Management of acute myocardial infarction in patients presenting with ST-segment elevation.. ACC/AHA guide-lines for the management of patients with ST-elevation myocardial infarction—
Trang 1European Resuscitation Council Guidelines for Resuscitation 2005 S93 biomarkers and/or new ECG changes consistent
with ischaemia when a medical approach or PCI is
planned Give clopidogrel to patients with STEMI
up to 75 years of age receiving fibrinolytic therapy,
ASA and heparin Clopidogrel, 300 mg, can be given
instead of ASA to patients with a suspected ACS who
have a true allergy to or gastrointestinal
intoler-ance of ASA
Primary and secondary prevention
interventions
Start preventive interventions, at the latest, at the
initial admission with a confirmed diagnosis of ACS
Give a beta-blocker as soon as possible unless
con-traindicated or poorly tolerated Treat all patients
with a statin (HRG co-enzyme A reductase inhibitor)
unless contraindicated or poorly tolerated Start an
ACE inhibitor in all patients with STEMI, all patients
with STEMI and left ventricular systolic
impair-ment, and consider it in all other patients with
STEMI unless contraindicated or poorly tolerated
In patients unable to tolerate an ACE inhibitor, an
angiotensin receptor blocker may be used as a
sub-stitute in those patients with left ventricular
sys-tolic impairment
Beta-blockers
Several studies, undertaken mainly in the
pre-reperfusion era, indicate decreased mortality and
incidence of reinfarction and cardiac rupture as
well as a lower incidence of VF and
supraventric-ular arrhythmia in patients treated early with a
beta-blocker.56,57 Intravenous beta-blockade may
also reduce mortality in patients undergoing
pri-mary PCI who are not on oral beta-blockers.58
Haemodynamically stable patients presenting
with an ACS should be given intravenous
beta-blockers promptly, followed by regular oral therapy
unless contraindicated or poorly tolerated
Con-traindications to beta-blockers include
hypoten-sion, bradycardia, second- or third-degree AV block,
moderate to severe congestive heart failure and
severe reactive airway disease Give a beta-blocker
irrespective of the need for early revascularisation
therapy
Anti-arrhythmics
Apart from the use of a beta-blocker as
recom-mended above, there is no evidence to support
the use of anti-arrhythmic prophylaxis after ACS
VF accounts for most of the early deaths from
ACS; the incidence of VF is highest in the first
hours after onset of symptoms.59,60 This explains why numerous studies have been performed with the aim of demonstrating the prophylactic effect
of arrhythmic therapy The effects of anti-arrhythmic drugs (lidocaine, magnesium, disopy-ramide, mexiletine, verapamil) given prophylacti-cally to patients with ACS have been studied.61—63 Prophylaxis with lidocaine reduces the incidence
of VF but may increase mortality.58Routine treat-ment with magnesium in patients with AMI does not improve mortality.64 Arrhythmia prophylaxis using disopyramide, mexiletine or verapamil, given within the first hours of an ACS, does not improve mortality.63 In contrast, intravenous beta-blockers reduced the incidence of VF when given to patients with ACS.56,57
Angiotensin-converting enzyme inhibitors and angiotensin-II receptor blockers
Oral angiotensin-converting inhibitors (ACE) inhibi-tors reduce mortality when given to patients with acute myocardial infarction with or without early reperfusion therapy.65,66The beneficial effects are most pronounced in patients presenting with ante-rior infarction, pulmonary congestion or left ven-tricular ejection fraction <40%.66 Do not give ACE inhibitors if the systolic blood pressure is less than
100 mmHg at admission or if there is a known con-traindication to these drugs.66 A trend towards higher mortality has been documented if an intra-venous ACE inhibitor is started within the first 24 h after onset of symptoms.67Therefore, give an oral ACE inhibitor within 24 h after symptom onset in patients with AMI regardless of whether early reper-fusion therapy is planned, particularly in those patients with anterior infarction, pulmonary con-gestion or left ventricular ejection fraction below 40% Do not give intravenous ACE inhibitors within
24 h of onset of symptoms Give an angiotensin receptor blocker (ARB) to patients intolerant of ACE inhibitors
Statins
Statins reduce the incidence of major adverse car-diovascular events when given within a few days after onset of ACS Start statin therapy within 24 h
of onset of symptoms of ACS If patients are already receiving statin therapy, do not stop it.68
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18 Gurfinkel EP, Manos EJ, Mejail RI, et al Low molecular weight heparin versus regular heparin or aspirin in the treatment
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19 Freimark D, Matetzky S, Leor J, et al Timing of aspirin administration as a determinant of survival of patients with acute myocardial infarction treated with thrombolysis Am
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20 Husted SE, Kristensen SD, Vissinger H, Morn B, Schmidt EB, Nielsen HK Intravenous acetylsalicylic acid—–dose-related effects on platelet function and fibrinolysis in healthy males Thromb Haemost 1992;68:226—9.
21 Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mor-tality and major morbidity results from all randomised trials
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22 Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction Gruppo Italiano per lo Studio della Streptochinasi nell’Infarto Miocardico (GISSI) Lancet 1986;1:397—402.
23 The GUSTO investigators An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction N Engl J Med 1993;329:673—82.
24 Boersma E, Maas AC, Deckers JW, Simoons ML Early throm-bolytic treatment in acute myocardial infarction: reappraisal
of the golden hour Lancet 1996;348:771—5.
25 De Luca G, van’t Hof AW, de Boer MJ, et al Time-to-treatment significantly affects the extent of ST-segment res-olution and myocardial blush in patients with acute myocar-dial infarction treated by primary angioplasty Eur Heart J 2004;25:1009—13.
26 Morrison LJ, Verbeek PR, McDonald AC, Sawadsky BV, Cook
DJ Mortality and prehospital thrombolysis for acute myocar-dial infarction: a meta-analysis JAMA 2000;283:2686—92.
27 Welsh RC, Goldstein P, Adgey J, et al Variations in pre-hospital fibrinolysis process of care: insights from the Assess-ment of the Safety and Efficacy of a New Thrombolytic 3 Plus international acute myocardial infarction pre-hospital care survey Eur J Emerg Med 2004;11:134—40.
28 Weaver W, Cerqueira M, Hallstrom A, et al Prehospital-initiated vs hospital-Prehospital-initiated thrombolytic therapy: the Myocardial Infacrtion Triage and Intervention Trial (MITI) JAMA 1993;270:1203—10.
29 European Myocardial Infarction Project Group (EMIP) Pre-hospital thrombolytic therapy in patients with suspected acute myocardial infarction The European Myocardial Infarction Project Group N Engl J Med 1993;329:383—9.
30 White HD Debate: should the elderly receive thrombolytic therapy, or primary angioplasty? Current Control Trials Car-diovasc Med 2000;1:150—4.
31 Weaver WD, Simes RJ, Betriu A, et al Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review JAMA 1997;278:2093—8.
32 Keeley EC, Boura JA, Grines CL Primary angioplasty ver-sus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials Lancet 2003;361:13—20.
33 Widimsky P, Budesinsky T, Vorac D, et al Long distance transport for primary angioplasty vs immediate thrombol-ysis in acute myocardial infarction Final results of the
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domized national multicentre trial—PRAGUE-2 Eur Heart J
2003;24:94—104.
34 Steg PG, Bonnefoy E, Chabaud S, et al Impact of time to
treatment on mortality after prehospital fibrinolysis or
pri-mary angioplasty: data from the CAPTIM randomized clinical
trial Circulation 2003;108:2851—6.
35 Dalby M, Bouzamondo A, Lechat P, Montalescot G
Trans-fer for primary angioplasty versus immediate thrombolysis
in acute myocardial infarction: a meta-analysis Circulation
2003;108:1809—14.
36 Scheller B, Hennen B, Hammer B, et al Beneficial effects of
immediate stenting after thrombolysis in acute myocardial
infarction J Am Coll Cardiol 2003;42:634—41.
37 Fernandez-Aviles F, Alonso JJ, Castro-Beiras A, et al
Rou-tine invasive strategy within 24 h of thrombolysis versus
ischaemia-guided conservative approach for acute
myocar-dial infarction with ST-segment elevation (GRACIA-1): a
ran-domised controlled trial Lancet 2004;364:1045—53.
38 Hochman JS, Sleeper LA, Webb JG, et al Early
revascular-ization in acute myocardial infarction complicated by
car-diogenic shock SHOCK Investigators Should we emergently
revascularize occluded coronaries for cardiogenic shock N
Engl J Med 1999;341:625—34.
39 Hochman JS, Sleeper LA, White HD, et al One-year
sur-vival following early revascularization for cardiogenic shock.
JAMA 2001;285:190—2.
40 Antman EM, McCabe CH, Gurfinkel EP, et al Enoxaparin
prevents death and cardiac ischemic events in unstable
angina/non-Q-wave myocardial infarction Results of the
thrombolysis in myocardial infarction (TIMI) 11B trial
Cir-culation 1999;100:1593—601.
41 Cohen M, Demers C, Gurfinkel EP, et al A comparison of
low-molecular-weight heparin with unfractionated heparin for
unstable coronary artery disease Efficacy and Safety of
Sub-cutaneous Enoxaparin in Non-Q-Wave Coronary Events Study
Group N Engl J Med 1997;337:447—52.
42 Petersen JL, Mahaffey KW, Hasselblad V, et al Efficacy
and bleeding complications among patients randomized to
enoxaparin or unfractionated heparin for antithrombin
ther-apy in non-ST-Segment elevation acute coronary syndromes:
a systematic overview JAMA 2004;292:89—96.
43 Ferguson JJ, Califf RM, Antman EM, et al Enoxaparin vs
unfractionated heparin in high-risk patients with
non-ST-segment elevation acute coronary syndromes managed with
an intended early invasive strategy: primary results of the
SYNERGY randomized trial JAMA 2004;292:45—54.
44 Van de Werf FJ, Armstrong PW, Granger C, Wallentin L
Effi-cacy and safety of tenecteplase in combination with
enoxa-parin, abciximab, or unfractionated heparin: the
ASSENT-3 randomised trial in acute myocardial infarction Lancet
2001;358:605—13.
45 Wallentin L, Goldstein P, Armstrong PW, et al Efficacy
and safety of tenecteplase in combination with the
low-molecular-weight heparin enoxaparin or unfractionated
hep-arin in the prehospital setting: the Assessment of the Safety
and Efficacy of a New Thrombolytic Regimen (ASSENT)-3
PLUS randomized trial in acute myocardial infarction
Cir-culation 2003;108:135—42.
46 Boersma E, Harrington RA, Moliterno DJ, et al Platelet
gly-coprotein IIb/IIIa inhibitors in acute coronary syndromes:
a meta-analysis of all major randomised clinical trials.
Lancet 2002;359:189—98 [erratum appears in Lancet 2002
Jun 15;359(9323):2120].
47 Simoons ML Effect of glycoprotein IIb/IIIa receptor blocker
abciximab on outcome in patients with acute coronary
syn-dromes without early coronary revascularisation: the GUSTO
IV-ACS randomised trial Lancet 2001;357:1915—24.
48 Topol EJ Reperfusion therapy for acute myocardial infarc-tion with fibrinolytic therapy or combinainfarc-tion reduced fibri-nolytic therapy and platelet glycoprotein IIb/IIIa inhibition: the GUSTO V randomised trial Lancet 2001;357:1905—14.
49 Montalescot G, Borentain M, Payot L, Collet JP, Thomas D Early vs late administration of glycoprotein IIb/IIIa inhibitors
in primary percutaneous coronary intervention of acute ST-segment elevation myocardial infarction: a meta-analysis JAMA 2004;292:362—6.
50 van’t Hof AW, Ernst N, de Boer MJ, et al Facilitation of primary coronary angioplasty by early start of a glycopro-tein 2b/3a inhibitor: results of the ongoing tirofiban in myocardial infarction evaluation (On-TIME) trial Eur Heart
J 2004;25:837—46.
51 A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE) CAPRIE Steer-ing Committee Lancet 1996;348:1329—39.
52 Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation N Engl J Med 2001;345:494—502.
53 Mehta SR, Yusuf S, Peters RJ, et al Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy
in patients undergoing percutaneous coronary intervention: the PCI-CURE study Lancet 2001;358:527—33.
54 Steinhubl SR, Berger PB, Mann IIIrd JT, et al Early and sus-tained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial JAMA 2002;288:2411—20.
55 Sabatine MS, Cannon CP, Gibson CM, et al Addition of clopidogrel to aspirin and fibrinolytic therapy for myocar-dial infarction with ST-segment elevation N Engl J Med 2005;352:1179—89.
56 The MIAMI Trial Research Group Metoprolol in acute myocar-dial infarction (MIAMI): a randomised placebo-controlled international trial Eur Heart J 1985;6:199—226.
57 Randomised trial of intravenous atenolol among 16 027 cases of suspected acute myocardial infarction: ISIS-1 First International Study of Infarct Survival Collaborative Group Lancet 1986;2:57—66.
58 Halkin A, Grines CL, Cox DA, et al Impact of intra-venous beta-blockade before primary angioplasty on sur-vival in patients undergoing mechanical reperfusion ther-apy for acute myocardial infarction J Am Coll Cardiol 2004;43:1780—7.
59 Campbell RW, Murray A, Julian DG Ventricular arrhythmias
in first 12 h of acute myocardial infarction: natural history study Br Heart J 1981;46:351—7.
60 O’Doherty M, Tayler DI, Quinn E, Vincent R, Chamberlain DA Five hundred patients with myocardial infarction monitored within one hour of symptoms BMJ 1983;286:1405—8.
61 Teo KK, Yusuf S, Furberg CD Effects of prophylactic antiar-rhythmic drug therapy in acute myocardial infarction An overview of results from randomized controlled trials JAMA 1993;270:1589—95.
62 Sadowski ZP, Alexander JH, Skrabucha B, et al Multicen-ter randomized trial and a systematic overview of lidocaine
in acute myocardial infarction Am Heart J 1999;137:792— 8.
63 McAlister FA, Teo KK Antiarrhythmic therapies for the prevention of sudden cardiac death Drugs 1997;54:235— 52.
64 ISIS-4: a randomised factorial trial assessing early oral capto-pril, oral mononitrate, and intravenous magnesium sulphate
in 58,050 patients with suspected acute myocardial infarc-tion ISIS-4 (Fourth International Study of Infarct Survival) Collaborative Group Lancet 1995;345:669—85.
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65 Teo KK, Yusuf S, Pfeffer M, et al Effects of long-term
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66 ACE Inhibitor MI Collaborative Group Indications for
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67 Swedberg K, Held P, Kjekshus J, Rasmussen K, Ryden L, Wedel H Effects of the early administration of enalapril
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Trang 5Resuscitation (2005)67S1, S97—S133
European Resuscitation Council Guidelines for
Resuscitation 2005
Section 6 Paediatric life support
Dominique Biarent, Robert Bingham, Sam Richmond, Ian Maconochie, Jonathan Wyllie, Sheila Simpson, Antonio Rodriguez Nunez,
David Zideman
Introduction
The process
The European Resuscitation Council (ERC) issued
guidelines for paediatric life support (PLS) in 1994,
1998 and 2000.1—4 The last edition was based on
the International Consensus on Science published
by the American Heart Association in collaboration
with the International Liaison Committee on
Resus-citation (ILCOR), undertaking a series of
evidence-based evaluations of the science of resuscitation
which culminated in the publication of the
Guide-lines 2000 for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care in August 2000.5,6
This process was repeated in 2004/2005, and the
resulting Consensus on Science and Treatment
Rec-ommendations were published simultaneously in
Resuscitation, Circulation and Pediatrics in
Novem-ber 2005.7,8 The PLS Working Party of the ERC has
considered this document and the supporting
sci-entific literature, and has recommended changes
to the ERC PLS Guidelines These are presented in
this paper
Guidelines changes
The approach to changes has been to alter the guidelines in response to convincing new scientific evidence and, where possible, to simplify them in order to assist teaching and retention As before, there remains a paucity of good-quality evidence on paediatric resuscitation specifically and some con-clusions have had to be drawn from animal work and extrapolated adult data
The current guidelines have a strong focus on simplification based on the knowledge that many children receive no resuscitation at all because res-cuers fear doing harm This fear is fuelled by the knowledge that resuscitation guidelines for chil-dren are different Consequently, a major area of study was the feasibility of applying the same guid-ance for all adults and children Bystander resusci-tation improves outcome significantly,9,10and there
is good evidence from paediatric animal models that even doing chest compressions or expired air ventilation alone may be better than doing noth-ing at all.11 It follows that outcomes could be improved if bystanders, who would otherwise do nothing, were encouraged to begin resuscitation, even if they do not follow an algorithm targeted specifically at children There are, however,
dis-0300-9572/$ — see front matter © 2005 European Resuscitation Council All Rights Reserved Published by Elsevier Ireland Ltd doi:10.1016/j.resuscitation.2005.10.010
Trang 6S98 D Biarent et al tinct differences between the predominantly adult
arrest of cardiac origin and asphyxial arrest, which
is most common in children,12so a separate
paedi-atric algorithm is justified for those with a duty to
respond to paediatric emergencies (usually
health-care professionals), who are also in a position to
receive enhanced training
Compression:ventilation ratios
The ILCOR treatment recommendation was that
the compression:ventilation ratio should be based
on whether one or more than one rescuers were
present ILCOR recommends that lay rescuers,
who usually learn only single rescuer techniques,
should be taught to use a ratio of 30
compres-sions to 2 ventilations, which is the same as the
adult guidelines and enables anyone trained in
BLS techniques to resuscitate children with
mini-mal additional information Two or more rescuers
with a duty to respond should learn a different
ratio (15:2), as this has been validated by animal
and manikin studies.13—17 This latter group, who
would normally be healthcare professionals, should
receive enhanced training targeted specifically at
the resuscitation of children Although there are
no data to support the superiority of any
partic-ular ratio in children, ratios of between 5:1 and
15:2 have been studied in manikins, and animal
and mathematical models, and there is increasing
evidence that the 5:1 ratio delivers an inadequate
number of compressions.14,18There is certainly no
justification for having two separate ratios for
chil-dren aged greater or less than 8 years, so a single
ratio of 15:2 for multiple rescuers with a duty to
respond is a logical simplification
It would certainly negate any benefit of
simplic-ity if lay rescuers were taught a different ratio for
use if there were two of them, but those with a duty
to respond can use the 30:2 ratio if they are alone,
particularly if they are not achieving an adequate
number of compressions because of difficulty in the
transition between ventilation and compression
Age definitions
The adoption of single compression:ventilation
ratios for children of all ages, together with the
change in advice on the lower age limit for the
use of automated external defibrillators (AEDs),
renders the previous guideline division between
children above and below 8 years of age
unneces-sary The differences between adult and paediatric
resuscitation are based largely on differing
aeti-ology, as primary cardiac arrest is more common
in adults whereas children usually suffer from
sec-ondary cardiac arrest The onset of puberty, which
is the physiological end of childhood, is the most logical landmark for the upper age limit for use
of paediatric guidance This has the advantage of being simple to determine, in contrast to an age limit in years, as age may be unknown at the start of resuscitation Clearly, it is inappropriate and unnec-essary to establish the onset of puberty formally; if rescuers believe the victim to be a child they should use the paediatric guidelines If a misjudgement is made and the victim turns out to be a young adult, little harm will accrue, as studies of aetiology have shown that the paediatric pattern of arrest contin-ues into early adulthood.19An infant is a child under
1 year of age; a child is between 1 year and puberty
It is necessary to differentiate between infants and older children, as there are some important differ-ences between these two groups
Chest compression technique
The modification to age definitions enables a sim-plification of the advice on chest compression Advice for determining the landmarks for infant compression is now the same as for older chil-dren, as there is evidence that the previous rec-ommendation could result in compression over the upper abdomen.20 Infant compression technique remains the same: two-finger compression for sin-gle rescuers and two-thumb, encircling technique for two or more rescuers,21—25but for older children there is no division between the one- or two-hand technique.26 The emphasis is on achieving an ade-quate depth of compression with minimal interrup-tions, using one or two hands according to rescuer preference
Automated external defibrillators
Case reports published since International Guide-lines 2000 have reported safe and successful use of AEDs in children less than 8 years of age.27,28 Fur-thermore, recent studies have shown that AEDs are capable of identifying arrhythmias in children accu-rately and that, in particular, they are extremely unlikely to advise a shock inappropriately.29,30 Con-sequently, advice on the use of AEDs has been revised to include all children aged greater than 1 year.31Nevertheless, if there is any possibility that
an AED may need to be used in children, the pur-chaser should check that the performance of the particular model has been tested against paediatric arrhythmias
Many manufacturers now supply purpose-made paediatric pads or programmes, which typically attenuate the output of the machine to 50—75 J.32
Trang 7European Resuscitation Council Guidelines for Resuscitation 2005 S99 These devices are recommended for children aged
1—8 years.33,34 If no such system or manually
adjustable machine is available, an unmodified
adult AED may be used in children older than 1
year.35 There is currently insufficient evidence to
support a recommendation for or against the use of
AEDs in children aged less than 1 year
Manual defibrillators
The 2005 Consensus Conference treatment
rec-ommendation for paediatric ventricular fibrillation
(VF) or paediatric pulseless ventricular
tachycar-dia (VT) is to defibrillate promptly In adult ALS,
the recommendation is to give a single shock and
then resume CPR immediately without checking for
a pulse or reassessing the rhythm (see Section 3) As
a consequence of this single-shock strategy, when
using a monophasic defibrillator in adults a higher
initial energy dose than used previously is
recom-mended (360 J versus 200 J) (see Section 3) The
ideal energy dose for safe and effective
defibril-lation in children is unknown, but animal models
and small paediatric series show that doses larger
than 4 J kg−1defibrillate effectively with negligible
side effects.27,34,36,37 Biphasic shocks are at least
as effective and produce less post-shock myocardial
dysfunction than monophasic shocks.33,34,37—40 For
simplicity of sequence and consistency with adult
BLS and ALS, we recommend a single-shock strategy
using a non-escalating dose of 4 J kg−1(monophasic
or biphasic) for defibrillation in children
Foreign-body airway obstruction sequence
The guidance for managing foreign-body airway
obstruction (FBAO) in children has been
simpli-fied and brought into closer alignment to the adult
sequence These changes are discussed in detail at
the end of this section
In the following text the masculine includes the
feminine and ‘child’ refers to both infants and
chil-dren unless noted otherwise
6a Paediatric basic life support
Sequence of action
Rescuers who have been taught adult BLS and have
no specific knowledge of paediatric resuscitation
may use the adult sequence, with the exception
that they should perform 5 initial breaths followed
by approximately 1 min of CPR before they go for
help (Figure 6.1; also see adult BLS guideline)
Figure 6.1 Paediatric basic life support algorithm.
The following sequence is to be observed by those with a duty to respond to paediatric emer-gencies (usually health professionals)
1 Ensure the safety of rescuer and child
2 Check the child’s responsiveness
• Gently stimulate the child and ask loudly:
‘‘Are you all right?’’
• Do not shake infants or children with sus-pected cervical spinal injuries
3a If the child responds by answering or moving
• leave the child in the position in which you find him (provided he is not in further danger)
• check his condition and get help if needed
• reassess him regularly 3b If the child does not respond
• shout for help;
• open the child’s airway by tilting the head and lifting the chin, as follows:
o initially with the child in the position in which you find him, place your hand on his forehead and gently tilt his head back;
o at the same time, with your fingertip(s) under the point of the child’s chin, lift the chin Do not push on the soft tissues under the chin as this may block the airway;
o if you still have difficulty in opening the air-way, try the jaw thrust method Place the first two fingers of each hand behind each side of the child’s mandible and push the jaw forward;
o both methods may be easier if the child is turned carefully onto his back
Trang 8S100 D Biarent et al.
If you suspect that there may have been an injury
to the neck, try to open the airway using chin lift or
jaw thrust alone If this is unsuccessful, add head
tilt a small amount at a time until the airway is
open
4 Keeping the airway open, look, listen and feel
for normal breathing by putting your face close
to the child’s face and looking along the chest
• Look for chest movements
• Listen at the child’s nose and mouth for breath
sounds
• Feel for air movement on your cheek
Look, listen and feel for no more than 10 s before
deciding
5a If the child is breathing normally
• turn the child on his side into the recovery
position (see below)
• check for continued breathing
5b If the child isnot breathing or is making agonal
gasps (infrequent, irregular breaths)
• carefully remove any obvious airway
obstruc-tion;
• give five initial rescue breaths;
• while performing the rescue breaths, note
any gag or cough response to your action
These responses or their absence will form
part of your assessment of signs of a
circu-lation, which will be described later
Rescue breaths for a child over 1 year are
per-formed as follows (Figure 6.2)
• Ensure head tilt and chin lift
Figure 6.2 Mouth-to-mouth ventilation— child © 2005
ERC
• Pinch the soft part of the nose closed with the index finger and thumb of your hand on his fore-head
• Open his mouth a little, but maintain the chin upwards
• Take a breath and place your lips around the mouth, making sure that you have a good seal
• Blow steadily into the mouth over about 1—1.5 s, watching for chest rise
• Maintain head tilt and chin lift, take your mouth away from the victim and watch for his chest to fall as air is expelled
• Take another breath and repeat this sequence five times Identify effectiveness by seeing that the child’s chest has risen and fallen in a similar fashion to the movement produced by a normal breath
Rescue breaths for an infant are performed as follows (Figure 6.3)
• Ensure a neutral position of the head and a chin lift
• Take a breath and cover the mouth and nasal apertures of the infant with your mouth, making sure you have a good seal If the nose and mouth cannot be covered in the older infant, the res-cuer may attempt to seal only the infant’s nose
or mouth with his mouth (if the nose is used, close the lips to prevent air escape)
• Blow steadily into the infant’s mouth and nose over 1—1.5 s, sufficient to make the chest visibly rise
• Maintain head tilt and chin lift, take your mouth away from the victim and watch for his chest to fall as air is expelled
• Take another breath and repeat this sequence five times
Figure 6.3 Mouth-to-mouth and nose ventilation—
infant © 2005 ERC
Trang 9European Resuscitation Council Guidelines for Resuscitation 2005 S101
If you have difficulty achieving an effective breath,
the airway may be obstructed
• Open the child’s mouth and remove any visible
obstruction Do not perform a blind finger sweep
• Ensure that there is adequate head tilt and chin
lift but also that the neck is not over-extended
• If head tilt and chin lift have not opened the
air-way, try the jaw thrust method
• Make up to five attempts to achieve effective
breaths; if still unsuccessful, move on to chest
compressions
6 Assess the child’s circulation Take no more than
10 s to
• look for signs of a circulation This includes
any movement, coughing or normal breathing
(not agonal gasps, which are infrequent,
irreg-ular breaths);
• check the pulse (if you are a health care
provider) but ensure you take no more than
10 s
If the child is aged over 1 year, feel for the
carotid pulse in the neck
In an infant, feel for the brachial pulse on the
inner aspect of the upper arm
7a If you are confident that you can detect signs of
a circulation within 10 s
• continue rescue breathing, if necessary, until
the child starts breathing effectively on his
own
• turn the child onto his side (into the recovery
position) if he remains unconscious
• re-assess the child frequently
7b If there are no signs of a circulation, or no pulse
or a slow pulse (less than 60 min−1 with poor
perfusion), or you are not sure
• start chest compressions
• combine rescue breathing and chest
compres-sions
Chest compressions are performed as follows
For all children, compress the lower third of the
sternum To avoid compressing the upper abdomen,
locate the xiphisternum by finding the angle where
the lowest ribs join in the middle Compress the
sternum one finger’s breadth above this; the
com-pression should be sufficient to depress the
ster-num by approximately one third of the depth of
the chest Release the pressure and repeat at a
rate of about 100 min−1 After 15 compressions,
tilt the head, lift the chin, and give two effective
breaths Continue compressions and breaths in a
ratio of 15:2 Lone rescuers may use a ratio of 30:2,
particularly if having difficulty with the transition
between compression and ventilation Although the
Figure 6.4 Chest compression — infant © 2005 ERC.
rate of compressions will be 100 min−1, the actual
number delivered per minute will be less than 100 because of pauses to give breaths The best method for compression varies slightly between infants and children
To perform chest compression in infants, the lone rescuer compresses the sternum with the tips of two fingers (Figure 6.4) If there are two or more rescuers, use the encircling technique Place both thumbs flat side by side on the lower third of the sternum (as above) with the tips pointing towards the infant’s head Spread the rest of both hands with the fingers together to encircle the lower part
of the infant’s rib cage with the tips of the fin-gers supporting the infant’s back Press down on the lower sternum with the two thumbs to depress it approximately one third of the depth of the infant’s chest
To perform chest compression in children over
1 year of age, place the heel of one hand over the lower third of the sternum (as above) (Figures 6.5 and 6.6) Lift the fingers to ensure that pressure is not applied over the child’s ribs Position yourself vertically above the victim’s chest and, with your arm straight, compress the sternum to depress it by approximately one third of the depth
of the chest In larger children or for small rescuers, this is achieved most easily by using both hands with the fingers interlocked
8 Continue resuscitation until
• the child shows signs of life (spontaneous res-piration, pulse, movement)
• qualified help arrives
• you become exhausted
When to call for assistance
It is vital for rescuers to get help as quickly as pos-sible when a child collapses
Trang 10S102 D Biarent et al.
• When more than one rescuer is available, one
starts resuscitation while another rescuer goes
for assistance
• If only one rescuer is present, undertake
resus-citation for about 1 min before going for
assis-tance To minimise interruption in CPR, it may
be possible to carry an infant or small child while
summoning help
• The only exception to performing 1 min of CPR
before going for help is in the case of a child with
a witnessed, sudden collapse when the rescuer is
alone In this case cardiac arrest is likely to be
arrhythmogenic in origin and the child will need
defibrillation Seek help immediately if there is
no one to go for you
Recovery position
An unconscious child whose airway is clear, and who
is breathing spontaneously, should be turned on his
side into the recovery position There are several
Figure 6.5 Chest compression with one hand — child.
© 2005 ERC
Figure 6.6 Chest compression with two hands — child.
© 2005 ERC
recovery positions; each has its advocates There are important principles to be followed
• Place the child in as near true lateral position
as possible, with his mouth dependent to enable free drainage of fluid
• The position should be stable In an infant this may require the support of a small pillow or
a rolled-up blanket placed behind the back to maintain the position
• Avoid any pressure on the chest that impairs breathing
• It should be possible to turn the child onto his side and to return him back easily and safely, taking into consideration the possibility of cervical spine injury
• Ensure the airway can be observed and accessed easily
• The adult recovery position is suitable for use in children
Foreign-body airway obstruction (FBAO)
No new evidence on this subject was presented dur-ing the 2005 Consensus Conference Back blows, chest thrusts and abdominal thrusts all increase intrathoracic pressure and can expel foreign bod-ies from the airway In half of the episodes, more than one technique is needed to relieve the obstruction.41There are no data to indicate which measure should be used first or in which order they should be applied If one is unsuccessful, try the others in rotation until the object is cleared The International Guidelines 2000 algorithm is difficult to teach and knowledge retention poor The FBAO algorithm for children has been simpli-fied and aligned with the adult version (Figure 6.7) This should improve skill retention and encourage people, who might otherwise have been reluctant,
to perform FBAO manoeuvres on children
Figure 6.7 Paediatric foreign body airway obstruction
algorithm