Part 5: Adult Basic Life Support
2010; Lippincott Williams & Wilkins; Volume: 122; Issue: 16_suppl_2 Linguagem: Inglês
10.1161/circulationaha.110.970996
ISSN1524-4539
AutoresMichael R. Sayre, Rudolph W. Koster, Martin Botha, Diana M. Cave, Michael T. Cudnik, Anthony J. Handley, Tetsuo Hatanaka, Mary Fran Hazinski, Ian Jacobs, Koenraad G. Monsieurs, Peter T. Morley, Jerry P. Nolan, Andrew H. Travers, Tom P. Aufderheide, Jocelyn Berdowski, Robert A. Berg, Maaret Castrén, Manya Charette, Sung Phil Chung, David C. Cone, Daniel P. Davis, Csaba Diószeghy, James V. Dunford, Dana P. Edelson, Peter Fenici, Raúl J. Gazmuri, Laura S. Gold, Anton P.M. Gorgels, Colin A. Graham, Ahamed H. Idris, Jan L. Jensen, Peter Köhl, Peter J. Kudenchuk, Michaël Kuiper, Douglas F. Kupas, E. Brooke Lerner, Bo Løfgren, Raina M. Merchant, Tommaso Pellis, Gavin D. Perkins, Thomas D. Rea, Andrea Scapigliati, Robert A. Swor, Kéiichi Tanaka, Nigel M. Turner, Tyler F. Vadeboncoeur, Christian Vaillancourt, Antonius van Stipdonk, Barbara Vantroyen,
Tópico(s)Trauma Management and Diagnosis
ResumoHomeCirculationVol. 122, No. 16_suppl_2Part 5: Adult Basic Life Support Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBPart 5: Adult Basic Life Support2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Michael R. Sayre, Rudolph W. Koster, Martin Botha, Diana M. Cave, Michael T. Cudnik, Anthony J. Handley, Tetsuo Hatanaka, Mary Fran Hazinski, Ian Jacobs, Koen Monsieurs, Peter T. Morley, Jerry P. Nolan, Andrew H. Travers, Adult Basic Life Support Chapter Collaborators Tom P. Aufderheide, Jocelyn Berdowski, Robert A. Berg, Maaret Castrén, Manya Charette, Sung Phil Chung, David C. Cone, Daniel P. Davis, Csaba Dioszeghy, James V. Dunford, Dana P. Edelson, Peter Fenici, Raúl J. Gazmuri, Laura S. Gold, Anton P.M. Gorgels, Colin A. Graham, Ahamed Idris, Jan L. Jensen, Peter Kohl, Peter J. Kudenchuk, Michael A. Kuiper, Douglas Kupas, E. Brooke Lerner, Bo Løfgren, Raina Merchant, Tommaso Pellis, Gavin D. Perkins, Thomas D. Rea, Andrea Scapigliati, Robert A. Swor, Keiichi Tanaka, Nigel M. Turner, Tyler F. Vadeboncoeur, Christian Vaillancourt, Antonius M.W. van Stipdonk and Barbara Vantroyen Michael R. SayreMichael R. Sayre , Rudolph W. KosterRudolph W. Koster , Martin BothaMartin Botha , Diana M. CaveDiana M. Cave , Michael T. CudnikMichael T. Cudnik , Anthony J. HandleyAnthony J. Handley , Tetsuo HatanakaTetsuo Hatanaka , Mary Fran HazinskiMary Fran Hazinski , Ian JacobsIan Jacobs , Koen MonsieursKoen Monsieurs , Peter T. MorleyPeter T. Morley , Jerry P. NolanJerry P. Nolan , Andrew H. TraversAndrew H. Travers , Adult Basic Life Support Chapter Collaborators , Tom P. AufderheideTom P. Aufderheide , Jocelyn BerdowskiJocelyn Berdowski , Robert A. BergRobert A. Berg , Maaret CastrénMaaret Castrén , Manya CharetteManya Charette , Sung Phil ChungSung Phil Chung , David C. ConeDavid C. Cone , Daniel P. DavisDaniel P. Davis , Csaba DioszeghyCsaba Dioszeghy , James V. DunfordJames V. Dunford , Dana P. EdelsonDana P. Edelson , Peter FeniciPeter Fenici , Raúl J. GazmuriRaúl J. Gazmuri , Laura S. GoldLaura S. Gold , Anton P.M. GorgelsAnton P.M. Gorgels , Colin A. GrahamColin A. Graham , Ahamed IdrisAhamed Idris , Jan L. JensenJan L. Jensen , Peter KohlPeter Kohl , Peter J. KudenchukPeter J. Kudenchuk , Michael A. KuiperMichael A. Kuiper , Douglas KupasDouglas Kupas , E. Brooke LernerE. Brooke Lerner , Bo LøfgrenBo Løfgren , Raina MerchantRaina Merchant , Tommaso PellisTommaso Pellis , Gavin D. PerkinsGavin D. Perkins , Thomas D. ReaThomas D. Rea , Andrea ScapigliatiAndrea Scapigliati , Robert A. SworRobert A. Swor , Keiichi TanakaKeiichi Tanaka , Nigel M. TurnerNigel M. Turner , Tyler F. VadeboncoeurTyler F. Vadeboncoeur , Christian VaillancourtChristian Vaillancourt , Antonius M.W. van StipdonkAntonius M.W. van Stipdonk and Barbara VantroyenBarbara Vantroyen Originally published19 Oct 2010https://doi.org/10.1161/CIRCULATIONAHA.110.970996Circulation. 2010;122:S298–S324is corrected byCorrectionNote From the Writing Group: Throughout this article, the reader will notice combinations of superscripted letters and numbers (eg, "Initial RecognitionBLS-003A, BLS-003B"). These callouts are hyperlinked to evidence-based worksheets, which were used in the development of this article. An appendix of worksheets, applicable to this article, is located at the end of the text. The worksheets are available in PDF format and are open access.The 2010 international evidence evaluation process addressed many questions related to the performance of basic life support. These have been grouped into the following categories: (1) epidemiology and recognition of cardiac arrest, (2) chest compressions, (3) airway and ventilation, (4) compression-ventilation sequence, (5) special circumstances, (6) emergency medical services (EMS) system, and (7) risks to the victim. Defibrillation is discussed separately in Part 6 because it is both a basic and an advanced life support skill. In the following summary, each question specific to the population, intervention, control group, and outcome (PICO Question) is listed with the consensus on science and treatment recommendation.There have been several important advances in the science of resuscitation since the last ILCOR review in 2005. Not all topics reviewed in 2005 were reviewed in 2010. When evaluating the published science, evidence reviewers considered studies with adult and pediatric victims of cardiac arrest published or accepted for publication in peer-reviewed journals. However, the treatment recommendations in this chapter generally are limited to treatment of adult victims of cardiac arrest. Please see Part 10: "Pediatric Basic and Advanced Life Support" for information on basic life support for pediatric cardiac arrest victims. The following is a summary of the most important evidence-based recommendations for the performance of basic life support in adults: Rescuers should begin CPR if the victim is unresponsive and not breathing (ignoring occasional gasps). Gasping should not prevent initiation of CPR because gasping is not normal breathing, and gasping is a sign of cardiac arrest.Following initial assessment, rescuers may begin CPR with chest compressions rather than opening the airway and delivering rescue breathing.All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest.A strong emphasis on delivering high-quality chest compressions remains essential: rescuers should push hard to a depth of at least 2 inches (or 5 cm) at a rate of at least 100 compressions per minute, allow full chest recoil, and minimize interruptions in chest compressions.Rescuers trained to provide ventilations use a compression-ventilation ratio of 30:2.For untrained rescuers, EMS dispatchers should provide telephone instruction in chest compression–only CPR.Epidemiology and Recognition of Cardiac ArrestMillions of people die prematurely every year from sudden cardiac arrest (SCA) worldwide, often associated with coronary heart disease. The following section summarizes the burden, risk factors, and potential interventions to reduce the risk.EpidemiologyIncidenceBLS-014BWhat is the incidence, prevalence, and etiology of cardiopulmonary arrest in-hospital and out-of-hospital?Consensus on ScienceMeasuring the global incidence of cardiac arrest is challenging, because there are many different definitions of patient populations. The Table lists the average crude incidence per 100 000 population reported for adult cases of cardiac arrest and cases of all ages (children and adults). The number of studies included is shown for each category.1–22Table. Global Incidence of Cardiac Arrest per 100 000 PopulationIncidence Definition (No. of Studies)All Ages IncludedAdult OnlyMean(SD)Mean(SD)Incidence of out-of-hospital cardiac arrest (n=5)82.9(21.4)213.1(177)Incidence of patients considered for CPR (n=34)76.3(35.7)95.9(30.5)Incidence of arrest with CPR initiated (n=55)41.5(18.4)64.2(19.9)Incidence of arrest with CPR initiated, cardiac cause (n=87)40.5(17.1)61.8(37.7)Adjusted incidence of arrest with CPR initiated, cardiac cause (n=14)56.6(13.7)84.7(58.8)Percentage of cases with CPR initiated (n=43)72.3(20.4)68.9(25.6)Percentage of cases with cardiac etiology (n=48)71.8(12.4)72.0(11.8)There are no significant differences in the incidence of out-of-hospital cardiac arrest (OHCA) or the incidence of patients in whom resuscitation was attempted with all causes of arrest when comparing Europe, North America, Asia, and Australia. The incidence of patients with OHCA considered for resuscitation is lower in Asia (55 per year per 100 000 population) than in Europe (86), North America (94), and Australia (113). The incidence of patients in OHCA with presumed cardiac cause in whom resuscitation was attempted is higher in North America (58 per year per 100 000 population) than in the other three continents (35 in Europe, 32 in Asia, and 44 in Australia).For in-hospital cardiac arrest, there are more limited incidence data.23Recognition of Cardiac ArrestEarly recognition is a key step in the initiation of early treatment of cardiac arrest and relies on using the most accurate method of determining cardiac arrest.Initial RecognitionBLS-003A, BLS-003BIn adults and children who are unresponsive (out-of-hospital and in-hospital), are there any specific factors (or clinical decision rules) as opposed to standard assessment that increase the likelihood of diagnosing cardiac arrest (as opposed to nonarrest conditions, such as postseizure, hypoglycemia or intoxication)?Consensus on SciencePulse CheckThere are no studies assessing the accuracy of checking the pulse to detect human cardiac arrest. There have been 9 LOE D5 studies demonstrating that both lay rescuers24–26 and healthcare providers27–32 have difficulty mastering the pulse check and remembering how to perform it. Three LOE D5 studies support the ability of healthcare providers to perform the pulse check; 2 evaluated the direct ear-to-chest method in infants,33,34 and the third supported an alternative technique for the carotid pulse check when tested by dental students on healthy volunteers.35 In 1 LOE D5 study,36 the technique of simultaneous pulse check and breathing check by professional rescuers increased the diagnostic accuracy.Two LOE D5 studies32,37 conducted in infants and children with nonpulsatile circulation during extracorporeal membrane oxygenation (ECMO) demonstrated that doctors and nurses in a pediatric tertiary care institution, when blinded to whether the child was receiving ECMO support or not, commonly assessed pulse status inaccurately and often took longer than 10 seconds. In these pediatric studies, healthcare professionals were able to accurately detect a pulse by palpation only 80% of the time. They mistakenly perceived a pulse when it was nonexistent 14% to 24% of the time and failed to detect a pulse when present in 21% to 36% of the assessments. Although some of the children in this study were pulseless, all children had circulation (ie, none were in cardiac arrest), so other signs typically associated with pulseless arrest (delayed capillary refill, poor color) were absent in this population.Breathing AssessmentSeveral studies have shown that lay rescuers do not easily master the techniques of breathing assessment, and they are often unable to recognize agonal gasps (LOE D525,26,38,39). There is a high incidence of agonal gasps after cardiac arrest (LOE D440–43), and EMS dispatchers have difficulty in diagnosing agonal gasping.40Several strategies for teaching students how to differentiate agonal gasps from normal breathing have been evaluated. In 1 LOE D5 study,44 teaching recognition of agonal gasps using a video clip improved the accuracy of lay rescuers in recognizing cardiac arrest. Another study (LOE D545) demonstrated that detection of true cardiac arrest cases improved after introduction of the question "Is he breathing regularly?" in a seizure complaint question sequence used by EMS dispatchers.Signs of CirculationIn the past, students were taught to recognize cardiac arrest by looking for the absence of signs of circulation, such as movement. No studies were found that measured the sensitivity and specificity of that approach for diagnosing cardiac arrest. An LOE D4 study46 showed that CPR guidance by EMS dispatchers was impeded by callers mentioning "signs of life."Treatment RecommendationIt is reasonable that lay rescuers and healthcare professionals use the combination of unresponsiveness and absent or abnormal breathing to identify cardiac arrest. Palpation of the pulse as the sole indicator of the presence or absence of cardiac arrest is unreliable. Agonal gasps are common during cardiac arrest and should not be considered normal breathing. The general public and EMS dispatchers should be taught how to recognize agonal gasps as a sign of cardiac arrest.Etiology of Cardiac ArrestBLS-050A, BLS-050BIn adults and children with presumed cardiac arrest (out-of-hospital and in-hospital), are there any factors/characteristics that increase the likelihood of differentiating between an SCA (ie, VF or pulseless ventricular tachycardia [VT]) and other etiologies (eg, drowning, acute airway obstruction)?Consensus on ScienceIn 1 registry study (LOE 247), cardiac arrest was more likely to be due to a cardiac cause in victims above the age of 35 years and to a noncardiac cause up to the age of 35 years. Two other registry studies (LOE 348,49) do not demonstrate diagnostically useful cutoff ages. An additional registry study (LOE 250) demonstrated that 83% of cardiac arrests under the age of 19 years are of noncardiac origin. One prospective study (LOE 251) and 1 retrospective study (LOE 352) showed that identification of the cause of cardiac arrest by healthcare providers can be inaccurate, leading to an underestimation of noncardiac etiology cardiac arrest, in particular, failure to diagnose exsanguination. Additional studies in children are summarized in Part 10: "Pediatric Basic and Advanced Life Support."Treatment RecommendationFor lay rescuers there is insufficient evidence to recommend any diagnostically reliable method to differentiate SCA of cardiac origin from one of noncardiac origin. Except in cases of obvious external causes of cardiac arrest (eg, gunshot wound, drowning), professional rescuers should rely on rhythm analysis from cardiac monitors or AEDs and other diagnostic tests to determine the cause of cardiac arrest.Check for Circulation During BLSBLS-008BIn adults and children with cardiac arrest (out-of-hospital and in-hospital), does the interruption of CPR to check circulation, as opposed to no interruption of CPR, improve outcome (eg, ROSC, survival)?Consensus on ScienceA study in manikins (LOE D529) confirmed a low ability ( 80/min were associated with ROSC. An observational study of 506 patients with out-of-hospital cardiac arrest showed improved survival to hospital discharge with increasing chest compression fraction (CCF, ie, proportion of total resuscitation time during which compressions are delivered), and best results when a CCF >0.60 was achieved. With compression rates between 100 and 127 per minute, this CCF corresponded with >60 chest compressions delivered in each minute. However, there was not an association between compression rate and survival (LOE 470).Treatment RecommendationIt is reasonable for lay rescuers and healthcare providers to perform chest compressions for adults at a rate of at least 100 compressions per minute. There is insufficient evidence to recommend a specific upper limit for compression rate. Pauses should be minimized to maximize the number of compressions delivered per minute.Chest Compression DepthBLS-006A, BLS-006BIn adults and children with cardiac arrest (out-of-hospital and in-hospital), does any specific compression depth, as opposed to standard care (ie, depth specified in treatment algorithm), improve outcome (eg, ROSC, survival)?Consensus on ScienceThree adult human LOE 4 studies71–73 showed that the measured compression depth during adult human resuscitation is often less than 4 cm (1.5 inches). No human studies directly compared the effectiveness of a compression depth of 4 to 5 cm (1.5 to 2 inches) with alternative compression depths.One adult human LOE 4 case series,74 2 adult human studies with retrospective control groups (LOE 375,76), and 1 LOE 5 study77 suggest that compressions of 5 cm (2 inches) or more may improve the success of defibrillation and ROSC. These findings are supported by 3 swine studies (LOE 578–80) showing improved survival with deeper compression depths and 1 adult human study (LOE 481) showing that improved force on the chest produced a linear increase in systolic blood pressure. However, 1 swine study (LOE 582) reported no improvement of myocardial blood flow with increased compression depth from 4 cm to 5 cm, although coronary perfusion pressure (CPP) improved from 7 to 14 mm Hg.Treatment RecommendationIt is reasonable to compress the sternum at least 2 inches/5 cm for all adult cardiac arrest victims. There is insufficient evidence to recommend a specific upper limit for chest compression depth.Chest DecompressionBLS-045AIn adults and children with cardiac arrest (out-of-hospital and in-hospital), does optimizing chest wall recoil during CPR, compared with standard care, improve outcome (eg, ROSC, survival)?Consensus on ScienceThere are no human studies specifically evaluating ROSC or survival to hospital discharge with or without complete chest wall recoil during CPR. One LOE 4 out-of-hospital case series83 documented a 46% incidence of incomplete chest recoil by professional rescuers using the CPR technique recommended in 2000, and 2 in-hospital pediatric case series demonstrated a 23% incidence of incomplete recoil that was more common just after switching providers of chest compressions (LOE 484,85). Another LOE 4 study86 electronically recorded chest recoil during in-hospital pediatric cardiac arrests and found that leaning on the chest occurred in half of all chest compressions. Animal studies (LOE 587,88) demonstrate significant reductions in mean arterial pressure, coronary perfusion pressure, cardiac output, and myocardial blood flow with only small amounts of incomplete chest recoil. Chest recoil can be increased significantly with simple techniques; for example, lifting the heel of the hand slightly but completely off the chest during CPR improved chest recoil in a manikin model. However, these alternative techniques may also reduce compression depth (LOE 583,89).Treatment RecommendationWhile allowing complete recoil of the chest after each compression may improve circulation, there is insufficient evidence to determine the optimal method to achieve the goal without compromising other aspects of chest compression technique.Firm Surface for Chest CompressionsBLS-035A, BLS-035BFor adults or children in cardiac arrest on a bed (out-of-hospital and in-hospital), does the performance of CPR on a hard surface like a backboard or deflatable mattress, compared with performance of CPR on a regular mattress, improve outcome (eg, ROSC, survival)?Consensus on ScienceOne case series (LOE 490) and 4 manikin studies (LOE 591–94) demonstrated that chest compressions performed on a bed are often too shallow. However, the case series (LOE 490) and 1 of the manikin studies (LOE 594) found that accelerometer-based CPR feedback devices failed to correct for compression of the underlying mattress, so it overestimated actual compression depth and may have contributed to delivery of shallow chest compressions. Two studies using manikins weighted to 70 kg (LOE 594,95) suggested that adequate compressions can be performed on a bed if the immediate feedback mechanism measures actual chest compression, regardless of the presence or absence of a backboard. No studies have examined the risks or benefits of moving the patient from a bed to the floor to perform CPR.No studies in humans have evaluated the risks or benefits of placing a backboard beneath a patient during CPR. Manikin studies (LOE 594,96,97) suggested that placing a backboard may improve compression depth by a few millimeters. One manikin study (LOE 598) showed that deflating a special mattress improved compression efficiency, but another manikin study (LOE 593) failed to demonstrate any benefit from deflating an air-filled mattress.Treatment RecommendationCPR should be performed on a firm surface when possible. Air-filled mattresses should be routinely deflated during CPR. There is insufficient evidence for or against the use of backboards during CPR. If a backboard is used, rescuers should minimize delay in initiation of chest compressions, minimize interruption in chest compressions, and take care to avoid dislodging catheters and tubes during backboard placement.Feedback for Chest Compression QualityBLS-020A, BLS-020BIn adults and children in cardiac arrest (out-of-hospital and in-hospital), does the use of feedback regarding the mechanics of CPR quality (eg, rate and depth of compressions and/or ventilations), compared with no feedback, improve any outcomes (eg, ROSC, survival)?Consensus on ScienceChest compression frequency, rate, and depth provided by lay responders (LOE 499), hospital teams (LOE 471), and EMS personnel (LOE 473,100) were insufficient when compared with recommended methods. Ventilation rates higher than recommended during CPR will impede venous return (LOE 5).101CPR feedback/prompt devices may improve several discrete measures (ventilation rate, end-tidal CO2, and compression rate, depth, and chest recoil) that have been linked with CPR quality. Eleven studies investigated the effect of giving real-time CPR performance feedback to rescuers during actual cardiac arrest events in both in-hospital and out-of-hospital settings. Two studies in adults (LOE 2102,103) and 1 study in children (LOE 2104) showed improved end-tidal CO2 measurements and consistent chest compression rates when feedback was provided from audio prompts (metronomes or sirens).In 4 LOE 3 studies75,86,105,106 and 2 LOE 4 studies,76,107 real-time feedback from force transducers and accelerometer devices was useful in improving CPR quality metrics, including compression depth, rate, and complete chest recoil. Two manikin studies (LOE 590,94) demonstrated the potential for overestimating compression depth when using an accelerometer chest compression feedback device if compressions are performed (with or without a backboard) on a soft surface. No studies to date have demonstrated a significant improvement in long-term survival related to the use of CPR feedback/prompt devices during actual cardiac arrest events (LOE 375).In 1 retrospective analysis of cardiac arrest records and 1 report of 2 cases (LOE 4108,109), changes in transthoracic impedance were potentially useful to measure ventilation rate and detect esophageal intubation. In a case series (LOE 4110), capnography and chest-wall impedance algorithms were inaccurate for determining ventilation rate.Treatment RecommendationIt is reasonable for providers and EMS agencies to monitor and improve CPR quality, ensuring adherence to recommended compression rate and depth and ventilation rates. Real-time chest compression–sensing and feedback/prompt technology (ie, visual and auditory prompting devices) may be useful adjuncts during resuscitation efforts. However, rescuers should be aware of the potential overestimation of compression depth when the victim is on a soft surface.Alternative Compression Techniques"Cough" CPRBLS-017A, BLS-017B, BLS-017CIn adult cardiac arrest (out-of-hospital and in-hospital), does the use of alternative methods of manual CPR (eg, cough CPR, precordial thump, fist pacing), compared with standard CPR, improve any outcomes (eg, ROSC, survival)?Consensus on ScienceA few case reports (LOE 4111–118) documented limited benefit of cough CPR during the initial seconds to minutes of cardiac arrest in patients who remained conscious in a controlled, monitored setting of electrophysiology testing with patient instruction prior to the onset of anticipated cardiac arrest.Treatment RecommendationUse of cough CPR may be considered only for patients maintaining consciousness during the initial seconds to minutes of VF or pulseless VT cardiac arrest in a witnessed, monitored, hospital setting (such as a cardiac catheterization laboratory).Precordial ThumpBLS-017A, BLS-017B, BLS-017CIn adult cardiac arrest (out-of-hospital and in-hospital), does the use of alternative methods of manual CPR (eg, cough CPR, precordial thump, fist pacing), compared with standard CPR, improve any outcomes (eg, ROSC, survival)?Consensus on ScienceIn 5 prospective case series of out-of-hospital (LOE 4119–123) and 2 series (LOE 4120,121) of in-hospital VF cardiac arrest, healthcare
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