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The 1998 European Resuscitation Council Guidelines for Adult Advanced Life Support

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The 1998 European Resuscitation Council Guidelines for Adult Advanced Life Support Resuscitation 37 (1998) 81–90 The 1998 European Resuscitation Council guidelines for adult advanced life support A statement from the Working Group on Advanced Life Support, and approved by the executive committee of the European Resuscitation Council Colin Robertson (UK), Petter Steen (Norway), Jennifer Adgey (UK), Leo Bossaert (Belgium) *, Pierre Carli (France), Douglas Chamberlain (UK), Wolfgang Dick (Germany), Lars Ekstrom (Sweden), Svein A Hapnes (Norway), Stig Holmberg (Sweden), Rudolph Juchems (Germany), Fulvio Kette (Italy), Rudy Koster (Netherlands), Francisco J de Latorre (Spain), Karl Lindner (Austria), Narcisco Perales (Spain) 1 1. Introduction The ERC ALS working group recognised that the previous guidelines necessitated a level of rhythm recog- The publication of guidelines for advanced life sup- nition, interpretation and subsequent decision-making port (ALS) by the European Resuscitation Council that some users found difficult. While automated exter- (ERC) in 1992 was a landmark in international co-op- nal defibrillators (AED’s) ease some of these problems, eration and co-ordination [1]. Previously, individual the 1992 guidelines were not specifically designed for countries or groups had produced guidelines [2] but for these devices. These 1998 ALS guidelines are applicable the first time an international group of experts pro- to manual and automated external defibrillators. Deci- duced consensus views based on the best available sion making has been reduced to a minimum whenever information. Since 1992, even wider international col- possible. This increases clarity, while still allowing indi- laboration and support has occurred. In particular, the viduals with specialist knowledge to apply their establishment of the International Liaison Committee expertise. on Resuscitation (ILCOR) has facilitated global co-op- Changes in guidelines are only the first step in the eration and discussion between representatives from process of care. Their implementation necessitates con- North America, Europe, Southern Africa, Australia, siderable effort. Training materials and methods may and most recently Latin America. The Advisory State- require modification, information must be disseminated ment produced in 1997 by ILCOR forms the basis for and, perhaps most importantly, evaluation of efficacy is these guidelines [3]. needed. For these purposes, reporting and publication The 1992 ERC guideline documents indicated that of out-of-hospital and in-hospital cardiac arrest events review would occur on a regular basis. Change is not using the Utstein templates [4,5] is strongly advised to advocated for its own sake, and is not warranted provide objective outcome assessment. without convincing scientific or educational reasons. The limitations of guidelines must be recognised. As Education and its organisation is a process with a long always in the practice of medicine, words and flow latency, and it can be confusing and distracting for charts must be interpreted with common sense and an trainers and trainees if the message lacks consistency. appreciation of their intent. While much is known about the theory and practice of resuscitation, in many areas our ignorance is profound. Resuscitation practice * Corresponding author. 1 With contributions from: Raoul Alasino (CLAR), Vic Callanan remains as much an art as a science. Further, the (ARC), Richard Cummins (AHA), Walter Kloeck (RCSA) and Brian interpretation of guidelines may differ according to the Connolly (HSFC) environment in which they are employed. We acknowl- 0300-9572/98/$19.00 © 1998 European Resuscitation Council. Published by Elsevier Science Ireland Ltd. PII S0300-9572(98)00035-5 82 C. Robertson et al. / Resuscitation 37 (1998) 81–90 edge that individual resuscitation councils may wish to sequentially overlapping shocks producing a rapidly customise the details while accepting that the guiding shifting electrical vector during a multi-pulse shock, principles are universal. Any such changes must be may reduce the energy requirements for successful defi- approved by the ERC if they are to be regarded by this brillation [24–26]. Automated defibrillators that can organisation as representing their official guidelines. deliver a current-based shock appropriate to the mea- sured transthoracic impedance are available and are being evaluated. Their use may increase the efficacy of 2. Precursors to cardiac arrest individual shocks, while reducing myocardial injury in patients with unusually high, or low, transthoracic In the so-called industrialised world, the commonest impedance [27,28]. cause of adult sudden cardiac death is ischaemic heart The use of groups of three shocks is retained, the disease [6–9]. Prevention of cardiac arrest is to be initial sequence having energies of 200 J, 200 J and 360 greatly preferred to post hoc treatment. The ‘Manage- J. The reasons for choosing 200 J as the energy for the ment of peri-arrest arrhythmias’ produced by the ERC first two shocks of conventional wave-form defibrilla- in 1994 and updated in 1996 and 1998 provides guid- tion have been presented [29]. Subsequent shocks, if ance for treatment of arrhythmias which may lead to required, should have energies of 360 J. If a co-ordi- the development and recurrence of cardiac arrest in nated rhythm has supervened for a limited interval, critical situations [10]. there is no strong scientific basis for deciding whether Small, but important, sub-groups of patients sustain one should revert to 200 J or continue at 360 J. There cardiac arrest in certain special circumstances other is evidence that myocardial injury, both functionally than ischaemic heart disease. These include trauma, and morphologically, is greater with increasing ener- drug overdose, hypothermia, immersion, anaphylaxis, gies, but the comparative success rates for defibrillation pregnancy, hypovolaemia. While this ALS algorithm is attempts at this point with 200 J versus 360 J are universally applicable, specific modifications may be unknown. Both strategies are therefore acceptable. required to maximise the likelihood of success in these Most AED’s have an algorithm that does not revert to circumstances. 200 J after a short period of non VF/VT. In this case, defibrillation should continue with 360 J instead of restarting the AED to allow a 200 J shock to be given. 3. Specific ALS interventions and their use in the ALS Alternative waveforms and energy levels are acceptable algorithm if demonstrated to be of equal or greater net clinical benefit in terms of safety and efficacy. 3.1. Defibrillation A pulse check is required after a shock (and should be prompted by an AED), only if the waveform In adults, the commonest primary arrhythmia at the changes to one compatible with cardiac output. Thus if onset of cardiac arrest is ventricular fibrillation (VF) or VF, or VT with an identical waveform, persists after pulseless ventricular tachycardia (VT) [11–14]. The the first 200 J shock, the second shock at 200 J is given overwhelming majority of eventual survivors come without a pulse check being carried out. If, in turn, this from this group [15–18]. If the definitive therapy for shock is unsuccessful, the third shock—this time at 360 these arrhythmias, defibrillation, can be implemented J—is given. With modern defibrillators, charging times promptly, a perfusing cardiac rhythm may be restored are sufficiently short for three shocks to be adminis- and lead to long-term survival. The only interventions tered within 1 min. which have been shown unequivocally to improve long- Only a very small proportion of the delivered electri- term survival are basic life support and defibrillation. cal energy traverses the myocardium during transtho- VF is an readily treatable rhythm, but the chances of racic defibrillation [30] and efforts to maximise this successful defibrillation decline substantially with the proportion are important. The commonest defects are passage of each minute [19,20]. The amplitude and inadequate contact with the chest wall, failure or poor waveform of VF deteriorate rapidly reflecting the deple- use of couplants to aid the passage of current at the tion of myocardial high energy phosphate stores interface between the paddles and the chest wall, and [21,22]. The rate of decline in success depends in part faulty paddle positioning or size [31–34]. One paddle upon the provision and adequacy of BLS [23]. As a should be placed below the right clavicle in the mid- result, the priority is to minimise any delay between the clavicular line and the other over the lower left ribs in onset of cardiac arrest and the administration of defi- the mid/anterior axillary line (just outside the position brillating shocks. of the normal cardiac apex). In female patients the At present, the most commonly used transthoracic second pad/paddle should be placed firmly on the chest defibrillation waveform has a damped sinusoidal pat- wall just outside the position of the normal cardiac tern. Newer techniques such as biphasic waveforms, or apex avoiding the breast tissue [35]. C. Robertson et al. / Resuscitation 37 (1998) 81–90 83 If unsuccessful, other positions such as Apex–Poste- 52]. To improve the scientific basis for future recom- rior can be considered [36,37]. Although the polarity of mendations, the use of new techniques should be the electrodes affects success with internal techniques carefully evaluated by clinical trials before implementa- such as implantable defibrillators, during transthoracic tion into prehospital and in-hospital practice. defibrillation the polarity
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