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Die Anaesthesiologie
Erschienen in: Der Anaesthesist 12/2010

01.12.2010 | Notfallmedizin

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

verfasst von: Prof. Dr. V. Wenzel, M.Sc., S.G. Russo, H.R. Arntz, J. Bahr, M.A. Baubin, B.W. Böttiger, B. Dirks, U. Kreimeier, M. Fries, C. Eich

Erschienen in: Die Anaesthesiologie | Ausgabe 12/2010

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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.
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Metadaten
Titel
Kommentar zu den Leitlinien 2010 zur kardiopulmonalen Reanimation des European Resuscitation Council
verfasst von
Prof. Dr. V. Wenzel, M.Sc.
S.G. Russo
H.R. Arntz
J. Bahr
M.A. Baubin
B.W. Böttiger
B. Dirks
U. Kreimeier
M. Fries
C. Eich
Publikationsdatum
01.12.2010
Verlag
Springer-Verlag
Erschienen in
Die Anaesthesiologie / Ausgabe 12/2010
Print ISSN: 2731-6858
Elektronische ISSN: 2731-6866
DOI
https://doi.org/10.1007/s00101-010-1820-9

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