest movement When the chest is moving If the heart rate is not detectable or slow (< 60) Start chest compressions 3 compressions to each breath Reassess heart rate every 30 seconds If the heart rate is not detectable or slow (< 60) Consider venous access and drugs
  19. 19. 19self-adhesive pads (if the size of the ♦♦ Implementation of a rapidchild’s chest allows this). Chest com- response system in a paediatric in-pressions are paused briefly once the patient setting may reduce rates ofdefibrillator is charged to deliver the cardiac and respiratory arrest and in-shock. For simplicity and consistency hospital mortality.with adult BLS and ALS guidance, asingle-shock strategy using a non-escalating dose of 4 J kg-1 (preferably ♦♦ New topics in the 2010 guidelinesbiphasic, but monophasic is accepta- include channelopathies and severalble) is recommended for defibrillation new special circumstances: trauma,in children. single ventricle pre and post 1st stage repair, post Fontan circulation, and pulmonary hypertension.♦♦ Cuffed tracheal tubes can be usedsafely in infants and young children.The size should be selected by apply- Resuscitation of babies ating a validated formula. birth The following are the main changes that♦♦ The safety and value of using cricoid have been made to the guidelines for re-pressure during tracheal intubation is suscitation at birth in 2010:not clear. Therefore, the application ofcricoid pressure should be modified or ♦♦ For uncompromised babies, adiscontinued if it impedes ventilation delay in cord clamping of at least oneor the speed or ease of intubation. minute from the complete delivery of the infant, is now recommended. As yet there is insufficient evidence to♦♦ Monitoring exhaled carbon diox- recommend an appropriate time foride (CO2), ideally by capnography, is clamping the cord in babies who arehelpful to confirm correct tracheal severely compromised at birth.tube position and recommended dur-ing CPR to help assess and optimise itsquality. ♦♦ For term infants, air should be used for resuscitation at birth. If, despite effective ventilation, oxygenation (ide-♦♦ Once spontaneous circulation is ally guided by oximetry) remains unac-restored, inspired oxygen should be ceptable, use of a higher concentrationtitrated to limit the risk of hyperoxa- of oxygen should be considered.emia.
  20. 20. 20 ♦♦ Preterm babies less than 32 weeks start mask ventilation, particularly if gestation may not reach the same there is persistent bradycardia. transcutaneous oxygen saturations in air as those achieved by term babies. Therefore blended oxygen and air ♦♦ If adrenaline is given then the should be given judiciously and its use intravenous route is recommended guided by pulse oximetry. If a blend using a dose of 10-30 microgram kg-1. of oxygen and air is not available use If the tracheal route is used, it is likely what is available. that a dose of at least 50-100 micro- gram kg-1 will be needed to achieve a similar effect to 10 microgram kg-1 ♦♦ Preterm babies of less than 28 intravenously. weeks gestation should be completely covered in a food-grade plastic wrap or bag up to their necks, without drying, ♦♦ Detection of exhaled carbon diox- immediately after birth. They should ide in addition to clinical assessment then be nursed under a radiant heater is recommended as the most reliable and stabilised. They should remain method to confirm placement of a tra- wrapped until their temperature has cheal tube in neonates with spontane- been checked after admission. For ous circulation. these infants delivery room tempera- tures should be at least 26°C. ♦♦ Newly born infants born at term or near-term with evolving moderate to ♦♦ The recommended compression: severe hypoxic – ischaemic encepha- ventilation ratio for CPR remains at 3:1 lopathy should, where possible, be for newborn resuscitation. treated with therapeutic hypother- mia. This does not affect immediate resuscitation but is important for post- ♦♦ Attempts to aspirate meconium resuscitation care. from the nose and mouth of the unborn baby, while the head is still on the perineum, are not recommended. If presented with a floppy, apnoeic baby born through meconium it is rea- sonable to rapidly inspect the orophar- ynx to remove potential obstructions. If appropriate expertise is available, tracheal intubation and suction may be useful. However, if attempted intu- bation is prolonged or unsuccessful,
  21. 21. 21Principles of education in ♦♦ Basic and advanced life supportresuscitation knowledge and skills deteriorate in as little as three to six months. The useThe key issues identified by the Educa- of frequent assessments will identifytion, Implementation and Teams (EIT) those individuals who require refresh-task force of the International LiaisonCommittee on Resuscitation (ILCOR) er training to help maintain theirduring the Guidelines 2010 evidence knowledge and skills.evaluation process are: ♦♦ CPR prompt or feedback devices ♦♦ Educational interventions should improve CPR skill acquisition and be evaluated to ensure that they retention and should be considered reliably achieve the learning objec- during CPR training for laypeople and tives. The aim is to ensure that learn- healthcare professionals. ers acquire and retain the skills and knowledge that will enable them to act correctly in actual cardiac arrests ♦♦ An increased emphasis on non- and improve patient outcomes. technical skills (NTS) such as leader- ship, teamwork, task management and structured communication will ♦♦ Short video/computer self-instruc- help improve the performance of CPR tion courses, with minimal or no and patient care. instructor coaching, combined with hands-on practice can be considered as an effective alternative to instruc- ♦♦ Team briefings to plan for resusci- tor-led basic life support (CPR and tation attempts, and debriefings based AED) courses. on performance during simulated or actual resuscitation attempts should be used to help improve resuscitation ♦♦ Ideally all citizens should be trained team and individual performance. in standard CPR that includes com- pressions and ventilations. There are circumstances however where train- ♦♦ Research about the impact of ing in compression-only CPR is appro- resuscitation training on actual patient priate (e.g., opportunistic training outcomes is limited. Although manikin with very limited time). Those trained studies are useful, researchers should in compression-only CPR should be be encouraged to study and report the encouraged to learn standard CPR. impact of educational interventions on actual patient outcomes.
  22. 22. 22 Edited by Jerry Nolan Authors Jerry P. Nolan Charles Deakin Jasmeet Soar Rudolph W. Koster David A. Zideman Jonathan Wyllie Dominique Biarent Bernd Böttiger Leo L. Bossaert on behalf of the ERC Guidelines Writing Group Acknowledgements: The ERC staff members Annelies Pické, Christophe Bostyn, Jeroen Janssens, Hilary Phelan and Bart Vissers for their administrative support. Het Geel Punt bvba, Melkouwen 42a, 2590 Berlaar, Belgium (hgp@hetgeelpunt.be) for creating the algorithms and Griet Demesmaeker (grietdemesmaeker@gmail.com) for the cover design.
  23. 23. 23Become a member of the ERCYou can choose between * Full membership on paper and electronic * Full membership electronic version onlyFull members on paper and electronic (€ 140 for 12 months) enjoy: - a subscription to Resuscitation, the official Journal of the ERC - online access to Resuscitation (including all previous issues) - reduction in the ERC-shop - special registration rates at ERC congressesFull members electronic version only (€ 115 for 12 months) enjoy: - online access to Resuscitation (including all previous issues) - reduction in the ERC-shop - special registration rates at ERC congressesThese benefits add to all the benefits you experienced as a web member: - participate in ERC forums - download items from libraries - stay updated with our ERC News LetterIMPORTANTERC currently offers combined membership possibilities with a number oforganisations, with an additional discount: Belgian Resuscitation Council,Norwegian Resuscitation Council, Resuscitation Council UK.If you are already a member of one of these organisations, please contacttheir secretariat for additional information about combined membershippossibilities.
  24. 24. www.erc.eduwww.CPRguidelines.eu

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