Elsevier

Resuscitation

Volume 81, Issue 10, October 2010, Pages 1293-1304
Resuscitation

European Resuscitation Council Guidelines for Resuscitation 2010 Section 3. Electrical therapies: Automated external defibrillators, defibrillation, cardioversion and pacing

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Summary of changes since 2005 Guidelines

The most important changes in the 2010 European Resuscitation Council (ERC) guidelines for electrical therapies include:

  • The importance of early, uninterrupted chest compressions is emphasised throughout these guidelines.

  • Much greater emphasis on minimising the duration of the pre-shock and post-shock pauses. The continuation of compressions during charging of the defibrillator is recommended.

  • Immediate resumption of chest compressions following defibrillation is also emphasised; in combination

A vital link in the Chain of Survival

Defibrillation is a key link in the Chain of Survival and is one of the few interventions that have been shown to improve outcome from VF/VT cardiac arrest. The previous guidelines published in 2005 rightly emphasized the importance of early defibrillation with minimum delay.1, 2

The probability of successful defibrillation and subsequent survival to hospital discharge declines rapidly with time3, 4 and the ability to deliver early defibrillation is one of the most important factors in

Automated external defibrillators

Automated external defibrillators are sophisticated, reliable computerised devices that use voice and visual prompts to guide lay rescuers and healthcare professionals to safely attempt defibrillation in cardiac arrest victims. Some AEDs combine guidance for defibrillation with guidance for the delivery of optimal chest compressions. Use of AEDs by lay or non-healthcare rescuers is covered in Section 2.19

In many situations, an AED is used to provide initial defibrillation but is subsequently

Minimising the pre-shock pause

The delay between stopping chest compressions and delivery of the shock (the pre-shock pause) must be kept to an absolute minimum; even 5–10 s delay will reduce the chances of the shock being successful.31, 32, 42 The pre-shock pause can easily be reduced to less than 5 s by continuing compressions during charging of the defibrillator and by having an efficient team coordinated by a leader who communicates effectively. The safety check to ensure that nobody is in contact with the patient at the

One-shock versus three-stacked shock sequence

A major change in the 2005 guidelines was the recommendation to give single rather than three-stacked shocks. This was because animal studies had shown that relatively short interruptions in external chest compression to deliver rescue breaths114, 115 or perform rhythm analysis33 were associated with post-resuscitation myocardial dysfunction and reduced survival. Interruptions in external chest compression also reduced the chances of converting VF to another rhythm.32 Analysis of CPR

Defibrillation of children

Cardiac arrest is less common in children. Common causes of VF in children include trauma, congenital heart disease, long QT interval, drug overdose and hypothermia.164, 165, 166 Ventricular fibrillation is relatively rare compared with adult cardiac arrest, occurring in 7-15% of paediatric and adolescent arrests.166, 167, 168, 169, 170, 171 Rapid defibrillation of these patients may improve outcome.171, 172

The optimal energy level, waveform and shock sequence is unknown but as with adults,

Cardioversion

If electrical cardioversion is used to convert atrial or ventricular tachyarrhythmias, the shock must be synchronised to occur with the R wave of the electrocardiogram rather than with the T wave: VF can be induced if a shock is delivered during the relative refractory portion of the cardiac cycle.183 Synchronisation can be difficult in VT because of the wide-complex and variable forms of ventricular arrhythmia. Inspect the synchronisation marker carefully for consistent recognition of the R

Pacing

Consider pacing in patients with symptomatic bradycardia refractory to anti-cholinergic drugs or other second line therapy (see Section 4).113 Immediate pacing is indicated especially when the block is at or below the His-Purkinje level. If transthoracic pacing is ineffective, consider transvenous pacing. Whenever a diagnosis of asystole is made, check the ECG carefully for the presence of P waves because this will likely respond to cardiac pacing. The use of epicardial wires to pace the

Implantable cardioverter defibrillators

Implantable cardioverter defibrillators (ICDs) are becoming increasingly common as the devices are implanted more frequently as the population ages. They are implanted because a patient is considered to be at risk from, or has had, a life-threatening shockable arrhythmia and are usually embedded under the pectoral muscle below the left clavicle (in a similar position to pacemakers, from which they cannot be immediately distinguished). On sensing a shockable rhythm, an ICD will discharge

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