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Kommentar zu den Leitlinien 2010 zur kardiopulmonalen Reanimation des European Resuscitation Council

Comments on the 2010 guidelines on cardiopulmonary resuscitation of the European Resuscitation Council

  • Notfallmedizin
  • Published:
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Zusammenfassung

Erwachsene

Thoraxkompressionen (mindestens 100/min, mindestens 5-cm-Drucktiefe): Beatmung (Atemzugvolumen 500–600 ml, Inspirationszeit 1s, FIO2 möglichst 1,0) im Verhältnis 30: 2 durchführen. Jegliche Unterbrechungen der Thoraxkompressionen vermeiden. Nach jeder Defibrillation (initial biphasisch 120–200 J, monophasisch 360 J; dann mit der jeweils höchsten Energie) unverzüglich unabhängig vom resultierenden EKG-Rhythmus für 2 min CPR durchführen. Die Intubation gilt als optimale Methode der Atemwegssicherung während einer CPR, ist jedoch ausschließlich dem in der Intubation erfahrenen Helfer vorbehalten. Laryngoskopie während laufender Thoraxkompressionen durchführen, für die Platzierung des Tubus Thoraxkompressionen maximal 10 s unterbrechen. Supraglottische Atemwegshilfen sind Alternativen zur endotrachealen Intubation. Zugangswege für Notfallmedikamente bei Erwachsenen und Kindern: Erste Wahl i.v., zweite Wahl intraossär (i.o.). Vasopressoren: Alle 3–5 min 1 mg Adrenalin i.v. Nach der dritten erfolglosen Defibrillation Amiodaron i.v. (300 mg), Repetition (150 mg) möglich. Natriumbikarbonat (50 ml, 8,4%ig) nur bei exzessiver Hyperkalämie, vorbestehender metabolischer Acidose oder Intoxikation mit trizyklischen Antidepressiva, Theophyllin (5 mg/kgKG) erwägen. Thrombolyse bei Spontankreislauf nur bei Myokardinfarkt und fulminanter Lungenembolie, während laufender kardiopulmonaler Reanimation („cardiopulmonary resuscitation“, CPR) nur bei Hinweisen auf fulminante Lungenembolie. „Active-compression-decompression“- (ACD-), maschinelle und „Inspiratory-threshold-valve“- (ITV-)CPR sind guter Standard-CPR nicht überlegen.

Kinder

Effektivste Verbesserung des Outcome durch Verhinderung eines manifesten Atem-Kreislauf-Stillstands. Basismaßnahmen: Initial 5 Beatmungen, dann Thoraxkompressionen (100–120/min, Tiefe ca. ein Drittel des Thoraxdurchmessers) und Beatmung im Verhältnis 15:2. Fremdkörperverlegung der Atemwege mit unzureichendem Hustenstoß: alternierend Rückenschläge und Thoraxkompressionen (Säuglinge) bzw. abdominelle Kompressionen (Kinder >1 Jahr). Behandlung potenziell reversibler Ursachen („4 Hs und HITS“: Hypoxie und Hypovolämie, Hypo- und Hyperkalämie, Hypothermie sowie Herzbeuteltamponade, Intoxikation, Thromboembolie, Spannungspneumothorax). Erweiterte Maßnahmen: Adrenalin 10 µg/kgKG i.v. oder i.o. alle 3–5 min. Defibrillation (4 J/kgKG; mono- oder biphasisch) gefolgt von 2-min-CPR, dann EKG- und Pulskontrolle.

Neugeborene

Zunächst Entfaltung der Lungen mit Beutel-Maske-Beatmung [Atemwegsdruck (pAW) 20–40 cmH2O]. Bei anhaltender Herzfrequenz <60/min: Thoraxkompressionen (120/min) und Beatmung im Verhältnis 3:1. Erhalten der Normothermie bei Frühgeborenen mit Einwickeln in Haushaltsfolie o. Ä.

Postreanimationsphase

Frühe, protokollbasierte intensivmedizinische Stabilisierung, inklusive frühzeitiger milder therapeutischer Hypothermie, ungeachtet des initialen Herzrhythmus [32–34°C für 12–24 h (Erwachsene) oder 24 h (Kinder), langsame Wiedererwärmung (<0,5°C/h)]. Perkutane Koronarintervention (PCI) ist bei vermuteter koronarer Herzkrankheit (KHK) zu erwägen. Erstellung der neurologischen Prognose <72 h nach der CPR mit somatosensorisch-evozierten Potenzialen, biochemischen Tests und neurologischer Untersuchung.

Akutes Koronarsyndrom

Schon bei Verdacht präklinisch 12-Kanal-EKG. Neben der Schmerztherapie frühzeitig Acetylsalicylsäure (160–325 mg p.o. oder i.v.) und Clopidogrel p.o. (75–600 mg je nach Strategie, bei ST-Strecken-Hebungs-Infarkt („ST-elevation myocardial infarction“, STEMI) und geplanter PCI auch Prasugrel (60 mg). Antithrombine wie Heparin (60 IU/kgKG, maximal 4000 IU), Enoxaparin, Bivalirudin oder Fondaparinux in Abhängigkeit von der Diagnose (STEMI- oder „non-ST-elevation myocardial infarction-acute coronary syndrome“, Non-STEMI-ACS) und der geplanten therapeutischen Strategie. Bei STEMI Reperfusionsstrategie unter Berücksichtigung von Symptomdauer, Verzögerung bis zur PCI, Alter und Infarktlokalisation.

Trauma

Vorrangiges Ziel beim schwersten hämorrhagischen Schock ist die definitive Blutungskontrolle. Für eine erfolgreiche CPR beim traumatischen Kreislaufstillstand sind ein Mindestmaß an zirkulierendem Intravasalvolumen und ein konsequentes Atemwegsmanagement mit Aufhebung bzw. Vermeidung einer Hypoxämie essenziell. Eine aggressive Infusionstherapie und unerwünschte Effekte einer kontrollierten Beatmung (Hyperventilation, hohe Beatmungsdrücke) können das Outcome von schwerst schockierten Traumapatienten verschlechtern.

Training

Jegliche Ausbildung ist besser als keine; eine Vereinfachung der Inhalte und Prozesse ist zielführend.

Abstract

Adults

Administer chest compressions (minimum 100/min, minimum 5 cm depth) at a ratio of 30:2 with ventilation (tidal volume 500–600 ml, inspiration time 1 s, FIO2 if possible 1.0). Avoid any interruptions in chest compressions. After every single defibrillation attempt (initially biphasic 120–200 J, monophasic 360 J, subsequently with the respective highest energy), chest compressions are initiated again immediately for 2 min independent of the ECG rhythm. Tracheal intubation is the optimal method for securing the airway during resuscitation but should be performed only by experienced airway management providers. Laryngoscopy is performed during ongoing chest compressions; interruption of chest compressions for a maximum of 10 s to pass the tube through the vocal cords. Supraglottic airway devices are alternatives to tracheal intubation. Drug administration routes for adults and children: first choice IV, second choice intraosseous (IO). Vasopressors: 1 mg epinephrine every 3–5 min IV. After the third unsuccessful defibrillation amiodarone (300 mg IV), repetition (150 mg) possible. Sodium bicarbonate (50 ml 8.4%) only for excessive hyperkaliemia, metabolic acidosis, or intoxication with tricyclic antidepressants. Consider aminophylline (5 mg/kgBW). Thrombolysis during spontaneous circulation only for myocardial infarction or massive pulmonary embolism; during on-going cardiopulmonary resuscitation (CPR) only when indications of massive pulmonary embolism. Active compression-decompression (ACD-CPR) and inspiratory threshold valve (ITV-CPR) are not superior to good standard CPR.

Children

Most effective improvement of outcome by prevention of full cardiorespiratory arrest. Basic life support: initially five rescue breaths, followed by chest compressions (100–120/min depth about one third of chest diameter), compression-ventilation ratio 15:2. Foreign body airway obstruction with insufficient cough: alternate back blows and chest compressions (infants), or abdominal compressions (children >1 year). Treatment of potentially reversible causes: (“4 Hs and 4 Ts”) hypoxia and hypovolaemia, hypokalaemia and hyperkalaemia, hypothermia, and tension pneumothorax, tamponade, toxic/therapeutic disturbances, thrombosis (coronary/pulmonary). Advanced life support: adrenaline (epinephrine) 10 µg/kgBW IV or IO every 3–5 min. Defibrillation (4 J/kgBW; monophasic or biphasic) followed by 2 min CPR, then ECG and pulse check.

Newborns

Initially inflate the lungs with bag-valve mask ventilation (pAW 20–40 cmH2O). If heart rate remains <60/min, start chest compressions (120 chest compressions/min) and ventilation with a ratio 3:1. Maintain normothermia in preterm babies by covering them with foodgrade plastic wrap or similar.

Postresuscitation phase

Early protocol-based intensive care stabilization; initiate mild hypothermia early regardless of initial cardiac rhythm [32–34°C for 12–24 h (adults) or 24 h (children); slow rewarming (<0.5°C/h)]. Consider percutaneous coronary intervention (PCI) in patients with presumed cardiac ischemia. Prediction of CPR outcome is not possible at the scene, determine neurological outcome <72 h after cardiac arrest with somatosensory evoked potentials, biochemical tests and neurological examination.

Acute coronary syndrome

Even if only a weak suspicion of an acute coronary syndrome is present, record a prehospital 12-lead ECG. In parallel to pain therapy, administer aspirin (160–325 mg PO or IV) and clopidogrel (75–600 mg depending on strategy); in ST-elevation myocardial infarction (STEMI) and planned PCI also prasugrel (60 mg PO). Antithrombins, such as heparin (60 IU/kgBW, max. 4000 IU), enoxaparin, bivalirudin or fondaparinux depending on the diagnosis (STEMI or non-STEMI-ACS) and the planned therapeutic strategy. In STEMI define reperfusion strategy depending on duration of symptoms until PCI, age and location of infarction.

Trauma

In severe hemorrhagic shock, definitive control of bleeding is the most important goal. For successful CPR of trauma patients a minimal intravascular volume status and management of hypoxia are essential. Aggressive fluid resuscitation, hyperventilation and excessive ventilation pressure may impair outcome in patients with severe hemorrhagic shock.

Training

Any CPR training is better than nothing; simplification of contents and processes is the main aim.

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Authors and Affiliations

  1. Univ.-Klinik für Anaesthesie und Intensivmedizin, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich

    V. Wenzel M.Sc. & M.A. Baubin

  2. Zentrum Anaesthesiologie, Rettungs- und Intensivmedizin, Universitätsmedizin Göttingen, Göttingen, Deutschland

    S.G. Russo, J. Bahr & C. Eich

  3. Klinik für Kardiologie und Pulmologie, Universitätsklinikum Charité – Campus Benjamin-Franklin, Berlin, Deutschland

    H.R. Arntz

  4. Klinik für Anästhesiologie und operative Intensivmedizin, Universität zu Köln, Köln, Deutschland

    B.W. Böttiger

  5. Universitätsklinik für Anästhesiologie, Sektion Notfallmedizin, Klinikum der Universität Ulm, Ulm, Deutschland

    B. Dirks

  6. Universitätsklinik für Anästhesiologie, Klinikum der Ludwigs-Maximilian-Universität, München, Deutschland

    U. Kreimeier

  7. Klinik für Operative Intensivmedizin, Universitätsklinikum Aachen, Aachen, Deutschland

    M. Fries

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  1. V. Wenzel M.Sc.
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  7. B. Dirks
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  8. U. Kreimeier
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  9. M. Fries
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  10. C. Eich
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Corresponding author

Correspondence to V. Wenzel M.Sc..

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Alle Autoren waren Delegierte des European Resuscitation Council in der internationalen Arbeitsgruppe zur Neuerstellung der Reanimationsleitlinien. Weiterhin sind in zusätzlichen Funktionen: B. Böttiger: Chairman des European Resuscitation Council, M. Baubin: Delegierter und Chairman des Austrian Resuscitation Council, B. Dirks: Delegierter und Chairman des German Resuscitation Council, U. Kreimeier: Schriftführer des German Resuscitation Council, J. Bahr: Schatzmeister des European Resuscitation Council und H.R. Arntz: 2. Vorsitzender des German Resuscitation Council, Mitglied der Acute Coronary Syndromes working group des European Resuscitation Council und principle author Acute Coronary Syndromes Chapter of the European Resuscitation Council Guidelines 2010.

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Wenzel, V., Russo, S., Arntz, H. et al. Kommentar zu den Leitlinien 2010 zur kardiopulmonalen Reanimation des European Resuscitation Council. Anaesthesist 59, 1105–1123 (2010). https://doi.org/10.1007/s00101-010-1820-9

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