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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Algorithm for the treatment of cardiac arrest in the hospital&#46; &#42;Airway&#44; respiration&#44; circulation&#44; disability&#44; exposure&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In October 2010&#44; the journals <span class="elsevierStyleItalic">Resuscitation</span><a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and <span class="elsevierStyleItalic">Circulation</span><a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> simultaneously published the guides of the ERC &#40;European Resuscitation Council&#41; and of the AHA &#40;American Heart Association&#41; relating to cardiopulmonary resuscitation &#40;CPR&#41;&#46; These guides offer an update to the previous guidelines&#44; published in the year 2005&#44; and are based on the more recent International Consensus on Resuscitation Science and Treatment Recommendations &#40;CoSTR&#41;&#46; In this context&#44; the new guides incorporate the results of systematic reviews&#44; involving strict methodological criteria&#44; corresponding to over 270 topics related to CPR and prepared by over 300 international experts&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">These reviews of the literature&#44; carried out to offer answers to the questions raised by each of the working groups of the International Liaison Committee on Resuscitation&#44; were prepared using a standardized worksheet that included a grading system designed to define the level of evidence of each study&#46; The International Consensus Conference&#44; held in Dallas in February 2010&#44; and its published conclusions and recommendations&#44; constitute the basis of the ERC guides of 2010&#46; Although the guides are derived from the CoSTR document of 2010&#44; they represent consensus among the members of the Executive Committee of the ERC&#46; The Committee considers that these new recommendations are the most effective and easiest to learn interventions supported by the current state of knowledge&#44; research and experience&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The current guides on advanced life support &#40;ALS&#41; recommend some changes with respect to the previous guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> These changes are described in the present article&#44; together with the reasons for such changes&#46; However&#44; many of the recommendations in the ERC guides of 2005 remain without change in the year 2010&#44; either because no new studies have been published&#44; or because the new evidence generated since 2005 simply reinforces the already existing evidence&#46; In addition&#44; the current universal algorithm for advanced life support &#40;ALS&#41; is presented&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The changes in the recommendations are presented divided into the following sections&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Prevention of in-hospital cardiac arrest &#40;CA&#41;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Resuscitation in the hospital</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Simplified ALS algorithm</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0040" class="elsevierStylePara elsevierViewall">CPR techniques and devices</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Post-resuscitation care</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Prognosis</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">&#8220;Non-heart beating&#8221; donors and reference centers in CA</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Prevention of in-hospital cardiac arrest &#40;CA&#41;</span><p id="par0060" class="elsevierStylePara elsevierViewall">The current recommendations stress the importance of the early identification of those hospitalized patients who are experiencing a worsening of their condition&#44; and of the possibility of avoiding progression towards cardiac arrest &#40;CA&#41;-thus defining prevention of the latter as a first link in the chain of survival&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In order to prevent in-hospital CA&#44; hospital centers should incorporate a care system including the following elements&#58; &#40;a&#41; training of the healthcare personnel to recognize the signs of patient worsening and the reasons for offering a rapid response to the disease&#59; &#40;b&#41; adequate and regular monitorization of the vital signs of hospitalized patients&#59; &#40;c&#41; clear guidelines &#40;e&#46;g&#46;&#44; based on call criteria or warning or alarm sign scores&#41; to help the personnel in the early detection of patient worsening&#59; &#40;d&#41; a uniform and clear system for requesting help&#59; and &#40;e&#41; a clinical response to calls for help that is both appropriate and on time&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The following strategies are proposed for preventing avoidable in-hospital CA&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">1&#46;</span><p id="par0075" class="elsevierStylePara elsevierViewall">The provision of care for critical patients or patients at risk of clinical deterioration in the appropriate hospital areas&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In other words&#44; care should be provided adapted to the seriousness of the condition of each individual patient&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">2&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Each patient should have a documented plan for monitoring of the opportune vital signs&#44; identifying the variables to be measured and the frequency of measurement&#44; in accordance to the severity of the disease or the probability of clinical worsening&#46; The guides suggest the monitorization of simple physiological variables &#40;heart rate&#44; blood pressure&#44; respiratory frequency&#44; level of consciousness&#44; temperature and SpO<span class="elsevierStyleInf">2</span>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a> A data collection sheet should be used&#44; allowing regular measurement and registry of the vital signs&#44; and of the early warning scores&#44; when used&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">3&#46;</span><p id="par0085" class="elsevierStylePara elsevierViewall">An alarm and tracing system &#40;&#8220;call criteria&#8221; or early warning system&#41; should be used to identify patients in critical condition and&#47;or at risk of clinical worsening and CA&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows an example of early warning score for the identification of critical patients&#44; based on the evaluation of multiple vital signs&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">4&#46;</span><p id="par0090" class="elsevierStylePara elsevierViewall">An adequate clinical response to alterations in physiological parameters should be provided&#44; based on the alarm and tracing system used&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">5&#46;</span><p id="par0095" class="elsevierStylePara elsevierViewall">The hospital should have a clearly identified response to critical disease&#46; This may include the designation of a resuscitation team capable of responding in an adequate period of time to the acute clinical situations identified by the alarm and tracing system or other indicators&#46; This service should be available 24<span class="elsevierStyleHsp" style=""></span>h a day&#46; The team should include professionals capable of resolving situations requiring acute or critical patient care&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">6&#46;</span><p id="par0100" class="elsevierStylePara elsevierViewall">All the clinical personnel should be trained to identify&#44; monitor and manage critical patients&#44; and must know their role in the rapid response system&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">7&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Identification is required of those patients in which CA represents a foreseeable terminal event&#44; of those subjects in which CPR is inappropriate&#44; and of those patients who do not wish to receive CPR&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Accordingly&#44; hospitals should have an &#8220;orders not to start CPR&#8221; policy&#44; based on national guides that are understood by all clinical personnel members&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">8&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Auditing should be ensured of CA&#44; &#8220;false arrests&#8221;&#44; unexpected deaths and non-expected admissions to the ICU&#44; making use of common databases&#46; The antecedents and clinical responses of such events must also be audited&#46;</p></li></ul></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resuscitation in the hospital</span><p id="par0115" class="elsevierStylePara elsevierViewall">When CA occurs in the hospital&#44; the division between basic life support &#40;BLS&#41; and advanced life support &#40;ALS&#41; is arbitrary&#59; in practice&#44; the resuscitation process is a <span class="elsevierStyleItalic">continuum</span> and is based on common sense applied to each concrete situation&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Cardiac arrest must be identified immediately&#44; and help must be requested using a pre-established standard telephone number&#46; CPR is to start immediately&#44; using airway accessories &#40;e&#46;g&#46;&#44; pocket masks&#41; and&#44; where indicated&#44; defibrillation should be performed as soon as possible &#40;in all cases within 3<span class="elsevierStyleHsp" style=""></span>min after CA&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The precise sequence of actions after in-hospital CA depends on many factors&#44; including&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall">The location where arrest occurs &#40;clinical&#47;non-clinical area&#44; monitored&#47;non-monitored area&#41;&#46; Patients with monitored arrest are generally diagnosed quickly&#46; In contrast&#44; patients in wards may have suffered a period of worsening and non-witnessed arrest&#46; Ideally&#44; all patients at high risk of suffering CA should be attended in a monitorized area with the availability of immediate resuscitation measures&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall">Training of the first responders&#44; and the number of responders&#46; In principle&#44; it is advisable for all healthcare professionals to be able to recognize CA&#44; call for help and start the CPR maneuvers&#46; Each hospital healthcare professional should do what he or she has been trained to do&#44; since there may be different levels of training and skill in dealing with the airway&#44; breathing and circulation&#46; Thus&#44; the resuscitators should undertake only those activities in which they have been trained and are competent&#46; When there is only one responder&#44; he or she must ensure that help has been called for and is underway&#46; If several professionals are available&#44; different actions can be taken simultaneously&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall">Available equipment and hospital response system for CA and medical emergencies&#46; All clinical areas should have immediate access to the resuscitation equipment and to drugs allowing rapid patient resuscitation&#46; The equipment to be used in CPR &#40;including defibrillators&#41;&#44; its distribution&#44; and the medication should be standardized throughout the hospital&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> The resuscitation team may take the form of a conventional CA team&#44; which is notified only when a case of CA has been identified&#46; Alternatively&#44; however&#44; hospitals may have strategies for identifying patients at risk of CA and for calling or alerting a team&#44; e&#46;g&#46;&#44; the medical emergencies team&#44; before CA actually occurs&#46; In-hospital CA is rarely sudden or unexpected&#59; a strategy that includes the identification of patients at risk of CA may be able to prevent some of these arrests&#44; or may contribute to avoid futile resuscitation attempts in patients who are unlikely to benefit from CPR&#46;</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Immediate actions in the case of patients collapsing in hospital</span><p id="par0145" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the general algorithm for the initial management of in-hospital CA&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0150" class="elsevierStylePara elsevierViewall">Ensure the safety of the personnel dealing with the arrest&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">-</span><p id="par0155" class="elsevierStylePara elsevierViewall">Check whether the patient responds&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">When the healthcare personnel witness patient collapse or find an apparently unconscious patient in a clinical area&#44; the first thing to do is call for help&#44; and then determine whether the patient responds&#46; The patient should be shaken at the shoulders and asked out loud&#58; &#8220;Are you OK&#63;&#8221;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">If there are other healthcare personnel members nearby&#44; simultaneous actions can be carried out&#46;</p></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">If the patient responds&#44; urgent medical evaluation is required&#44; in accordance with the acute critical patient care protocol applied in each hospital center&#46; While the arrival of help is being awaited&#44; oxygen should be administered&#44; with monitorization and the insertion of a venous catheter&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">If the patient fails to respond&#44; the precise sequence of actions will depend on the training of the personnel attending the patient&#44; and on their experience in evaluating breathing and circulation&#46; It must be taken into account that healthcare personnel&#44; even when trained&#44; may not assess breathing and pulse reliably enough to confirm CA&#46; Agonal breathing &#40;occasional breaths&#44; slow&#44; laborious or noisy breathing&#41; is a sign of CA that should not be confused with life&#47;circulation signs&#46; The following sequence of actions is indicated in such cases&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">1&#46;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Call out for help &#40;if this has not been done yet&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">2&#46;</span><p id="par0185" class="elsevierStylePara elsevierViewall">Turn the patient on to his or her back and open the airway&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">3&#46;</span><p id="par0190" class="elsevierStylePara elsevierViewall">On opening the airway&#44; check for breathing&#58;<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">-</span><p id="par0195" class="elsevierStylePara elsevierViewall">Open the airway using the head tilt&#47;chin lift maneuver&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">-</span><p id="par0200" class="elsevierStylePara elsevierViewall">Examine inside the mouth&#46; Attempt to remove any foreign body or elements&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">-</span><p id="par0205" class="elsevierStylePara elsevierViewall">If neck injury is suspected&#44; attempt to open the airway applying mandibular traction&#46; If there are sufficient personnel members at hand&#44; aligned manual stabilization is indicated in order to minimize head movements&#46; The efforts to protect the cervical spine should not place oxygenation and ventilation at risk&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">-</span><p id="par0210" class="elsevierStylePara elsevierViewall">Keeping the airway open&#44; check whether the chest moves&#44; listen at the mouth of the patient for breathing sounds&#44; feeling the breath on the cheek&#44; in order to assess normal respiration&#46; It should take no more than 10<span class="elsevierStyleHsp" style=""></span>s to determine whether the patient is breathing normally or not&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">4&#46;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Check the circulation signs&#58;<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">-</span><p id="par0220" class="elsevierStylePara elsevierViewall">If the patient shows no signs of life &#40;consciousness&#44; purposeful movements&#44; normal breathing or cough&#41;&#44; start CPR maneuvering until more experienced help arrives&#44; or until the patient shows signs of life&#46;</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">-</span><p id="par0225" class="elsevierStylePara elsevierViewall">Those with experience in clinical assessment should evaluate the carotid pulse while simultaneously seeking signs of life&#44; during no more than 10<span class="elsevierStyleHsp" style=""></span>s&#46;</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">-</span><p id="par0230" class="elsevierStylePara elsevierViewall">If the patient seems to show no signs of life&#44; or in case of doubt&#44; CPR maneuvering should be started immediately&#46; Chest compression in a patient with a scantly beating heart is unlikely to cause injury&#46; However&#44; delays in diagnosing CA and in starting CPR have a negative impact upon patient survival&#44; and therefore should be avoided&#46;</p></li></ul></p></li></ul></p><p id="par0235" class="elsevierStylePara elsevierViewall">In the presence of a pulse or signs of life&#44; urgent medical assessment is required&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">If there is no breathing but a pulse is present &#40;i&#46;e&#46;&#44; respiratory arrest&#41;&#44; the patient should be ventilated&#44; checking circulation every 10 respirations&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Start of CPR in the hospital</span><p id="par0245" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">-</span><p id="par0250" class="elsevierStylePara elsevierViewall">A person starts CPR while others alert the resuscitation team and retrieve the resuscitation equipment and defibrillator&#46; If only one personnel member is present&#44; this would mean having to momentarily leave the patient&#46;</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">-</span><p id="par0255" class="elsevierStylePara elsevierViewall">Apply 30 chest compressions&#44; followed by two ventilations&#46;</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">-</span><p id="par0260" class="elsevierStylePara elsevierViewall">Minimize the interruptions and ensure quality compression&#46;</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">-</span><p id="par0265" class="elsevierStylePara elsevierViewall">Maintain the airway and ventilate the lungs with the most appropriate equipment immediately available&#58; pocket masks&#44; supraglottic devices and an auto-inflatable balloon or balloon-mask&#44; according to the locally applied protocol&#46; Tracheal intubation should only be attempted by trained persons who are competent and experienced in the technique&#46;</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">-</span><p id="par0270" class="elsevierStylePara elsevierViewall">Administer sufficient volume to allow normal chest elevation&#46; Add supplementary oxygen as soon as possible&#46;</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">-</span><p id="par0275" class="elsevierStylePara elsevierViewall">Following tracheal intubation of the patient or the insertion of a supraglottic device&#44; chest compression should be continued without interruption &#40;except for defibrillation or checking of the pulse where indicated&#41;&#44; at a rate of at least 100<span class="elsevierStyleHsp" style=""></span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; with lung ventilation at approximately 10 respirations min<span class="elsevierStyleSup">&#8722;1</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">-</span><p id="par0280" class="elsevierStylePara elsevierViewall">Once the defibrillator has arrived&#44; the rhythm in arrest must be analyzed&#46; If self-adhering defibrillation patches are available&#44; these should be placed without interrupting the chest compressions&#46; The use of self-adhering patches or of the &#8220;quick look&#8221; technique will allow rapid assessment of the cardiac rhythm&#46; With a manual defibrillator&#44; if the rhythm corresponds to ventricular fibrillation&#47;ventricular tachycardia without a pulse &#40;VF&#47;VT&#41;&#44; the defibrillator should be charged while another resuscitator continues with the chest compressions&#46; Once the defibrillator is charged&#44; a discharge should be applied&#46; If an automated external defibrillator &#40;AED&#41; is used&#44; follow the audiovisual indications of the AED&#46;</p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">-</span><p id="par0285" class="elsevierStylePara elsevierViewall">Resume the chest compressions immediately after the defibrillation attempt&#46; Minimize interruption of the chest compressions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">-</span><p id="par0290" class="elsevierStylePara elsevierViewall">Continue resuscitation until the resuscitation team arrives&#44; or until the patient shows signs of life&#46; Follow the voice instructions if an AED is used&#46; If a manual defibrillator is being used&#44; follow the universal advanced life support algorithm &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">-</span><p id="par0295" class="elsevierStylePara elsevierViewall">Once resuscitation is underway&#44; and if sufficient personnel are available&#44; prepare an intravenous catheter and the drugs that will probably be used &#40;e&#46;g&#46;&#44; adrenalin&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">-</span></span><p id="par0300" class="elsevierStylePara elsevierViewall">Even brief interruptions in chest compression worsen the prognosis&#46; Every effort therefore must be made to maintain effective chest compression throughout the resuscitation attempt&#46; The team leader should monitor the quality of CPR and alternate the participants in CPR if quality proves poor&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Simplified advanced life support algorithm</span><p id="par0305" class="elsevierStylePara elsevierViewall">The universal ALS algorithm of the ERC 2010 recommendations &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; is similar to the previous algorithm corresponding to the year 2005&#44; though the recommendations show some relevant changes&#44; and especially a different emphasis on some of them&#46; In general&#44; priority centers on simplification and rationalization to facilitate application of the algorithm&#46; The following should be underscored&#58;<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">1&#46;</span><p id="par0310" class="elsevierStylePara elsevierViewall">Interventions&#44; which undoubtedly contribute to improve survival in CA&#44; are effective basic life support &#40;BLS&#41;&#44; with uninterrupted high-quality chest compressions and an early defibrillation in VF&#47;VT&#46; Accordingly&#44; special emphasis is placed on the need for quality CPR&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> This would include the following&#58;<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">-</span><p id="par0315" class="elsevierStylePara elsevierViewall">The performance of high-quality chest compressions&#44; of adequate depth &#40;approximately 5<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; and allowing complete expansion of the chest&#46; If the airway has not been isolated&#44; a compression&#58; ventilation ratio of 30&#58;2 should be maintained&#59; if the airway has been isolated&#44; the frequency should be 100<span class="elsevierStyleHsp" style=""></span>bpm&#46;</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">-</span><p id="par0320" class="elsevierStylePara elsevierViewall">The compressions should be interrupted as little as possible through the resuscitation period&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> Brief interruptions should only be made to allow specific interventions such as defibrillation or tracheal intubation&#46; A delay of only 5&#8211;10<span class="elsevierStyleHsp" style=""></span>s is enough to reduce the chances for success in dealing with CA&#46; In order to shorten the pre-discharge pause&#44; the chest compressions should be continued while the defibrillator is being charged&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> Without assessing cardiac rhythm or pulse&#44; the chest compressions should be resumed immediately after discharge&#46; Even in cases where discharge proves successful and restores a perfusion rhythm&#44; it takes some time for post-discharge circulation to become established&#46;</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">-</span><p id="par0325" class="elsevierStylePara elsevierViewall">Avoid excessive ventilation&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">2&#46;</span><p id="par0330" class="elsevierStylePara elsevierViewall">Special emphasis continues to be placed on early defibrillation in patients with CA who present rhythms amenable to defibrillation&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#8211;20</span></a> In the same way as in the previous recommendations&#44; the new guidelines maintain the protocol of one discharge versus the sequence of three discharges for rhythms amenable to defibrillation&#44; with the same energy ratings in both mono- and biphasic waves&#44; and an increase in voltage for the second and subsequent discharges&#44; instead of maintaining a fixed voltage &#40;in defibrillators with biphasic waves&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">3&#46;</span><p id="par0335" class="elsevierStylePara elsevierViewall">In contrast to other clinical situations&#44; the recommendation is to deliver up to three rapid and consecutive &#40;grouped&#41; discharges in ventricular fibrillation&#47;ventricular tachycardia without a pulse &#40;VF&#47;VT&#41; occurring in the cardiac catheterization room or in the immediate postoperative period of heart surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> This same strategy can also be considered in the case of witnessed CA with VF&#47;VT&#44; when the patient has already been connected to a manual defibrillator&#46;</p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">4&#46;</span><p id="par0340" class="elsevierStylePara elsevierViewall">In the case of out-hospital CPR&#44; the new guidelines eliminate the recommendation to apply a predetermined period of CPR before defibrillation following CA not witnessed by the medical emergency services &#40;MES&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;22&#8211;24</span></a></p></li><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">5&#46;</span><p id="par0345" class="elsevierStylePara elsevierViewall">For the administration of drugs&#44; the recommendation to establish a peripheral venous access remains&#44; due to the rapidity&#44; efficacy and safety of the technique&#46; If a venous access cannot be established in the first 2<span class="elsevierStyleHsp" style=""></span>min of resuscitation maneuvering&#44; an intraosseous &#40;IO&#41; route should be attempted for the administration of drugs&#46; The increasing availability of these devices has made it easier to apply this technique&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a> The IO drug doses are the same as with the intravenous route&#46; This form of administration has been found to be safe and effective&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;28</span></a></p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">6&#46;</span><p id="par0350" class="elsevierStylePara elsevierViewall">Drug treatment&#46; Despite a lack of data from human clinical studies reporting improvements in survival&#44; the current 2010 guides continue to indicate adrenalin as the only vasopressor drug in the treatment of CA&#46;<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">-</span><p id="par0355" class="elsevierStylePara elsevierViewall">The administration of drugs should only be considered once the first discharges have been applied &#40;where indicated&#41;&#44; and following the start of chest compressions and ventilation&#46; Therefore&#44; during the treatment of CA secondary to VF&#47;VT&#44; we should administer 1<span class="elsevierStyleHsp" style=""></span>mg of adrenalin after the third discharge&#44; once the chest compressions have been resumed&#44; and then every 3&#8211;5<span class="elsevierStyleHsp" style=""></span>min &#40;during alternate CPR cycles&#41;&#46; CPR should not be interrupted for the administration of drugs&#46; There are no alternative vasopressors capable of improving survival versus adrenalin&#46;</p></li><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">-</span><p id="par0360" class="elsevierStylePara elsevierViewall">Although there is no evidence that the administration of any antiarrhythmic drug&#44; on a routine basis&#44; is able to improve survival at hospital discharge&#44; the new guides continue to recommend the administration of amiodarone in refractory ventricular fibrillation&#44;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a> after the third discharge&#46; The dose likewise remains the same&#58; 300<span class="elsevierStyleHsp" style=""></span>mg for the first dose&#44; and the perfusion of 900<span class="elsevierStyleHsp" style=""></span>mg in 24<span class="elsevierStyleHsp" style=""></span>h&#46; A posterior 150<span class="elsevierStyleHsp" style=""></span>mg bolus dose can be administered&#46;</p></li><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">-</span><p id="par0365" class="elsevierStylePara elsevierViewall">It is acknowledged that asystolia is fundamentally due to the primary myocardial disease rather than to an excessive vagal tone&#44; and that there is no clear evidence that atropine improves the results in CA&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;32</span></a> Therefore&#44; and in contrast to the previous guidelines of 2005&#44; the routine use of atropine in asystolia or electrical activity without a pulse &#40;EAWP&#41; is no longer recommended&#44; and has been eliminated from the ALS algorithm&#46; Such a medication would only be used in the context of bradyarrhythmias&#46;</p></li><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">-</span><p id="par0370" class="elsevierStylePara elsevierViewall">In recent years&#44; a number of studies have examined the role of fibrinolytic treatment in the context of CA&#44; with a view to eliminating the coronary and&#47;or pulmonary thrombus&#46; The conclusions are that such treatment should not be used on a routine basis in CA&#44; but that should be considered when CA is caused by acute pulmonary embolism&#8211;either diagnosed or suspected&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#8211;36</span></a> CPR in course is not a contraindication to fibrinolysis&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">7&#46;</span><p id="par0375" class="elsevierStylePara elsevierViewall">Less emphasis is placed on early tracheal intubation&#46; This technique should only be performed by highly skilled resuscitators&#44; with minimum interruption of the chest compressions&#46; Only a small pause in the compressions should be allowed in order to advance the tube beyond the vocal cords &#40;no more than 10<span class="elsevierStyleHsp" style=""></span>s&#41;&#46; Alternatively&#44; and in order to avoid the interruptions&#44; attempted tracheal intubation can be postponed until spontaneous circulation has been recovered&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> There is no conclusive clinical evidence that early intubation improves survival without sequelae at hospital discharge&#46; When the personnel members dealing with CA are not trained in tracheal intubation&#44; the use of supraglottic devices &#40;e&#46;g&#46;&#44; a laryngeal mask&#41; is regarded as an acceptable alternative for airway isolation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">8&#46;</span><p id="par0380" class="elsevierStylePara elsevierViewall">Since plasma drug concentration is unpredictable when medication is administered via the tracheal route&#44; the optimum drug dosage is not known&#44; and on the other hand there is now an increased availability of intraosseous devices&#59; as a result&#44; the administration of drugs through the tracheal tube is no longer recommended&#46; The administration of drugs through a supraglottic device is even less reliable&#46;</p></li><li class="elsevierStyleListItem" id="lsti0300"><span class="elsevierStyleLabel">9&#46;</span><p id="par0385" class="elsevierStylePara elsevierViewall">In line with the previous recommendations&#44; the new guides do not advise the routine use of any circulatory device as a substitute for manual chest compression&#46; However&#44; in certain patients requiring prolonged CPR maneuvering&#44; as in the case of transfers&#44; hypothermia&#44; pulmonary embolism subjected to fibrinolysis&#44; or patients undergoing computed tomography or percutaneous coronary interventions&#44; mechanical devices are effectively being used&#46;</p></li><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel">10&#46;</span><p id="par0390" class="elsevierStylePara elsevierViewall">The same importance as before is placed on correction of the potential reversible causes&#44; maintaining the rule of the 4 &#8220;Hs&#8221; and 4 &#8220;Ts&#8221;&#46;</p></li></ul></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0395" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a> provide a schematic summary of the sequence of interventions in CA&#44; in both rhythms amenable to defibrillation and in those not amenable to defibrillation&#44; respectively&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Cardiopulmonary resuscitation techniques and devices</span><p id="par0400" class="elsevierStylePara elsevierViewall">As regards the different techniques and devices used during CPR maneuvering&#44; mention should be made of the following&#58;<ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel">1&#46;</span><p id="par0405" class="elsevierStylePara elsevierViewall">Less emphasis is placed on the role of precordial percussion&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#44;39</span></a> This technique should not be used in non-witnessed out-hospital CA&#46; Precordial percussion should be considered in patients presenting witnessed&#44; monitored and unstable VT &#40;including VT without a pulse&#41;&#44; if a defibrillator cannot be immediately used&#46; However&#44; the technique should not delay either CPR maneuvering of defibrillator discharges&#46;</p></li><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">2&#46;</span><p id="par0410" class="elsevierStylePara elsevierViewall">The 2005 guides recommended the use of an exhaled CO<span class="elsevierStyleInf">2</span> detector to confirm placement of the tracheal tube&#46; In addition&#44; it was indicated that end-tidal CO<span class="elsevierStyleInf">2</span> &#40;PetCO<span class="elsevierStyleInf">2</span>&#41; monitorization could be useful as a noninvasive indicator of cardiac output during CPR maneuvering&#46; The current 2010 guidelines place greater emphasis on the use of capnography&#44; recommending quantitative registry of the capnographic wave to confirm and continuously monitor the position of the tracheal tube&#59; monitor the quality of CPR&#59; and afford an early indication of the recovery of spontaneous circulation&#46; Although other methods are available for confirming the position of the tracheal tube&#44; continuous capnographic wave registry is the most reliable option&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40&#44;41</span></a> The monitorization of this wave is particularly important in moments when the tracheal tube may become displaced from its correct position&#44; as during patient transfer&#46; In order for the capnographic system to measure exhaled CO<span class="elsevierStyleInf">2</span>&#44; there must be blood flow through the lungs&#46; In this context&#44; ineffective compressions&#44; a drop in cardiac output&#44; or a new situation of CA &#40;in a patient who had already recovered spontaneous circulation&#41;&#44; are associated with decreased PetCO<span class="elsevierStyleInf">2</span>&#46; In contrast&#44; the restoration of spontaneous circulation increases PetCO<span class="elsevierStyleInf">2</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0320"><span class="elsevierStyleLabel">3&#46;</span><p id="par0415" class="elsevierStylePara elsevierViewall">The potential role of ultrasound in ALS is acknowledged&#46; Although no study has shown the use of ultrasound to improve the prognosis of CA&#44; it is clear that echocardiography is able to detect a number of the potentially reversible causes of CA &#40;e&#46;g&#46;&#44; pericardial tamponade&#44; pulmonary embolism&#44; hypovolemia&#44; pneumothorax&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#8211;44</span></a> However&#44; the incorporation of ultrasound to ALS requires important training in order to be used in only certain situations&#44; and with minimum interruption of the chest compressions &#40;attempting to obtain &#8220;useful&#8221; images in under 10<span class="elsevierStyleHsp" style=""></span>s&#41;&#46; The sub-xiphoid window is advised&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Post-resuscitation care</span><p id="par0420" class="elsevierStylePara elsevierViewall">In contrast to the guides of 2005&#44; the current guidelines of 2010 attach special attention and importance to post-CA syndrome and post-resuscitation care&#46; Post-CA syndrome comprises post-CA brain damage&#44; post-CA myocardial dysfunction&#44; the systemic response to ischemia&#47;reperfusion&#44; and persistence of the triggering or causal disorder&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> The severity of this syndrome varies according to the duration and cause of CA&#46; Post-CA brain damage can be exacerbated by failure of the microcirculation&#44; impaired auto-regulation&#44; hypercapnia&#44; hyperoxia&#44; fever&#44; hyperglycemia and seizures&#46;</p><p id="par0425" class="elsevierStylePara elsevierViewall">It is clearly accepted that success in the recovery of spontaneous circulation is only the first step towards full recovery in patients with CA&#46; It is important to acknowledge that the treatment received in this post-resuscitation period exerts a significant influence upon the ultimate neurological prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">47&#8211;49</span></a> The post-resuscitation phase begins in the place where the recovery of spontaneous circulation is achieved&#44; though once stabilized&#44; the patient must be moved to intensive care for continuous monitorization and treatment&#46; <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a> and <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> summarize the actions and multisystemic approach required in the post-resuscitation care of the adult patient&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0430" class="elsevierStylePara elsevierViewall">The most important changes in the current guides can be summarized as follows&#58;<ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0325"><span class="elsevierStyleLabel">1&#46;</span><p id="par0435" class="elsevierStylePara elsevierViewall">The introduction of a detailed and structured post-resuscitation treatment protocol can improve survival among patients with CA following the recovery of spontaneous circulation&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a></p></li><li class="elsevierStyleListItem" id="lsti0330"><span class="elsevierStyleLabel">2&#46;</span><p id="par0440" class="elsevierStylePara elsevierViewall">Airway and ventilation&#58; As in the previous guides&#44; consideration is required of tracheal intubation&#44; sedation and mechanical ventilation in any patient with altered brain function&#46; Emphasis is placed on the fact that both hypoxemia and hypercapnia increase the probability of ulterior CA&#44; and can contribute to secondary brain damage&#46; Different animal studies have found that hypoxemia induces oxidative stress and causes post-ischemic neuron damage&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> In an experimental study and in a clinical registry it has been found that post-resuscitation hyperoxemia is associated to a poorer prognosis compared with normo- or hypoxemia&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> In clinical practice&#44; the recommendation is to adjust the inhaled oxygen fraction in order to keep arterial oxygen saturation &#40;as determined by blood gases and&#47;or pulsioximetry&#41; in the range of 94&#8211;98&#37;&#44; which could be referred to as &#8220;controlled reoxygenation&#8221;&#46;</p><p id="par0445" class="elsevierStylePara elsevierViewall">Following CA&#44; hypocapnia induced by hyperventilation produces brain ischemia &#40;secondary to cerebral vasoconstriction and a decrease in cerebral blood flow&#41;&#46; There are no data in support of a specific target arterial PCO<span class="elsevierStyleInf">2</span> following resuscitation&#44; though it seems reasonable to adjust ventilation to secure normocapnia&#44; with monitorization based on capnography and the arterial blood gas values&#46;</p></li><li class="elsevierStyleListItem" id="lsti0335"><span class="elsevierStyleLabel">3&#46;</span><p id="par0450" class="elsevierStylePara elsevierViewall">Circulation&#58; Increased emphasis is placed on the usefulness of primary coronary intervention in appropriate patients&#44; including comatose individuals&#44; with the sustained recovery of spontaneous circulation after CA&#46; Given the high percentage of patients with CA who suffer coronary disease&#44; and the well established indication of coronariography and early primary coronary intervention in post-CA patients with ST-segment elevation acute myocardial infarction &#40;AMI&#41;&#44; it is recommended that this intervention should be considered in all post-CA patients in which the existence of coronary disease is suspected&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50&#44;53&#8211;56</span></a> In addition&#44; several studies have indicated that the combination of therapeutic hypothermia and primary coronary intervention is both feasible and safe after CA secondary to AMI&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50&#44;57&#44;58</span></a></p><p id="par0455" class="elsevierStylePara elsevierViewall">The treatment of post-CA hemodynamic instability with fluids&#44; inotropic agents and vasopressors can be guided by physiological and laboratory test parameters such as blood pressure&#44; heart rate&#44; diuresis&#44; plasma lactate and central venous oxygen levels&#46; Although early target-guided therapy is well established in the management of sepsis and has been proposed as a therapeutic strategy after CA&#44; no controlled and randomized studies have warranted its routine use&#46; As targets&#44; we should use mean blood pressure for ensuring adequate diuresis &#40;1<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h&#41; and normal or decreasing plasma lactate levels&#44; taking into consideration the normal blood pressure of the patient&#44; the cause of CA&#44; and the severity of any myocardial dysfunction&#46;</p></li><li class="elsevierStyleListItem" id="lsti0340"><span class="elsevierStyleLabel">4&#46;</span><p id="par0460" class="elsevierStylePara elsevierViewall">Control of seizures&#58; The appearance of seizures increases brain metabolism and can cause brain damage&#46; In a way similar to the specifications of the previous guidelines&#44; the new guides stress the immediate and effective management of seizures with benzodiazepines&#44; phenytoin&#44; sodium valproate&#44; propofol or a barbiturate&#46; Myoclonus may prove difficult to treat&#59; clonazepam is the most effective drug&#44; but sodium valproate&#44; levetiracetam and propofol can be effective alternatives&#46; There are no studies definitively warranting the use of prophylactic drug treatment against seizures after CA in adult patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0345"><span class="elsevierStyleLabel">5&#46;</span><p id="par0465" class="elsevierStylePara elsevierViewall">Blood glucose control&#58; There is a strong correlation between elevated blood glucose after CA resuscitation and a poor neurological prognosis&#46; Control of blood glucose is therefore recommended&#46; The resuscitation guidelines of 2010 have revised this recommendation&#46; Based on the data available at the time of preparation of the guides&#44; the recommendation is to keep blood glucose after the recovery of spontaneous circulation at levels of &#8804;10<span class="elsevierStyleHsp" style=""></span>mmol&#47;l &#40;180<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> Severe hypoglycemia is associated to increased mortality in critical patients&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a> and comatose individuals are at special risk of suffering undetected hypoglycemia&#46; It is therefore agreed that hypoglycemia should be avoided&#46; Strict blood glucose control &#40;72&#8211;108<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; 4&#8211;6<span class="elsevierStyleHsp" style=""></span>mmol&#47;l&#41; should not be applied in adults with recovery of spontaneous circulation after CA&#44; due to the increased risk of hypoglycemia&#46;</p></li><li class="elsevierStyleListItem" id="lsti0350"><span class="elsevierStyleLabel">6&#46;</span><p id="par0470" class="elsevierStylePara elsevierViewall">Therapeutic hypothermia&#58; In a clearer manner and in the context of more global post-resuscitation care&#44; the new 2010 guidelines underscore the key role of therapeutic hypothermia&#46; This technique would be applicable to comatose CA survivors initially associated to both rhythms not amenable to fibrillation and to rhythms amenable to defibrillation&#46; There is admittedly less evidence in favor of its use after CA due to rhythms not amenable to defibrillation&#46;</p><p id="par0475" class="elsevierStylePara elsevierViewall">In the recommendations&#44; careful revision is made of the following&#58;<ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0355"><span class="elsevierStyleLabel">-</span><p id="par0480" class="elsevierStylePara elsevierViewall">The physiological bases explaining why moderate hypothermia has been shown to be neuroprotective and improves the prognosis after a period of global hypoxia-brain ischemia&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a></p></li><li class="elsevierStyleListItem" id="lsti0360"><span class="elsevierStyleLabel">-</span><p id="par0485" class="elsevierStylePara elsevierViewall">What post-CA patients should receive therapeutic hypothermia&#63; There is good evidence supporting the use of induced hypothermia in comatose survivors of out-hospital CA caused by rhythms amenable to defibrillation&#46; It seems reasonable to extrapolate these data to other types of CA involving other initial rhythms or in-hospital arrest&#44; though the supporting evidence in these cases is of lower level&#46;</p></li><li class="elsevierStyleListItem" id="lsti0365"><span class="elsevierStyleLabel">-</span><p id="par0490" class="elsevierStylePara elsevierViewall">How should cooling be carried out&#63; The guides revise the possible different techniques for the induction and maintenance of hypothermia&#44; and the ways to posteriorly induce warming&#46; Internal and&#47;or external techniques can be used to start cooling&#46; The infusion of 30<span class="elsevierStyleHsp" style=""></span>ml&#47;kg of saline solution at 4<span class="elsevierStyleHsp" style=""></span>&#176;C reduces the core temperature approximately 1&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C&#44;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">62&#8211;65</span></a> and has been shown to be safe and effective&#46; It can be used to start cooling from the pre-hospital setting&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">66&#44;67</span></a> In the maintenance phase it is preferable to use a cooling technique with effective temperature monitorization&#44; in order to avoid temperature fluctuations&#46; Temperature is normally monitored in the bladder and&#47;or esophagus&#46; There are no data suggesting that any specific cooling method improves survival when compared with any other cooling technique&#59; however&#44; internal devices allow more precise control of temperature compared with the external techniques&#46; Warming in turn is to be carried out slowly&#58; although the optimum rate has not been established&#44; the current consensus is that warming should be carried out at a rate of 0&#46;25&#8211;0&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C&#47;h&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a></p></li><li class="elsevierStyleListItem" id="lsti0370"><span class="elsevierStyleLabel">-</span><p id="par0495" class="elsevierStylePara elsevierViewall">When should hypothermia be carried out&#63; Data from experimental studies indicate that earlier cooling after the recovery of spontaneous circulation results in a better prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a> Although a number of studies have shown that hypothermia can be started early&#44; to date in the pre-hospital setting there are no data in humans proving that a given temperature&#8211;time target offers improved prognosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0375"><span class="elsevierStyleLabel">-</span><p id="par0500" class="elsevierStylePara elsevierViewall">The guides also revise the physiological effects&#44; complications and contraindications of hypothermia&#44; thus facilitating understanding of the technique and its application in clinical practice&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0380"><span class="elsevierStyleLabel">7&#46;</span><p id="par0505" class="elsevierStylePara elsevierViewall">Other treatments&#46; The current guides review the literature on neuroprotective drugs &#40;coenzyme Q10&#44; thiopental&#44; glucocorticoids&#44; nimodipine&#44; lidoflazine or diazepam&#41; used either alone or added to therapeutic hypothermia&#46; It is emphasized that these agents have not been shown to increase survival with neurologically intact situations when included in post-CA management&#46; There is also insufficient evidence to support the routine use of high-volume hemofiltration to improve the neurological prognosis in patients with recovery of spontaneous circulation after CA&#46;</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Prognosis</span><p id="par0510" class="elsevierStylePara elsevierViewall">The resuscitation guides of the year 2010 point out that many of the accepted predictors of poor survival in comatose CA survivors are not reliable&#44; particularly if the patient has been subjected to therapeutic hypothermia&#46; In general&#44; the potential predictors have been examined&#58;<ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0385"><span class="elsevierStyleLabel">-</span><p id="par0515" class="elsevierStylePara elsevierViewall">Clinical exploration&#46; There is no neurological clinical sign capable of reliably defining a poor prognosis &#40;Cerebral Performance Category &#40;CPC&#41; 3 or 4&#44; or death&#41; in under 24<span class="elsevierStyleHsp" style=""></span>h after CA&#46; The absence of pupil reaction to light and of corneal reflexes for over 72<span class="elsevierStyleHsp" style=""></span>h can reliably indicate a poor prognosis<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a> in adult comatose patients who have not been subjected to hypothermia and do not present confounding factors such as hypotension&#44; sedatives or muscle relaxants&#46;</p></li><li class="elsevierStyleListItem" id="lsti0390"><span class="elsevierStyleLabel">-</span><p id="par0520" class="elsevierStylePara elsevierViewall">Biochemical markers&#46; Although many markers have been studied&#44; the current evidence does not warrant the use of serum or cerebrospinal fluid biomarkers isolatedly as indicators of a poor prognosis in comatose patients after CA&#44; regardless of whether they are subjected to therapeutic hypothermia or not&#46; This is due to the limitations of the studies made to date&#44; with the inclusion of only a small number of patients and&#47;or to inconsistencies in the cutoff values used to predict a poor prognosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0395"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">-</span></span><p id="par0525" class="elsevierStylePara elsevierViewall">Electrophysiological markers&#58; No electrophysiological study is able to offer a fully reliable prognosis of the comatose patient in the first 24<span class="elsevierStyleHsp" style=""></span>h after CA&#46; In the absence of confounding factors or circumstances &#40;sedation&#44; hypotension&#44; hypothermia or hypoxemia&#41;&#44; it may be reasonable to use EEG &#40;identifying generalized suppression at under 20<span class="elsevierStyleHsp" style=""></span>&#956;V&#44; burst-suppression pattern with generalized epileptic activity&#44; or diffuse periodic complexes over flattened basal activity&#41;&#44; performed between 24 and 72<span class="elsevierStyleHsp" style=""></span>h after the recovery of spontaneous circulation&#44; as a help in predicting a poor prognosis among comatose CA survivors not subjected to hypothermia&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a> If somatosensory evoked potentials &#40;SSEPs&#41; are recorded after 24<span class="elsevierStyleHsp" style=""></span>h in comatose CA survivors not subjected to therapeutic hypothermia&#44; the bilateral absence of N20 cortical response to stimulation of the median nerve is indicative of a poor prognosis &#40;death or CPC 3 or 4&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a></p></li><li class="elsevierStyleListItem" id="lsti0400"><span class="elsevierStyleLabel">-</span><p id="par0530" class="elsevierStylePara elsevierViewall">Imaging studies&#58; Likewise&#44; no studies offering level one or two evidence have been found supporting the use of any imaging technique to reliably establish the prognosis of comatose CA survivors&#46; Overall&#44; the imaging studies that have been carried out are limited to small sample sizes&#44; with variability in the timing of imaging&#44; the lack of a standardized prognostic method for comparison purposes&#44; and the early withdrawal of care measures&#46; Despite its enormous potential&#44; neuroimaging is not recommended for routine decision taking in this context&#46;</p></li></ul></p><p id="par0535" class="elsevierStylePara elsevierViewall">As has been commented above&#44; defining a prognosis is even more complicated in patients who have been subjected to therapeutic hypothermia after cardiac arrest&#46; No neurological clinical signs&#44; electrophysiological studies&#44; biomarkers or imaging techniques have been found to offer a reliable neurological prognosis in the first 24<span class="elsevierStyleHsp" style=""></span>h after CA&#46; Based on the limited available evidence&#44; the potentially most reliable predictors of poor prognosis in patients subjected to therapeutic hypothermia are the bilateral absence of peak N20 in the SSEPs &#8805;24<span class="elsevierStyleHsp" style=""></span>h after CA &#40;false-positive rate 0&#37;&#44; 95&#37; CI&#58; 0&#8211;69&#37;&#41; and the absence of corneal and pupil reflexes three or more days after CA &#40;false-positive rate 0&#37;&#44; 95&#37; CI&#58; 0&#8211;48&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">72&#44;73</span></a> In a study carried out in patients subjected to post-CA therapeutic hypothermia&#44; an algorithm was developed based on a series of data &#40;clinical and electrophysiological&#41;&#44; demonstrating that the presence of two independent predictors of poor neurological prognosis &#40;incomplete recovery of trunk reflexes&#44; early myoclonus&#44; a non-reactive EEG tracing and bilateral cortical absence of SSEPs&#41; confirms a poor prognosis with a false-positive rate of 0&#37; &#40;95&#37; CI&#58; 0&#8211;14&#37;&#41;&#46; In general&#44; and given the limited available evidence&#44; decisions to limit care should not be taken on the basis of the results obtained with a single prognostic tool&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Non-heart beating donors and reference centers in cardiac arrest</span><p id="par0540" class="elsevierStylePara elsevierViewall">Lastly&#44; these recent resuscitation guides of 2010 raise two concepts that should be taken into account in relation to resuscitation&#46; Firstly&#44; since successful solid organ transplants have been performed after cardiac death&#44; the possibility has been suggested of recruiting some post-CA patients to expand the pool of organ donors &#40;&#8220;non-heart beating&#8221; donors&#41;&#44; which remains so scarce in comparison with the potential number of organ recipients&#46; Graft function after transplantation is conditioned by the duration of warm ischemia from the cessation of cardiac output to the time of organ preservation&#46; When a delay is expected in the time to starting organ preservation&#44; mechanical chest compression devices may be useful for maintaining adequate organ perfusion while the steps needed to allow organ donation are taken&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a></p><p id="par0545" class="elsevierStylePara elsevierViewall">There is enormous variability in survival among different hospitals that deal with patients resuscitated from cardiac arrest&#46; There is some low-level evidence that ICUs which treat more post-CA patients a year show improved survival figures compared with those Units which receive fewer such cases&#46; Several studies have reported improvements in survival after the implementation of a series of post-resuscitation care measures including therapeutic hypothermia and primary coronary intervention&#46; On the other hand&#44; several studies of out-hospital CA in adults have reported no effects upon survival at hospital discharge attributable to the transfer interval from the scene of CA to arrival in hospital&#44; provided recovery of spontaneous circulation is achieved on the scene and transfer is brief &#40;3&#8211;11<span class="elsevierStyleHsp" style=""></span>min&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">75&#44;76</span></a> This means that it may be safe not to transfer post-CA patients to local hospital centers but to ensure transfer to a regional CA center&#46; There is indirect evidence that regional cardiac resuscitation systems improve the prognosis of myocardial infarction with ST-segment elevation&#46; The consequence of these data is that the centers and healthcare systems specialized in CA may be effective&#44; though there is still no direct evidence in support of this hypothesis&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">77&#44;78</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Summary of the changes since the guides of 2005</span><p id="par0550" class="elsevierStylePara elsevierViewall">Finally&#44; it should be commented that many of the recommendations of the ERC guides of 2005 remain without changes&#44; either because no new studies have been published&#44; or because the new evidence generated since 2005 simply reinforces the already existing evidence&#46; However&#44; the evidence published since 2005 does point to the need for changes in some parts of the 2010 guidelines&#46; The changes of 2010 in relation to the guides of 2005&#44; referred to advanced life support&#44; can be summarized as follows<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#58;<ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0405"><span class="elsevierStyleLabel">-</span><p id="par0555" class="elsevierStylePara elsevierViewall">Increased emphasis on the importance of high-quality chest compressions with minimum interruption throughout any ALS attempt&#58; chest compressions are only briefly interrupted to allow specific interventions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0410"><span class="elsevierStyleLabel">-</span><p id="par0560" class="elsevierStylePara elsevierViewall">Increased emphasis on the use of &#8220;alarm and tracing systems&#8221; to detect patient worsening and allow treatment for the prevention of in-hospital CA&#46;</p></li><li class="elsevierStyleListItem" id="lsti0415"><span class="elsevierStyleLabel">-</span><p id="par0565" class="elsevierStylePara elsevierViewall">Increased attention to the alarm signs associated to the potential risk of sudden cardiac death outside the hospital&#46;</p></li><li class="elsevierStyleListItem" id="lsti0420"><span class="elsevierStyleLabel">-</span><p id="par0570" class="elsevierStylePara elsevierViewall">Elimination of the recommendation of a predetermined period of CPR before out-hospital defibrillation after CA not witnessed by the medical emergency services &#40;MES&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0425"><span class="elsevierStyleLabel">-</span><p id="par0575" class="elsevierStylePara elsevierViewall">Maintenance of the chest compressions while the defibrillator is being charged &#40;this serving to minimize the pre-discharge pause&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0430"><span class="elsevierStyleLabel">-</span><p id="par0580" class="elsevierStylePara elsevierViewall">Less emphasis on the role of precordial percussion&#46;</p></li><li class="elsevierStyleListItem" id="lsti0435"><span class="elsevierStyleLabel">-</span><p id="par0585" class="elsevierStylePara elsevierViewall">The delivery of up to three rapid and consecutive &#40;grouped&#41; discharges in ventricular fibrillation&#47;ventricular tachycardia without a pulse &#40;VF&#47;VT&#41; occurring in the cardiac catheterization room or in the immediate postoperative period of heart surgery&#46;</p></li><li class="elsevierStyleListItem" id="lsti0440"><span class="elsevierStyleLabel">-</span><p id="par0590" class="elsevierStylePara elsevierViewall">Drug administration through the tracheal tube is no longer advised &#40;if an intravenous access cannot be established&#44; the drugs should be administered via the intraosseous &#40;IO&#41; route&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0445"><span class="elsevierStyleLabel">-</span><p id="par0595" class="elsevierStylePara elsevierViewall">During the treatment of CA secondary to VF&#47;VT&#44; we should administer 1<span class="elsevierStyleHsp" style=""></span>mg of adrenalin after the third discharge&#44; once the chest compressions have been resumed&#44; and then every 3&#8211;5<span class="elsevierStyleHsp" style=""></span>min &#40;during alternate CPR cycles&#41;&#46; After the third discharge&#44; 300<span class="elsevierStyleHsp" style=""></span>mg of amiodarone are also administered&#46;</p></li><li class="elsevierStyleListItem" id="lsti0450"><span class="elsevierStyleLabel">-</span><p id="par0600" class="elsevierStylePara elsevierViewall">The routine use of atropine in asystolia or in electrical activity without a pulse &#40;EAWP&#41; is no longer recommended&#46;</p></li><li class="elsevierStyleListItem" id="lsti0455"><span class="elsevierStyleLabel">-</span><p id="par0605" class="elsevierStylePara elsevierViewall">Less emphasis is placed on early tracheal intubation&#44; unless carried out by trained persons who are very experienced in the technique&#44; and ensuring minimal interruption of the chest compressions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0460"><span class="elsevierStyleLabel">-</span><p id="par0610" class="elsevierStylePara elsevierViewall">Increased emphasis on the use of capnography to confirm and continuously monitor the position of the tracheal tube&#44; the quality of CPR&#44; and to afford an early indication of the recovery of spontaneous circulation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0465"><span class="elsevierStyleLabel">-</span><p id="par0615" class="elsevierStylePara elsevierViewall">The potential role of ultrasound in ALS is acknowledged&#46;</p></li><li class="elsevierStyleListItem" id="lsti0470"><span class="elsevierStyleLabel">-</span><p id="par0620" class="elsevierStylePara elsevierViewall">Recognition of the potential damage caused by hyperoxemia after achieving the recovery of spontaneous circulation&#58; once spontaneous circulation and arterial blood oxygen saturation &#40;SaO<span class="elsevierStyleInf">2</span>&#41; have been restored&#44; reliable monitorization can be carried out using pulsioximetry and&#47;or arterial blood gas measurements-adjusting the inhaled oxygen concentration to obtain SaO<span class="elsevierStyleInf">2</span> 94&#8211;98&#37;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0475"><span class="elsevierStyleLabel">-</span><p id="par0625" class="elsevierStylePara elsevierViewall">Much greater attention and emphasis is placed on treatment of post-CA syndrome&#46;</p></li><li class="elsevierStyleListItem" id="lsti0480"><span class="elsevierStyleLabel">-</span><p id="par0630" class="elsevierStylePara elsevierViewall">The implementation of a detailed and structured post-resuscitation treatment protocol is recognized as being able to improve survival among CA victims after the recovery of spontaneous circulation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0485"><span class="elsevierStyleLabel">-</span><p id="par0635" class="elsevierStylePara elsevierViewall">Increased emphasis is placed on the use of primary coronary intervention in appropriate cases &#40;including comatose patients&#41; with sustained recovery of spontaneous circulation after CA&#46;</p></li><li class="elsevierStyleListItem" id="lsti0490"><span class="elsevierStyleLabel">-</span><p id="par0640" class="elsevierStylePara elsevierViewall">Revision is made of the recommendation referred to blood glucose control&#58; in adults with sustained recovery of spontaneous circulation after CA&#44; blood glucose values of &#62;10<span class="elsevierStyleHsp" style=""></span>mmol&#47;l &#40;&#62;180<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; should be treated&#44; though avoiding hypoglycemia&#46;</p></li><li class="elsevierStyleListItem" id="lsti0495"><span class="elsevierStyleLabel">-</span><p id="par0645" class="elsevierStylePara elsevierViewall">Utilization of therapeutic hypothermia also in comatose CA survivors initially associated to rhythms both amenable and not amenable to defibrillation&#46; It is recognized that there is less evidence in favor of such use after CA involving rhythms not amenable to defibrillation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0500"><span class="elsevierStyleLabel">-</span><p id="par0650" class="elsevierStylePara elsevierViewall">Recognition that many of the accepted predictors of poor prognosis in comatose CA survivors are not reliable&#44; particularly if the patient has been subjected to therapeutic hypothermia&#46;</p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0655" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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          "identificador" => "xres9158"
          "titulo" => "Abstract"
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        1 => array:2 [
          "identificador" => "xpalclavsec10598"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres9159"
          "titulo" => "Resumen"
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          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Prevention of in-hospital cardiac arrest &#40;CA&#41;"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Resuscitation in the hospital"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Immediate actions in the case of patients collapsing in hospital"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Start of CPR in the hospital"
        ]
        9 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Simplified advanced life support algorithm"
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        10 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Cardiopulmonary resuscitation techniques and devices"
        ]
        11 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Post-resuscitation care"
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        12 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Prognosis"
        ]
        13 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Non-heart beating donors and reference centers in cardiac arrest"
        ]
        14 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Summary of the changes since the guides of 2005"
        ]
        15 => array:2 [
          "identificador" => "sec0060"
          "titulo" => "Conflicts of interest"
        ]
        16 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-03-06"
    "fechaAceptado" => "2011-03-11"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec10598"
          "palabras" => array:6 [
            0 => "Cardiac arrest"
            1 => "Resuscitation"
            2 => "Advanced life support"
            3 => "Post-resuscitation"
            4 => "Prognosis"
            5 => "Organ donation"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec10599"
          "palabras" => array:6 [
            0 => "Parada cardiaca"
            1 => "Resucitaci&#243;n"
            2 => "Soporte vital avanzado"
            3 => "Posresucitaci&#243;n"
            4 => "Pron&#243;stico"
            5 => "Donaci&#243;n de &#243;rganos"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We present some of the most important developments in advanced life support incorporating the new international recommendations for resuscitation 2010&#46; The study highlights aspects related to prevention and early detection of in-hospital cardiac arrest&#44; resuscitation in the hospital&#44; the new advanced life support algorithm&#44; the techniques and devices for cardiopulmonary resuscitation&#44; post-resuscitation care&#44; assessment of the prognosis of patients who survive initially&#44; and specific aspects of non-beating heart organ donation and the creation of cardiac arrest referral centers&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se presentan a continuaci&#243;n algunas de las novedades m&#225;s importantes en soporte vital avanzado que incorporan las nuevas recomendaciones internacionales en resucitaci&#243;n de 2010&#46; Se destacan los aspectos relacionados con la prevenci&#243;n y detecci&#243;n precoz de la parada cardiaca intrahospitalaria&#44; la resucitaci&#243;n en el hospital&#44; el nuevo algoritmo de soporte vital avanzado&#44; las t&#233;cnicas y dispositivos de resucitaci&#243;n cardiopulmonar&#44; los cuidados posresucitaci&#243;n&#44; la valoraci&#243;n del pron&#243;stico de los pacientes que sobreviven inicialmente a la parada y aspectos espec&#237;ficos relativos a la donaci&#243;n de &#243;rganos a coraz&#243;n parado y la creaci&#243;n de centros de referencia de parada cardiaca&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; P&#233;rez-Vela JL&#44; et al&#46; Novedades en soporte vital avanzado&#46; Med Intensiva&#46; 2011&#59;35&#58;373&#8211;87&#46;</p>"
      ]
    ]
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      0 => array:7 [
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        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Algorithm for the treatment of cardiac arrest in the hospital&#46; &#42;Airway&#44; respiration&#44; circulation&#44; disability&#44; exposure&#46;</p>"
        ]
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        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Algorithm of advanced life support in cardiac arrest&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
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            "Tamanyo" => 311040
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        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Intervention sequence in cardiac arrest&#46; Rhythm amenable to defibrillation&#46;</p>"
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      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Intervention sequence in cardiac arrest&#46; Rhythm not amenable to defibrillation&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Immediate post-cardiac arrest care in the adult&#46;</p>"
        ]
      ]
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        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Report if score<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>4&#46;</p>"
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                0 => """
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Parameter&#47;score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Respiratory frequency &#40;rpm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8804;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#8211;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#8211;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#8211;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oxygen saturation &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85&#8211;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90&#8211;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Temperature &#40;&#176;C&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8804;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#46;1&#8211;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#46;1&#8211;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;1&#8211;37&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#8211;38&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;38&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Heart rate &#40;bpm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8804;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#8211;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51&#8211;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#8211;110&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">111&#8211;130&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;130&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="8" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Systolic blood pressure &#40;separate evaluation&#41;</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sedation score &#40;independent&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#8211;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diuresis &#40;ml in 4<span class="elsevierStyleHsp" style=""></span>h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80&#8211;119&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">120&#8211;800&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;800&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab8749.png"
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          "notaPie" => array:1 [
            0 => array:2 [
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara">Sedation score&#58;</p> <p class="elsevierStyleNotepara">0&#58; Awake&#47;alert</p> <p class="elsevierStyleNotepara">1&#58; Asleep&#44; responds to stimuli</p> <p class="elsevierStyleNotepara">2&#58; Mild&#58; occasionally drowsy&#44; easily awakened</p> <p class="elsevierStyleNotepara">3&#58; Moderate&#58; often drowsy&#44; easy to awaken but cannot keep awake</p> <p class="elsevierStyleNotepara">4&#58; Severe&#58; difficult to awaken</p>"
            ]
          ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Modified early warning score&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Vital signs to evaluate&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ventilation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hemodynamics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cardiovascular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neurological&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metabolic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tracheal intubation if possible&#44; in comatoseCapnography&#58;Confirm airwayAdjust ventilationPetCO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#8776;<span class="elsevierStyleHsp" style=""></span>35&#8211;40PaCO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#8776;<span class="elsevierStyleHsp" style=""></span>40&#8211;45<span class="elsevierStyleHsp" style=""></span>mmHgChest Rx&#58;Confirm airwayDetect causes or complications of cardiac arrest&#44; e&#46;g&#46;&#44; lung edemaPulsioximetry&#47;gases&#58;Maintain adequate oxygenation and adjust FiO<span class="elsevierStyleInf">2</span>Sat pO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>94&#37;PaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#8776;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mmHgMechanical ventilation&#58;Minimize acute lung damage and potential oxygen toxicityTidal volume 6&#8211;8<span class="elsevierStyleHsp" style=""></span>ml&#47;kgAdjust minute volume for indicated PaCO<span class="elsevierStyleInf">2</span> and PetCO<span class="elsevierStyleInf">2</span>Adjust FiO<span class="elsevierStyleInf">2</span> for indicated SatpO<span class="elsevierStyleInf">2</span> and SaO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Blood pressure monitorization&#47;assess arterial catheterMaintain MBP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>65 or SBP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>90<span class="elsevierStyleHsp" style=""></span>mmHgTreatment hypotension&#58;FluidsDopamine 5&#8211;10<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;minNoradrenalin 0&#46;1&#8211;0&#46;5<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;minAdrenalin 0&#46;1&#8211;0&#46;5<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Cardiac monitorization&#58;<span class="elsevierStyleHsp" style=""></span>Detect and treat arrhythmias<span class="elsevierStyleHsp" style=""></span>No prophylactic antiarrhythmic drugs<span class="elsevierStyleHsp" style=""></span>Assess reversible causes12-lead ECG&#47;troponin&#58;<span class="elsevierStyleHsp" style=""></span>Detect ACS&#47;AMI with ST elevation<span class="elsevierStyleHsp" style=""></span>Assess QT-intervalTreatment ACS&#58;<span class="elsevierStyleHsp" style=""></span>Aspirin&#47;heparin<span class="elsevierStyleHsp" style=""></span>Transfer to center with options for primary coronary intervention<span class="elsevierStyleHsp" style=""></span>Consider primary coronary intervention&#47;fibrinolysisEchocardiogram to detect global stunning&#44; segment disorders&#44; structural myocardiopathy problemsTreatment of myocardial stunning&#58;<span class="elsevierStyleHsp" style=""></span>Fluids<span class="elsevierStyleHsp" style=""></span>Inotropic agents<span class="elsevierStyleHsp" style=""></span>Counterpulsation balloon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Serial explorations&#58;<span class="elsevierStyleHsp" style=""></span>To define coma&#44; brain damage and prognosis<span class="elsevierStyleHsp" style=""></span>Response to verbal instructions&#47;stimuli<span class="elsevierStyleHsp" style=""></span>Pupil and corneal reflexes and eye movements<span class="elsevierStyleHsp" style=""></span>Cough&#44; respirationEEG monitorization if comatoseAntiseizure drugs in case of crisisCore temperature if comatose&#58;<span class="elsevierStyleHsp" style=""></span>Prevent hyperpyrexia &#40;<span class="elsevierStyleItalic">T</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>37&#46;7<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;<span class="elsevierStyleHsp" style=""></span>Induce therapeutic hypothermia in absence of contraindications<span class="elsevierStyleHsp" style=""></span>After 24<span class="elsevierStyleHsp" style=""></span>h&#44; slow warming &#40;0&#46;25<span class="elsevierStyleHsp" style=""></span>&#176;C&#47;h&#41;Brain CT&#46; Discard primary intracranial processesSedation&#47;muscle relaxation&#46; Control shivers&#44; restlessness&#44; and adjust to mechanical ventilation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Serial lactate determinations to assess adequate perfusionPotassium to avoid hypokalemia &#40;which favors arrhythmias&#41;<span class="elsevierStyleHsp" style=""></span>Maintain K<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3&#46;5 mEq&#47;lDiuresis&#47;creatinine&#58;<span class="elsevierStyleHsp" style=""></span>Maintain euvolemiaRenal replacement therapy if necessary<span class="elsevierStyleHsp" style=""></span>Detect acute renal failureBlood glucose&#58; detect hyper-&#47;hypoglycemia<span class="elsevierStyleHsp" style=""></span>Treat hypoglycemia<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>80<span class="elsevierStyleHsp" style=""></span>mg&#47;dl<span class="elsevierStyleHsp" style=""></span>Treat hyperglycemia to reach blood glucose<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>180<span class="elsevierStyleHsp" style=""></span>mg&#47;dl<span class="elsevierStyleHsp" style=""></span>Use insulin protocolsAvoid hypotonic fluids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Multisystemic approach to post-cardiac arrest management&#46;</p>"
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    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:78 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "European Resuscitation Council for Resuscitation 2010&#46; Section 1&#58; Executive summary"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;P&#46; Nolan"
                            1 => "J&#46; Soar"
                            2 => "D&#46;A&#46; Zideman"
                            3 => "D&#46; Biarent"
                            4 => "L&#46;L&#46; Bossaert"
                            5 => "C&#46; Deakin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.resuscitation.2010.08.021"
                      "Revista" => array:6 [
                        "tituloSerie" => "Resuscitation"
                        "fecha" => "2010"
                        "volumen" => "81"
                        "paginaInicial" => "1219"
                        "paginaFinal" => "1276"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20956052"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Part 1&#58; executive summary&#58; 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;F&#46; Hazinski"
                            1 => "J&#46;P&#46; Nolan"
                            2 => "J&#46;E&#46; Billi"
                            3 => "B&#46;W&#46; Bottiger"
                            4 => "L&#46; Bossaert"
                            5 => "A&#46;R&#46; De Caen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/CIRCULATIONAHA.110.970897"
                      "Revista" => array:7 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "2010"
                        "volumen" => "122"
                        "numero" => "Suppl&#46; 2"
                        "paginaInicial" => "S250"
                        "paginaFinal" => "S275"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20956249"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "European Resuscitation Council Guidelines for Resuscitation 2010&#46; Section 4&#58; Adult advanced life support"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46;D&#46; Deakin"
                            1 => "J&#46;P&#46; Nolan"
                            2 => "J&#46; Soar"
                            3 => "K&#46; Sunde"
                            4 => "R&#46;W&#46; Koster"
                            5 => "G&#46;B&#46; Smith"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.resuscitation.2010.08.017"
                      "Revista" => array:6 [
                        "tituloSerie" => "Resuscitation"
                        "fecha" => "2010"
                        "volumen" => "81"
                        "paginaInicial" => "1305"
                        "paginaFinal" => "1352"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20956049"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "In-hospital cardiac arrest&#58; it is time for an in-hospital &#8220;chain&#8221; of prevention&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "G&#46;B&#46; Smith"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.resuscitation.2010.04.017"
                      "Revista" => array:6 [
                        "tituloSerie" => "Resuscitation"
                        "fecha" => "2010"
                        "volumen" => "81"
                        "paginaInicial" => "1209"
                        "paginaFinal" => "1211"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20598425"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guidelines on critical care services and personnel&#58; recommendations based on a system of categorization of three levels of care"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;T&#46; Haupt"
                            1 => "C&#46;E&#46; Bekes"
                            2 => "R&#46;J&#46; Brilli"
                            3 => "L&#46;C&#46; Carl"
                            4 => "A&#46;W&#46; Gray"
                            5 => "M&#46;S&#46; Jastremski"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.CCM.0000094227.89800.93"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2003"
                        "volumen" => "31"
                        "paginaInicial" => "2677"
                        "paginaFinal" => "2683"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14605541"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "&#8220;Identifying the hospitalised patient in crisis&#8221; &#8211; a consensus conference on the afferent limb of rapid response systems"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;A&#46; DeVita"
                            1 => "G&#46;B&#46; Smith"
                            2 => "S&#46;K&#46; Adam"
                            3 => "I&#46; Adams-Pizarro"
                            4 => "M&#46; Buist"
                            5 => "R&#46; Bellomo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.resuscitation.2009.12.008"
                      "Revista" => array:6 [
                        "tituloSerie" => "Resuscitation"
                        "fecha" => "2010"
                        "volumen" => "81"
                        "paginaInicial" => "375"
                        "paginaFinal" => "382"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20149516"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "NICE clinical guideline 50 Acutely ill patients in hospital&#58; recognition of and response to acute illness in adults in hospital"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Excellence NIfHaC"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2007"
                        "editorial" => "National Institute for Health and Clinical Excellence"
                        "editorialLocalizacion" => "London"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Recognising and responding to acute illness in adults in hospital&#58; summary of NICE guidance"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46; Armitage"
                            1 => "J&#46; Eddleston"
                            2 => "T&#46; Stokes"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/bmj.39272.679688.47"
                      "Revista" => array:6 [
                        "tituloSerie" => "BMJ"
                        "fecha" => "2007"
                        "volumen" => "335"
                        "paginaInicial" => "258"
                        "paginaFinal" => "259"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17673769"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Critical care outreach 2003&#58; progress in developing services&#46; The National Outreach Report&#46; London&#44; UK&#46; Department of Health and National Health Service Modernisation Agency&#46; London&#58; Department of Health and National Health Service Modernisation Agency&#59; 2003&#46;"
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A prospective controlled trial of the effect of a multi-faceted intervention on early recognition in deteriorating hospital patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "I&#46;A&#46; Mitchell"
                            1 => "H&#46; McKay"
                            2 => "C&#46;V&#46; Leuvan"
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Update in Intensive Care: News in resuscitation
Novelties in advanced life support
Novedades en soporte vital avanzado
J.L. Pérez-Velaa,e, J.B. López-Messab,e,
Corresponding author
jlopezme@saludcastillayleon.es

Corresponding author.
, H. Martín-Hernándezc,e, P. Herrero-Ansolad,e
a Hospital 12 de Octubre, Madrid, Spain
b Complejo Asistencial de Palencia, Palencia, Spain
c Hospital Galdakao-Usansolo, Bizkaia, Spain
d Servicio de Urgencias Médicas, SUMMA 112, Madrid, Spain
e Comité Directivo PNRCP (SEMICYUC), Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In October 2010&#44; the journals <span class="elsevierStyleItalic">Resuscitation</span><a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and <span class="elsevierStyleItalic">Circulation</span><a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> simultaneously published the guides of the ERC &#40;European Resuscitation Council&#41; and of the AHA &#40;American Heart Association&#41; relating to cardiopulmonary resuscitation &#40;CPR&#41;&#46; These guides offer an update to the previous guidelines&#44; published in the year 2005&#44; and are based on the more recent International Consensus on Resuscitation Science and Treatment Recommendations &#40;CoSTR&#41;&#46; In this context&#44; the new guides incorporate the results of systematic reviews&#44; involving strict methodological criteria&#44; corresponding to over 270 topics related to CPR and prepared by over 300 international experts&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">These reviews of the literature&#44; carried out to offer answers to the questions raised by each of the working groups of the International Liaison Committee on Resuscitation&#44; were prepared using a standardized worksheet that included a grading system designed to define the level of evidence of each study&#46; The International Consensus Conference&#44; held in Dallas in February 2010&#44; and its published conclusions and recommendations&#44; constitute the basis of the ERC guides of 2010&#46; Although the guides are derived from the CoSTR document of 2010&#44; they represent consensus among the members of the Executive Committee of the ERC&#46; The Committee considers that these new recommendations are the most effective and easiest to learn interventions supported by the current state of knowledge&#44; research and experience&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The current guides on advanced life support &#40;ALS&#41; recommend some changes with respect to the previous guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> These changes are described in the present article&#44; together with the reasons for such changes&#46; However&#44; many of the recommendations in the ERC guides of 2005 remain without change in the year 2010&#44; either because no new studies have been published&#44; or because the new evidence generated since 2005 simply reinforces the already existing evidence&#46; In addition&#44; the current universal algorithm for advanced life support &#40;ALS&#41; is presented&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The changes in the recommendations are presented divided into the following sections&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Prevention of in-hospital cardiac arrest &#40;CA&#41;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Resuscitation in the hospital</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Simplified ALS algorithm</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0040" class="elsevierStylePara elsevierViewall">CPR techniques and devices</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Post-resuscitation care</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Prognosis</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">&#8220;Non-heart beating&#8221; donors and reference centers in CA</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Prevention of in-hospital cardiac arrest &#40;CA&#41;</span><p id="par0060" class="elsevierStylePara elsevierViewall">The current recommendations stress the importance of the early identification of those hospitalized patients who are experiencing a worsening of their condition&#44; and of the possibility of avoiding progression towards cardiac arrest &#40;CA&#41;-thus defining prevention of the latter as a first link in the chain of survival&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In order to prevent in-hospital CA&#44; hospital centers should incorporate a care system including the following elements&#58; &#40;a&#41; training of the healthcare personnel to recognize the signs of patient worsening and the reasons for offering a rapid response to the disease&#59; &#40;b&#41; adequate and regular monitorization of the vital signs of hospitalized patients&#59; &#40;c&#41; clear guidelines &#40;e&#46;g&#46;&#44; based on call criteria or warning or alarm sign scores&#41; to help the personnel in the early detection of patient worsening&#59; &#40;d&#41; a uniform and clear system for requesting help&#59; and &#40;e&#41; a clinical response to calls for help that is both appropriate and on time&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The following strategies are proposed for preventing avoidable in-hospital CA&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">1&#46;</span><p id="par0075" class="elsevierStylePara elsevierViewall">The provision of care for critical patients or patients at risk of clinical deterioration in the appropriate hospital areas&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In other words&#44; care should be provided adapted to the seriousness of the condition of each individual patient&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">2&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Each patient should have a documented plan for monitoring of the opportune vital signs&#44; identifying the variables to be measured and the frequency of measurement&#44; in accordance to the severity of the disease or the probability of clinical worsening&#46; The guides suggest the monitorization of simple physiological variables &#40;heart rate&#44; blood pressure&#44; respiratory frequency&#44; level of consciousness&#44; temperature and SpO<span class="elsevierStyleInf">2</span>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a> A data collection sheet should be used&#44; allowing regular measurement and registry of the vital signs&#44; and of the early warning scores&#44; when used&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">3&#46;</span><p id="par0085" class="elsevierStylePara elsevierViewall">An alarm and tracing system &#40;&#8220;call criteria&#8221; or early warning system&#41; should be used to identify patients in critical condition and&#47;or at risk of clinical worsening and CA&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows an example of early warning score for the identification of critical patients&#44; based on the evaluation of multiple vital signs&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">4&#46;</span><p id="par0090" class="elsevierStylePara elsevierViewall">An adequate clinical response to alterations in physiological parameters should be provided&#44; based on the alarm and tracing system used&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">5&#46;</span><p id="par0095" class="elsevierStylePara elsevierViewall">The hospital should have a clearly identified response to critical disease&#46; This may include the designation of a resuscitation team capable of responding in an adequate period of time to the acute clinical situations identified by the alarm and tracing system or other indicators&#46; This service should be available 24<span class="elsevierStyleHsp" style=""></span>h a day&#46; The team should include professionals capable of resolving situations requiring acute or critical patient care&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">6&#46;</span><p id="par0100" class="elsevierStylePara elsevierViewall">All the clinical personnel should be trained to identify&#44; monitor and manage critical patients&#44; and must know their role in the rapid response system&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">7&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Identification is required of those patients in which CA represents a foreseeable terminal event&#44; of those subjects in which CPR is inappropriate&#44; and of those patients who do not wish to receive CPR&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Accordingly&#44; hospitals should have an &#8220;orders not to start CPR&#8221; policy&#44; based on national guides that are understood by all clinical personnel members&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">8&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Auditing should be ensured of CA&#44; &#8220;false arrests&#8221;&#44; unexpected deaths and non-expected admissions to the ICU&#44; making use of common databases&#46; The antecedents and clinical responses of such events must also be audited&#46;</p></li></ul></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resuscitation in the hospital</span><p id="par0115" class="elsevierStylePara elsevierViewall">When CA occurs in the hospital&#44; the division between basic life support &#40;BLS&#41; and advanced life support &#40;ALS&#41; is arbitrary&#59; in practice&#44; the resuscitation process is a <span class="elsevierStyleItalic">continuum</span> and is based on common sense applied to each concrete situation&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Cardiac arrest must be identified immediately&#44; and help must be requested using a pre-established standard telephone number&#46; CPR is to start immediately&#44; using airway accessories &#40;e&#46;g&#46;&#44; pocket masks&#41; and&#44; where indicated&#44; defibrillation should be performed as soon as possible &#40;in all cases within 3<span class="elsevierStyleHsp" style=""></span>min after CA&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The precise sequence of actions after in-hospital CA depends on many factors&#44; including&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall">The location where arrest occurs &#40;clinical&#47;non-clinical area&#44; monitored&#47;non-monitored area&#41;&#46; Patients with monitored arrest are generally diagnosed quickly&#46; In contrast&#44; patients in wards may have suffered a period of worsening and non-witnessed arrest&#46; Ideally&#44; all patients at high risk of suffering CA should be attended in a monitorized area with the availability of immediate resuscitation measures&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall">Training of the first responders&#44; and the number of responders&#46; In principle&#44; it is advisable for all healthcare professionals to be able to recognize CA&#44; call for help and start the CPR maneuvers&#46; Each hospital healthcare professional should do what he or she has been trained to do&#44; since there may be different levels of training and skill in dealing with the airway&#44; breathing and circulation&#46; Thus&#44; the resuscitators should undertake only those activities in which they have been trained and are competent&#46; When there is only one responder&#44; he or she must ensure that help has been called for and is underway&#46; If several professionals are available&#44; different actions can be taken simultaneously&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall">Available equipment and hospital response system for CA and medical emergencies&#46; All clinical areas should have immediate access to the resuscitation equipment and to drugs allowing rapid patient resuscitation&#46; The equipment to be used in CPR &#40;including defibrillators&#41;&#44; its distribution&#44; and the medication should be standardized throughout the hospital&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> The resuscitation team may take the form of a conventional CA team&#44; which is notified only when a case of CA has been identified&#46; Alternatively&#44; however&#44; hospitals may have strategies for identifying patients at risk of CA and for calling or alerting a team&#44; e&#46;g&#46;&#44; the medical emergencies team&#44; before CA actually occurs&#46; In-hospital CA is rarely sudden or unexpected&#59; a strategy that includes the identification of patients at risk of CA may be able to prevent some of these arrests&#44; or may contribute to avoid futile resuscitation attempts in patients who are unlikely to benefit from CPR&#46;</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Immediate actions in the case of patients collapsing in hospital</span><p id="par0145" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the general algorithm for the initial management of in-hospital CA&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0150" class="elsevierStylePara elsevierViewall">Ensure the safety of the personnel dealing with the arrest&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">-</span><p id="par0155" class="elsevierStylePara elsevierViewall">Check whether the patient responds&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">When the healthcare personnel witness patient collapse or find an apparently unconscious patient in a clinical area&#44; the first thing to do is call for help&#44; and then determine whether the patient responds&#46; The patient should be shaken at the shoulders and asked out loud&#58; &#8220;Are you OK&#63;&#8221;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">If there are other healthcare personnel members nearby&#44; simultaneous actions can be carried out&#46;</p></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">If the patient responds&#44; urgent medical evaluation is required&#44; in accordance with the acute critical patient care protocol applied in each hospital center&#46; While the arrival of help is being awaited&#44; oxygen should be administered&#44; with monitorization and the insertion of a venous catheter&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">If the patient fails to respond&#44; the precise sequence of actions will depend on the training of the personnel attending the patient&#44; and on their experience in evaluating breathing and circulation&#46; It must be taken into account that healthcare personnel&#44; even when trained&#44; may not assess breathing and pulse reliably enough to confirm CA&#46; Agonal breathing &#40;occasional breaths&#44; slow&#44; laborious or noisy breathing&#41; is a sign of CA that should not be confused with life&#47;circulation signs&#46; The following sequence of actions is indicated in such cases&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">1&#46;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Call out for help &#40;if this has not been done yet&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">2&#46;</span><p id="par0185" class="elsevierStylePara elsevierViewall">Turn the patient on to his or her back and open the airway&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">3&#46;</span><p id="par0190" class="elsevierStylePara elsevierViewall">On opening the airway&#44; check for breathing&#58;<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">-</span><p id="par0195" class="elsevierStylePara elsevierViewall">Open the airway using the head tilt&#47;chin lift maneuver&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">-</span><p id="par0200" class="elsevierStylePara elsevierViewall">Examine inside the mouth&#46; Attempt to remove any foreign body or elements&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">-</span><p id="par0205" class="elsevierStylePara elsevierViewall">If neck injury is suspected&#44; attempt to open the airway applying mandibular traction&#46; If there are sufficient personnel members at hand&#44; aligned manual stabilization is indicated in order to minimize head movements&#46; The efforts to protect the cervical spine should not place oxygenation and ventilation at risk&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">-</span><p id="par0210" class="elsevierStylePara elsevierViewall">Keeping the airway open&#44; check whether the chest moves&#44; listen at the mouth of the patient for breathing sounds&#44; feeling the breath on the cheek&#44; in order to assess normal respiration&#46; It should take no more than 10<span class="elsevierStyleHsp" style=""></span>s to determine whether the patient is breathing normally or not&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">4&#46;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Check the circulation signs&#58;<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">-</span><p id="par0220" class="elsevierStylePara elsevierViewall">If the patient shows no signs of life &#40;consciousness&#44; purposeful movements&#44; normal breathing or cough&#41;&#44; start CPR maneuvering until more experienced help arrives&#44; or until the patient shows signs of life&#46;</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">-</span><p id="par0225" class="elsevierStylePara elsevierViewall">Those with experience in clinical assessment should evaluate the carotid pulse while simultaneously seeking signs of life&#44; during no more than 10<span class="elsevierStyleHsp" style=""></span>s&#46;</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">-</span><p id="par0230" class="elsevierStylePara elsevierViewall">If the patient seems to show no signs of life&#44; or in case of doubt&#44; CPR maneuvering should be started immediately&#46; Chest compression in a patient with a scantly beating heart is unlikely to cause injury&#46; However&#44; delays in diagnosing CA and in starting CPR have a negative impact upon patient survival&#44; and therefore should be avoided&#46;</p></li></ul></p></li></ul></p><p id="par0235" class="elsevierStylePara elsevierViewall">In the presence of a pulse or signs of life&#44; urgent medical assessment is required&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">If there is no breathing but a pulse is present &#40;i&#46;e&#46;&#44; respiratory arrest&#41;&#44; the patient should be ventilated&#44; checking circulation every 10 respirations&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Start of CPR in the hospital</span><p id="par0245" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">-</span><p id="par0250" class="elsevierStylePara elsevierViewall">A person starts CPR while others alert the resuscitation team and retrieve the resuscitation equipment and defibrillator&#46; If only one personnel member is present&#44; this would mean having to momentarily leave the patient&#46;</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">-</span><p id="par0255" class="elsevierStylePara elsevierViewall">Apply 30 chest compressions&#44; followed by two ventilations&#46;</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">-</span><p id="par0260" class="elsevierStylePara elsevierViewall">Minimize the interruptions and ensure quality compression&#46;</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">-</span><p id="par0265" class="elsevierStylePara elsevierViewall">Maintain the airway and ventilate the lungs with the most appropriate equipment immediately available&#58; pocket masks&#44; supraglottic devices and an auto-inflatable balloon or balloon-mask&#44; according to the locally applied protocol&#46; Tracheal intubation should only be attempted by trained persons who are competent and experienced in the technique&#46;</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">-</span><p id="par0270" class="elsevierStylePara elsevierViewall">Administer sufficient volume to allow normal chest elevation&#46; Add supplementary oxygen as soon as possible&#46;</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">-</span><p id="par0275" class="elsevierStylePara elsevierViewall">Following tracheal intubation of the patient or the insertion of a supraglottic device&#44; chest compression should be continued without interruption &#40;except for defibrillation or checking of the pulse where indicated&#41;&#44; at a rate of at least 100<span class="elsevierStyleHsp" style=""></span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; with lung ventilation at approximately 10 respirations min<span class="elsevierStyleSup">&#8722;1</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">-</span><p id="par0280" class="elsevierStylePara elsevierViewall">Once the defibrillator has arrived&#44; the rhythm in arrest must be analyzed&#46; If self-adhering defibrillation patches are available&#44; these should be placed without interrupting the chest compressions&#46; The use of self-adhering patches or of the &#8220;quick look&#8221; technique will allow rapid assessment of the cardiac rhythm&#46; With a manual defibrillator&#44; if the rhythm corresponds to ventricular fibrillation&#47;ventricular tachycardia without a pulse &#40;VF&#47;VT&#41;&#44; the defibrillator should be charged while another resuscitator continues with the chest compressions&#46; Once the defibrillator is charged&#44; a discharge should be applied&#46; If an automated external defibrillator &#40;AED&#41; is used&#44; follow the audiovisual indications of the AED&#46;</p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">-</span><p id="par0285" class="elsevierStylePara elsevierViewall">Resume the chest compressions immediately after the defibrillation attempt&#46; Minimize interruption of the chest compressions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">-</span><p id="par0290" class="elsevierStylePara elsevierViewall">Continue resuscitation until the resuscitation team arrives&#44; or until the patient shows signs of life&#46; Follow the voice instructions if an AED is used&#46; If a manual defibrillator is being used&#44; follow the universal advanced life support algorithm &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">-</span><p id="par0295" class="elsevierStylePara elsevierViewall">Once resuscitation is underway&#44; and if sufficient personnel are available&#44; prepare an intravenous catheter and the drugs that will probably be used &#40;e&#46;g&#46;&#44; adrenalin&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">-</span></span><p id="par0300" class="elsevierStylePara elsevierViewall">Even brief interruptions in chest compression worsen the prognosis&#46; Every effort therefore must be made to maintain effective chest compression throughout the resuscitation attempt&#46; The team leader should monitor the quality of CPR and alternate the participants in CPR if quality proves poor&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Simplified advanced life support algorithm</span><p id="par0305" class="elsevierStylePara elsevierViewall">The universal ALS algorithm of the ERC 2010 recommendations &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; is similar to the previous algorithm corresponding to the year 2005&#44; though the recommendations show some relevant changes&#44; and especially a different emphasis on some of them&#46; In general&#44; priority centers on simplification and rationalization to facilitate application of the algorithm&#46; The following should be underscored&#58;<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">1&#46;</span><p id="par0310" class="elsevierStylePara elsevierViewall">Interventions&#44; which undoubtedly contribute to improve survival in CA&#44; are effective basic life support &#40;BLS&#41;&#44; with uninterrupted high-quality chest compressions and an early defibrillation in VF&#47;VT&#46; Accordingly&#44; special emphasis is placed on the need for quality CPR&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> This would include the following&#58;<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">-</span><p id="par0315" class="elsevierStylePara elsevierViewall">The performance of high-quality chest compressions&#44; of adequate depth &#40;approximately 5<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; and allowing complete expansion of the chest&#46; If the airway has not been isolated&#44; a compression&#58; ventilation ratio of 30&#58;2 should be maintained&#59; if the airway has been isolated&#44; the frequency should be 100<span class="elsevierStyleHsp" style=""></span>bpm&#46;</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">-</span><p id="par0320" class="elsevierStylePara elsevierViewall">The compressions should be interrupted as little as possible through the resuscitation period&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> Brief interruptions should only be made to allow specific interventions such as defibrillation or tracheal intubation&#46; A delay of only 5&#8211;10<span class="elsevierStyleHsp" style=""></span>s is enough to reduce the chances for success in dealing with CA&#46; In order to shorten the pre-discharge pause&#44; the chest compressions should be continued while the defibrillator is being charged&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> Without assessing cardiac rhythm or pulse&#44; the chest compressions should be resumed immediately after discharge&#46; Even in cases where discharge proves successful and restores a perfusion rhythm&#44; it takes some time for post-discharge circulation to become established&#46;</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">-</span><p id="par0325" class="elsevierStylePara elsevierViewall">Avoid excessive ventilation&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">2&#46;</span><p id="par0330" class="elsevierStylePara elsevierViewall">Special emphasis continues to be placed on early defibrillation in patients with CA who present rhythms amenable to defibrillation&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#8211;20</span></a> In the same way as in the previous recommendations&#44; the new guidelines maintain the protocol of one discharge versus the sequence of three discharges for rhythms amenable to defibrillation&#44; with the same energy ratings in both mono- and biphasic waves&#44; and an increase in voltage for the second and subsequent discharges&#44; instead of maintaining a fixed voltage &#40;in defibrillators with biphasic waves&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">3&#46;</span><p id="par0335" class="elsevierStylePara elsevierViewall">In contrast to other clinical situations&#44; the recommendation is to deliver up to three rapid and consecutive &#40;grouped&#41; discharges in ventricular fibrillation&#47;ventricular tachycardia without a pulse &#40;VF&#47;VT&#41; occurring in the cardiac catheterization room or in the immediate postoperative period of heart surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> This same strategy can also be considered in the case of witnessed CA with VF&#47;VT&#44; when the patient has already been connected to a manual defibrillator&#46;</p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">4&#46;</span><p id="par0340" class="elsevierStylePara elsevierViewall">In the case of out-hospital CPR&#44; the new guidelines eliminate the recommendation to apply a predetermined period of CPR before defibrillation following CA not witnessed by the medical emergency services &#40;MES&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;22&#8211;24</span></a></p></li><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">5&#46;</span><p id="par0345" class="elsevierStylePara elsevierViewall">For the administration of drugs&#44; the recommendation to establish a peripheral venous access remains&#44; due to the rapidity&#44; efficacy and safety of the technique&#46; If a venous access cannot be established in the first 2<span class="elsevierStyleHsp" style=""></span>min of resuscitation maneuvering&#44; an intraosseous &#40;IO&#41; route should be attempted for the administration of drugs&#46; The increasing availability of these devices has made it easier to apply this technique&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a> The IO drug doses are the same as with the intravenous route&#46; This form of administration has been found to be safe and effective&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;28</span></a></p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">6&#46;</span><p id="par0350" class="elsevierStylePara elsevierViewall">Drug treatment&#46; Despite a lack of data from human clinical studies reporting improvements in survival&#44; the current 2010 guides continue to indicate adrenalin as the only vasopressor drug in the treatment of CA&#46;<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">-</span><p id="par0355" class="elsevierStylePara elsevierViewall">The administration of drugs should only be considered once the first discharges have been applied &#40;where indicated&#41;&#44; and following the start of chest compressions and ventilation&#46; Therefore&#44; during the treatment of CA secondary to VF&#47;VT&#44; we should administer 1<span class="elsevierStyleHsp" style=""></span>mg of adrenalin after the third discharge&#44; once the chest compressions have been resumed&#44; and then every 3&#8211;5<span class="elsevierStyleHsp" style=""></span>min &#40;during alternate CPR cycles&#41;&#46; CPR should not be interrupted for the administration of drugs&#46; There are no alternative vasopressors capable of improving survival versus adrenalin&#46;</p></li><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">-</span><p id="par0360" class="elsevierStylePara elsevierViewall">Although there is no evidence that the administration of any antiarrhythmic drug&#44; on a routine basis&#44; is able to improve survival at hospital discharge&#44; the new guides continue to recommend the administration of amiodarone in refractory ventricular fibrillation&#44;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a> after the third discharge&#46; The dose likewise remains the same&#58; 300<span class="elsevierStyleHsp" style=""></span>mg for the first dose&#44; and the perfusion of 900<span class="elsevierStyleHsp" style=""></span>mg in 24<span class="elsevierStyleHsp" style=""></span>h&#46; A posterior 150<span class="elsevierStyleHsp" style=""></span>mg bolus dose can be administered&#46;</p></li><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">-</span><p id="par0365" class="elsevierStylePara elsevierViewall">It is acknowledged that asystolia is fundamentally due to the primary myocardial disease rather than to an excessive vagal tone&#44; and that there is no clear evidence that atropine improves the results in CA&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;32</span></a> Therefore&#44; and in contrast to the previous guidelines of 2005&#44; the routine use of atropine in asystolia or electrical activity without a pulse &#40;EAWP&#41; is no longer recommended&#44; and has been eliminated from the ALS algorithm&#46; Such a medication would only be used in the context of bradyarrhythmias&#46;</p></li><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">-</span><p id="par0370" class="elsevierStylePara elsevierViewall">In recent years&#44; a number of studies have examined the role of fibrinolytic treatment in the context of CA&#44; with a view to eliminating the coronary and&#47;or pulmonary thrombus&#46; The conclusions are that such treatment should not be used on a routine basis in CA&#44; but that should be considered when CA is caused by acute pulmonary embolism&#8211;either diagnosed or suspected&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#8211;36</span></a> CPR in course is not a contraindication to fibrinolysis&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">7&#46;</span><p id="par0375" class="elsevierStylePara elsevierViewall">Less emphasis is placed on early tracheal intubation&#46; This technique should only be performed by highly skilled resuscitators&#44; with minimum interruption of the chest compressions&#46; Only a small pause in the compressions should be allowed in order to advance the tube beyond the vocal cords &#40;no more than 10<span class="elsevierStyleHsp" style=""></span>s&#41;&#46; Alternatively&#44; and in order to avoid the interruptions&#44; attempted tracheal intubation can be postponed until spontaneous circulation has been recovered&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> There is no conclusive clinical evidence that early intubation improves survival without sequelae at hospital discharge&#46; When the personnel members dealing with CA are not trained in tracheal intubation&#44; the use of supraglottic devices &#40;e&#46;g&#46;&#44; a laryngeal mask&#41; is regarded as an acceptable alternative for airway isolation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">8&#46;</span><p id="par0380" class="elsevierStylePara elsevierViewall">Since plasma drug concentration is unpredictable when medication is administered via the tracheal route&#44; the optimum drug dosage is not known&#44; and on the other hand there is now an increased availability of intraosseous devices&#59; as a result&#44; the administration of drugs through the tracheal tube is no longer recommended&#46; The administration of drugs through a supraglottic device is even less reliable&#46;</p></li><li class="elsevierStyleListItem" id="lsti0300"><span class="elsevierStyleLabel">9&#46;</span><p id="par0385" class="elsevierStylePara elsevierViewall">In line with the previous recommendations&#44; the new guides do not advise the routine use of any circulatory device as a substitute for manual chest compression&#46; However&#44; in certain patients requiring prolonged CPR maneuvering&#44; as in the case of transfers&#44; hypothermia&#44; pulmonary embolism subjected to fibrinolysis&#44; or patients undergoing computed tomography or percutaneous coronary interventions&#44; mechanical devices are effectively being used&#46;</p></li><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel">10&#46;</span><p id="par0390" class="elsevierStylePara elsevierViewall">The same importance as before is placed on correction of the potential reversible causes&#44; maintaining the rule of the 4 &#8220;Hs&#8221; and 4 &#8220;Ts&#8221;&#46;</p></li></ul></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0395" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a> provide a schematic summary of the sequence of interventions in CA&#44; in both rhythms amenable to defibrillation and in those not amenable to defibrillation&#44; respectively&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Cardiopulmonary resuscitation techniques and devices</span><p id="par0400" class="elsevierStylePara elsevierViewall">As regards the different techniques and devices used during CPR maneuvering&#44; mention should be made of the following&#58;<ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel">1&#46;</span><p id="par0405" class="elsevierStylePara elsevierViewall">Less emphasis is placed on the role of precordial percussion&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#44;39</span></a> This technique should not be used in non-witnessed out-hospital CA&#46; Precordial percussion should be considered in patients presenting witnessed&#44; monitored and unstable VT &#40;including VT without a pulse&#41;&#44; if a defibrillator cannot be immediately used&#46; However&#44; the technique should not delay either CPR maneuvering of defibrillator discharges&#46;</p></li><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">2&#46;</span><p id="par0410" class="elsevierStylePara elsevierViewall">The 2005 guides recommended the use of an exhaled CO<span class="elsevierStyleInf">2</span> detector to confirm placement of the tracheal tube&#46; In addition&#44; it was indicated that end-tidal CO<span class="elsevierStyleInf">2</span> &#40;PetCO<span class="elsevierStyleInf">2</span>&#41; monitorization could be useful as a noninvasive indicator of cardiac output during CPR maneuvering&#46; The current 2010 guidelines place greater emphasis on the use of capnography&#44; recommending quantitative registry of the capnographic wave to confirm and continuously monitor the position of the tracheal tube&#59; monitor the quality of CPR&#59; and afford an early indication of the recovery of spontaneous circulation&#46; Although other methods are available for confirming the position of the tracheal tube&#44; continuous capnographic wave registry is the most reliable option&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40&#44;41</span></a> The monitorization of this wave is particularly important in moments when the tracheal tube may become displaced from its correct position&#44; as during patient transfer&#46; In order for the capnographic system to measure exhaled CO<span class="elsevierStyleInf">2</span>&#44; there must be blood flow through the lungs&#46; In this context&#44; ineffective compressions&#44; a drop in cardiac output&#44; or a new situation of CA &#40;in a patient who had already recovered spontaneous circulation&#41;&#44; are associated with decreased PetCO<span class="elsevierStyleInf">2</span>&#46; In contrast&#44; the restoration of spontaneous circulation increases PetCO<span class="elsevierStyleInf">2</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0320"><span class="elsevierStyleLabel">3&#46;</span><p id="par0415" class="elsevierStylePara elsevierViewall">The potential role of ultrasound in ALS is acknowledged&#46; Although no study has shown the use of ultrasound to improve the prognosis of CA&#44; it is clear that echocardiography is able to detect a number of the potentially reversible causes of CA &#40;e&#46;g&#46;&#44; pericardial tamponade&#44; pulmonary embolism&#44; hypovolemia&#44; pneumothorax&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#8211;44</span></a> However&#44; the incorporation of ultrasound to ALS requires important training in order to be used in only certain situations&#44; and with minimum interruption of the chest compressions &#40;attempting to obtain &#8220;useful&#8221; images in under 10<span class="elsevierStyleHsp" style=""></span>s&#41;&#46; The sub-xiphoid window is advised&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Post-resuscitation care</span><p id="par0420" class="elsevierStylePara elsevierViewall">In contrast to the guides of 2005&#44; the current guidelines of 2010 attach special attention and importance to post-CA syndrome and post-resuscitation care&#46; Post-CA syndrome comprises post-CA brain damage&#44; post-CA myocardial dysfunction&#44; the systemic response to ischemia&#47;reperfusion&#44; and persistence of the triggering or causal disorder&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> The severity of this syndrome varies according to the duration and cause of CA&#46; Post-CA brain damage can be exacerbated by failure of the microcirculation&#44; impaired auto-regulation&#44; hypercapnia&#44; hyperoxia&#44; fever&#44; hyperglycemia and seizures&#46;</p><p id="par0425" class="elsevierStylePara elsevierViewall">It is clearly accepted that success in the recovery of spontaneous circulation is only the first step towards full recovery in patients with CA&#46; It is important to acknowledge that the treatment received in this post-resuscitation period exerts a significant influence upon the ultimate neurological prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">47&#8211;49</span></a> The post-resuscitation phase begins in the place where the recovery of spontaneous circulation is achieved&#44; though once stabilized&#44; the patient must be moved to intensive care for continuous monitorization and treatment&#46; <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a> and <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> summarize the actions and multisystemic approach required in the post-resuscitation care of the adult patient&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0430" class="elsevierStylePara elsevierViewall">The most important changes in the current guides can be summarized as follows&#58;<ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0325"><span class="elsevierStyleLabel">1&#46;</span><p id="par0435" class="elsevierStylePara elsevierViewall">The introduction of a detailed and structured post-resuscitation treatment protocol can improve survival among patients with CA following the recovery of spontaneous circulation&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a></p></li><li class="elsevierStyleListItem" id="lsti0330"><span class="elsevierStyleLabel">2&#46;</span><p id="par0440" class="elsevierStylePara elsevierViewall">Airway and ventilation&#58; As in the previous guides&#44; consideration is required of tracheal intubation&#44; sedation and mechanical ventilation in any patient with altered brain function&#46; Emphasis is placed on the fact that both hypoxemia and hypercapnia increase the probability of ulterior CA&#44; and can contribute to secondary brain damage&#46; Different animal studies have found that hypoxemia induces oxidative stress and causes post-ischemic neuron damage&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> In an experimental study and in a clinical registry it has been found that post-resuscitation hyperoxemia is associated to a poorer prognosis compared with normo- or hypoxemia&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> In clinical practice&#44; the recommendation is to adjust the inhaled oxygen fraction in order to keep arterial oxygen saturation &#40;as determined by blood gases and&#47;or pulsioximetry&#41; in the range of 94&#8211;98&#37;&#44; which could be referred to as &#8220;controlled reoxygenation&#8221;&#46;</p><p id="par0445" class="elsevierStylePara elsevierViewall">Following CA&#44; hypocapnia induced by hyperventilation produces brain ischemia &#40;secondary to cerebral vasoconstriction and a decrease in cerebral blood flow&#41;&#46; There are no data in support of a specific target arterial PCO<span class="elsevierStyleInf">2</span> following resuscitation&#44; though it seems reasonable to adjust ventilation to secure normocapnia&#44; with monitorization based on capnography and the arterial blood gas values&#46;</p></li><li class="elsevierStyleListItem" id="lsti0335"><span class="elsevierStyleLabel">3&#46;</span><p id="par0450" class="elsevierStylePara elsevierViewall">Circulation&#58; Increased emphasis is placed on the usefulness of primary coronary intervention in appropriate patients&#44; including comatose individuals&#44; with the sustained recovery of spontaneous circulation after CA&#46; Given the high percentage of patients with CA who suffer coronary disease&#44; and the well established indication of coronariography and early primary coronary intervention in post-CA patients with ST-segment elevation acute myocardial infarction &#40;AMI&#41;&#44; it is recommended that this intervention should be considered in all post-CA patients in which the existence of coronary disease is suspected&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50&#44;53&#8211;56</span></a> In addition&#44; several studies have indicated that the combination of therapeutic hypothermia and primary coronary intervention is both feasible and safe after CA secondary to AMI&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50&#44;57&#44;58</span></a></p><p id="par0455" class="elsevierStylePara elsevierViewall">The treatment of post-CA hemodynamic instability with fluids&#44; inotropic agents and vasopressors can be guided by physiological and laboratory test parameters such as blood pressure&#44; heart rate&#44; diuresis&#44; plasma lactate and central venous oxygen levels&#46; Although early target-guided therapy is well established in the management of sepsis and has been proposed as a therapeutic strategy after CA&#44; no controlled and randomized studies have warranted its routine use&#46; As targets&#44; we should use mean blood pressure for ensuring adequate diuresis &#40;1<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h&#41; and normal or decreasing plasma lactate levels&#44; taking into consideration the normal blood pressure of the patient&#44; the cause of CA&#44; and the severity of any myocardial dysfunction&#46;</p></li><li class="elsevierStyleListItem" id="lsti0340"><span class="elsevierStyleLabel">4&#46;</span><p id="par0460" class="elsevierStylePara elsevierViewall">Control of seizures&#58; The appearance of seizures increases brain metabolism and can cause brain damage&#46; In a way similar to the specifications of the previous guidelines&#44; the new guides stress the immediate and effective management of seizures with benzodiazepines&#44; phenytoin&#44; sodium valproate&#44; propofol or a barbiturate&#46; Myoclonus may prove difficult to treat&#59; clonazepam is the most effective drug&#44; but sodium valproate&#44; levetiracetam and propofol can be effective alternatives&#46; There are no studies definitively warranting the use of prophylactic drug treatment against seizures after CA in adult patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0345"><span class="elsevierStyleLabel">5&#46;</span><p id="par0465" class="elsevierStylePara elsevierViewall">Blood glucose control&#58; There is a strong correlation between elevated blood glucose after CA resuscitation and a poor neurological prognosis&#46; Control of blood glucose is therefore recommended&#46; The resuscitation guidelines of 2010 have revised this recommendation&#46; Based on the data available at the time of preparation of the guides&#44; the recommendation is to keep blood glucose after the recovery of spontaneous circulation at levels of &#8804;10<span class="elsevierStyleHsp" style=""></span>mmol&#47;l &#40;180<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> Severe hypoglycemia is associated to increased mortality in critical patients&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a> and comatose individuals are at special risk of suffering undetected hypoglycemia&#46; It is therefore agreed that hypoglycemia should be avoided&#46; Strict blood glucose control &#40;72&#8211;108<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; 4&#8211;6<span class="elsevierStyleHsp" style=""></span>mmol&#47;l&#41; should not be applied in adults with recovery of spontaneous circulation after CA&#44; due to the increased risk of hypoglycemia&#46;</p></li><li class="elsevierStyleListItem" id="lsti0350"><span class="elsevierStyleLabel">6&#46;</span><p id="par0470" class="elsevierStylePara elsevierViewall">Therapeutic hypothermia&#58; In a clearer manner and in the context of more global post-resuscitation care&#44; the new 2010 guidelines underscore the key role of therapeutic hypothermia&#46; This technique would be applicable to comatose CA survivors initially associated to both rhythms not amenable to fibrillation and to rhythms amenable to defibrillation&#46; There is admittedly less evidence in favor of its use after CA due to rhythms not amenable to defibrillation&#46;</p><p id="par0475" class="elsevierStylePara elsevierViewall">In the recommendations&#44; careful revision is made of the following&#58;<ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0355"><span class="elsevierStyleLabel">-</span><p id="par0480" class="elsevierStylePara elsevierViewall">The physiological bases explaining why moderate hypothermia has been shown to be neuroprotective and improves the prognosis after a period of global hypoxia-brain ischemia&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a></p></li><li class="elsevierStyleListItem" id="lsti0360"><span class="elsevierStyleLabel">-</span><p id="par0485" class="elsevierStylePara elsevierViewall">What post-CA patients should receive therapeutic hypothermia&#63; There is good evidence supporting the use of induced hypothermia in comatose survivors of out-hospital CA caused by rhythms amenable to defibrillation&#46; It seems reasonable to extrapolate these data to other types of CA involving other initial rhythms or in-hospital arrest&#44; though the supporting evidence in these cases is of lower level&#46;</p></li><li class="elsevierStyleListItem" id="lsti0365"><span class="elsevierStyleLabel">-</span><p id="par0490" class="elsevierStylePara elsevierViewall">How should cooling be carried out&#63; The guides revise the possible different techniques for the induction and maintenance of hypothermia&#44; and the ways to posteriorly induce warming&#46; Internal and&#47;or external techniques can be used to start cooling&#46; The infusion of 30<span class="elsevierStyleHsp" style=""></span>ml&#47;kg of saline solution at 4<span class="elsevierStyleHsp" style=""></span>&#176;C reduces the core temperature approximately 1&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C&#44;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">62&#8211;65</span></a> and has been shown to be safe and effective&#46; It can be used to start cooling from the pre-hospital setting&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">66&#44;67</span></a> In the maintenance phase it is preferable to use a cooling technique with effective temperature monitorization&#44; in order to avoid temperature fluctuations&#46; Temperature is normally monitored in the bladder and&#47;or esophagus&#46; There are no data suggesting that any specific cooling method improves survival when compared with any other cooling technique&#59; however&#44; internal devices allow more precise control of temperature compared with the external techniques&#46; Warming in turn is to be carried out slowly&#58; although the optimum rate has not been established&#44; the current consensus is that warming should be carried out at a rate of 0&#46;25&#8211;0&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C&#47;h&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a></p></li><li class="elsevierStyleListItem" id="lsti0370"><span class="elsevierStyleLabel">-</span><p id="par0495" class="elsevierStylePara elsevierViewall">When should hypothermia be carried out&#63; Data from experimental studies indicate that earlier cooling after the recovery of spontaneous circulation results in a better prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a> Although a number of studies have shown that hypothermia can be started early&#44; to date in the pre-hospital setting there are no data in humans proving that a given temperature&#8211;time target offers improved prognosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0375"><span class="elsevierStyleLabel">-</span><p id="par0500" class="elsevierStylePara elsevierViewall">The guides also revise the physiological effects&#44; complications and contraindications of hypothermia&#44; thus facilitating understanding of the technique and its application in clinical practice&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0380"><span class="elsevierStyleLabel">7&#46;</span><p id="par0505" class="elsevierStylePara elsevierViewall">Other treatments&#46; The current guides review the literature on neuroprotective drugs &#40;coenzyme Q10&#44; thiopental&#44; glucocorticoids&#44; nimodipine&#44; lidoflazine or diazepam&#41; used either alone or added to therapeutic hypothermia&#46; It is emphasized that these agents have not been shown to increase survival with neurologically intact situations when included in post-CA management&#46; There is also insufficient evidence to support the routine use of high-volume hemofiltration to improve the neurological prognosis in patients with recovery of spontaneous circulation after CA&#46;</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Prognosis</span><p id="par0510" class="elsevierStylePara elsevierViewall">The resuscitation guides of the year 2010 point out that many of the accepted predictors of poor survival in comatose CA survivors are not reliable&#44; particularly if the patient has been subjected to therapeutic hypothermia&#46; In general&#44; the potential predictors have been examined&#58;<ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0385"><span class="elsevierStyleLabel">-</span><p id="par0515" class="elsevierStylePara elsevierViewall">Clinical exploration&#46; There is no neurological clinical sign capable of reliably defining a poor prognosis &#40;Cerebral Performance Category &#40;CPC&#41; 3 or 4&#44; or death&#41; in under 24<span class="elsevierStyleHsp" style=""></span>h after CA&#46; The absence of pupil reaction to light and of corneal reflexes for over 72<span class="elsevierStyleHsp" style=""></span>h can reliably indicate a poor prognosis<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a> in adult comatose patients who have not been subjected to hypothermia and do not present confounding factors such as hypotension&#44; sedatives or muscle relaxants&#46;</p></li><li class="elsevierStyleListItem" id="lsti0390"><span class="elsevierStyleLabel">-</span><p id="par0520" class="elsevierStylePara elsevierViewall">Biochemical markers&#46; Although many markers have been studied&#44; the current evidence does not warrant the use of serum or cerebrospinal fluid biomarkers isolatedly as indicators of a poor prognosis in comatose patients after CA&#44; regardless of whether they are subjected to therapeutic hypothermia or not&#46; This is due to the limitations of the studies made to date&#44; with the inclusion of only a small number of patients and&#47;or to inconsistencies in the cutoff values used to predict a poor prognosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0395"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">-</span></span><p id="par0525" class="elsevierStylePara elsevierViewall">Electrophysiological markers&#58; No electrophysiological study is able to offer a fully reliable prognosis of the comatose patient in the first 24<span class="elsevierStyleHsp" style=""></span>h after CA&#46; In the absence of confounding factors or circumstances &#40;sedation&#44; hypotension&#44; hypothermia or hypoxemia&#41;&#44; it may be reasonable to use EEG &#40;identifying generalized suppression at under 20<span class="elsevierStyleHsp" style=""></span>&#956;V&#44; burst-suppression pattern with generalized epileptic activity&#44; or diffuse periodic complexes over flattened basal activity&#41;&#44; performed between 24 and 72<span class="elsevierStyleHsp" style=""></span>h after the recovery of spontaneous circulation&#44; as a help in predicting a poor prognosis among comatose CA survivors not subjected to hypothermia&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a> If somatosensory evoked potentials &#40;SSEPs&#41; are recorded after 24<span class="elsevierStyleHsp" style=""></span>h in comatose CA survivors not subjected to therapeutic hypothermia&#44; the bilateral absence of N20 cortical response to stimulation of the median nerve is indicative of a poor prognosis &#40;death or CPC 3 or 4&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a></p></li><li class="elsevierStyleListItem" id="lsti0400"><span class="elsevierStyleLabel">-</span><p id="par0530" class="elsevierStylePara elsevierViewall">Imaging studies&#58; Likewise&#44; no studies offering level one or two evidence have been found supporting the use of any imaging technique to reliably establish the prognosis of comatose CA survivors&#46; Overall&#44; the imaging studies that have been carried out are limited to small sample sizes&#44; with variability in the timing of imaging&#44; the lack of a standardized prognostic method for comparison purposes&#44; and the early withdrawal of care measures&#46; Despite its enormous potential&#44; neuroimaging is not recommended for routine decision taking in this context&#46;</p></li></ul></p><p id="par0535" class="elsevierStylePara elsevierViewall">As has been commented above&#44; defining a prognosis is even more complicated in patients who have been subjected to therapeutic hypothermia after cardiac arrest&#46; No neurological clinical signs&#44; electrophysiological studies&#44; biomarkers or imaging techniques have been found to offer a reliable neurological prognosis in the first 24<span class="elsevierStyleHsp" style=""></span>h after CA&#46; Based on the limited available evidence&#44; the potentially most reliable predictors of poor prognosis in patients subjected to therapeutic hypothermia are the bilateral absence of peak N20 in the SSEPs &#8805;24<span class="elsevierStyleHsp" style=""></span>h after CA &#40;false-positive rate 0&#37;&#44; 95&#37; CI&#58; 0&#8211;69&#37;&#41; and the absence of corneal and pupil reflexes three or more days after CA &#40;false-positive rate 0&#37;&#44; 95&#37; CI&#58; 0&#8211;48&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">72&#44;73</span></a> In a study carried out in patients subjected to post-CA therapeutic hypothermia&#44; an algorithm was developed based on a series of data &#40;clinical and electrophysiological&#41;&#44; demonstrating that the presence of two independent predictors of poor neurological prognosis &#40;incomplete recovery of trunk reflexes&#44; early myoclonus&#44; a non-reactive EEG tracing and bilateral cortical absence of SSEPs&#41; confirms a poor prognosis with a false-positive rate of 0&#37; &#40;95&#37; CI&#58; 0&#8211;14&#37;&#41;&#46; In general&#44; and given the limited available evidence&#44; decisions to limit care should not be taken on the basis of the results obtained with a single prognostic tool&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Non-heart beating donors and reference centers in cardiac arrest</span><p id="par0540" class="elsevierStylePara elsevierViewall">Lastly&#44; these recent resuscitation guides of 2010 raise two concepts that should be taken into account in relation to resuscitation&#46; Firstly&#44; since successful solid organ transplants have been performed after cardiac death&#44; the possibility has been suggested of recruiting some post-CA patients to expand the pool of organ donors &#40;&#8220;non-heart beating&#8221; donors&#41;&#44; which remains so scarce in comparison with the potential number of organ recipients&#46; Graft function after transplantation is conditioned by the duration of warm ischemia from the cessation of cardiac output to the time of organ preservation&#46; When a delay is expected in the time to starting organ preservation&#44; mechanical chest compression devices may be useful for maintaining adequate organ perfusion while the steps needed to allow organ donation are taken&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a></p><p id="par0545" class="elsevierStylePara elsevierViewall">There is enormous variability in survival among different hospitals that deal with patients resuscitated from cardiac arrest&#46; There is some low-level evidence that ICUs which treat more post-CA patients a year show improved survival figures compared with those Units which receive fewer such cases&#46; Several studies have reported improvements in survival after the implementation of a series of post-resuscitation care measures including therapeutic hypothermia and primary coronary intervention&#46; On the other hand&#44; several studies of out-hospital CA in adults have reported no effects upon survival at hospital discharge attributable to the transfer interval from the scene of CA to arrival in hospital&#44; provided recovery of spontaneous circulation is achieved on the scene and transfer is brief &#40;3&#8211;11<span class="elsevierStyleHsp" style=""></span>min&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">75&#44;76</span></a> This means that it may be safe not to transfer post-CA patients to local hospital centers but to ensure transfer to a regional CA center&#46; There is indirect evidence that regional cardiac resuscitation systems improve the prognosis of myocardial infarction with ST-segment elevation&#46; The consequence of these data is that the centers and healthcare systems specialized in CA may be effective&#44; though there is still no direct evidence in support of this hypothesis&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">77&#44;78</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Summary of the changes since the guides of 2005</span><p id="par0550" class="elsevierStylePara elsevierViewall">Finally&#44; it should be commented that many of the recommendations of the ERC guides of 2005 remain without changes&#44; either because no new studies have been published&#44; or because the new evidence generated since 2005 simply reinforces the already existing evidence&#46; However&#44; the evidence published since 2005 does point to the need for changes in some parts of the 2010 guidelines&#46; The changes of 2010 in relation to the guides of 2005&#44; referred to advanced life support&#44; can be summarized as follows<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#58;<ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0405"><span class="elsevierStyleLabel">-</span><p id="par0555" class="elsevierStylePara elsevierViewall">Increased emphasis on the importance of high-quality chest compressions with minimum interruption throughout any ALS attempt&#58; chest compressions are only briefly interrupted to allow specific interventions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0410"><span class="elsevierStyleLabel">-</span><p id="par0560" class="elsevierStylePara elsevierViewall">Increased emphasis on the use of &#8220;alarm and tracing systems&#8221; to detect patient worsening and allow treatment for the prevention of in-hospital CA&#46;</p></li><li class="elsevierStyleListItem" id="lsti0415"><span class="elsevierStyleLabel">-</span><p id="par0565" class="elsevierStylePara elsevierViewall">Increased attention to the alarm signs associated to the potential risk of sudden cardiac death outside the hospital&#46;</p></li><li class="elsevierStyleListItem" id="lsti0420"><span class="elsevierStyleLabel">-</span><p id="par0570" class="elsevierStylePara elsevierViewall">Elimination of the recommendation of a predetermined period of CPR before out-hospital defibrillation after CA not witnessed by the medical emergency services &#40;MES&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0425"><span class="elsevierStyleLabel">-</span><p id="par0575" class="elsevierStylePara elsevierViewall">Maintenance of the chest compressions while the defibrillator is being charged &#40;this serving to minimize the pre-discharge pause&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0430"><span class="elsevierStyleLabel">-</span><p id="par0580" class="elsevierStylePara elsevierViewall">Less emphasis on the role of precordial percussion&#46;</p></li><li class="elsevierStyleListItem" id="lsti0435"><span class="elsevierStyleLabel">-</span><p id="par0585" class="elsevierStylePara elsevierViewall">The delivery of up to three rapid and consecutive &#40;grouped&#41; discharges in ventricular fibrillation&#47;ventricular tachycardia without a pulse &#40;VF&#47;VT&#41; occurring in the cardiac catheterization room or in the immediate postoperative period of heart surgery&#46;</p></li><li class="elsevierStyleListItem" id="lsti0440"><span class="elsevierStyleLabel">-</span><p id="par0590" class="elsevierStylePara elsevierViewall">Drug administration through the tracheal tube is no longer advised &#40;if an intravenous access cannot be established&#44; the drugs should be administered via the intraosseous &#40;IO&#41; route&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0445"><span class="elsevierStyleLabel">-</span><p id="par0595" class="elsevierStylePara elsevierViewall">During the treatment of CA secondary to VF&#47;VT&#44; we should administer 1<span class="elsevierStyleHsp" style=""></span>mg of adrenalin after the third discharge&#44; once the chest compressions have been resumed&#44; and then every 3&#8211;5<span class="elsevierStyleHsp" style=""></span>min &#40;during alternate CPR cycles&#41;&#46; After the third discharge&#44; 300<span class="elsevierStyleHsp" style=""></span>mg of amiodarone are also administered&#46;</p></li><li class="elsevierStyleListItem" id="lsti0450"><span class="elsevierStyleLabel">-</span><p id="par0600" class="elsevierStylePara elsevierViewall">The routine use of atropine in asystolia or in electrical activity without a pulse &#40;EAWP&#41; is no longer recommended&#46;</p></li><li class="elsevierStyleListItem" id="lsti0455"><span class="elsevierStyleLabel">-</span><p id="par0605" class="elsevierStylePara elsevierViewall">Less emphasis is placed on early tracheal intubation&#44; unless carried out by trained persons who are very experienced in the technique&#44; and ensuring minimal interruption of the chest compressions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0460"><span class="elsevierStyleLabel">-</span><p id="par0610" class="elsevierStylePara elsevierViewall">Increased emphasis on the use of capnography to confirm and continuously monitor the position of the tracheal tube&#44; the quality of CPR&#44; and to afford an early indication of the recovery of spontaneous circulation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0465"><span class="elsevierStyleLabel">-</span><p id="par0615" class="elsevierStylePara elsevierViewall">The potential role of ultrasound in ALS is acknowledged&#46;</p></li><li class="elsevierStyleListItem" id="lsti0470"><span class="elsevierStyleLabel">-</span><p id="par0620" class="elsevierStylePara elsevierViewall">Recognition of the potential damage caused by hyperoxemia after achieving the recovery of spontaneous circulation&#58; once spontaneous circulation and arterial blood oxygen saturation &#40;SaO<span class="elsevierStyleInf">2</span>&#41; have been restored&#44; reliable monitorization can be carried out using pulsioximetry and&#47;or arterial blood gas measurements-adjusting the inhaled oxygen concentration to obtain SaO<span class="elsevierStyleInf">2</span> 94&#8211;98&#37;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0475"><span class="elsevierStyleLabel">-</span><p id="par0625" class="elsevierStylePara elsevierViewall">Much greater attention and emphasis is placed on treatment of post-CA syndrome&#46;</p></li><li class="elsevierStyleListItem" id="lsti0480"><span class="elsevierStyleLabel">-</span><p id="par0630" class="elsevierStylePara elsevierViewall">The implementation of a detailed and structured post-resuscitation treatment protocol is recognized as being able to improve survival among CA victims after the recovery of spontaneous circulation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0485"><span class="elsevierStyleLabel">-</span><p id="par0635" class="elsevierStylePara elsevierViewall">Increased emphasis is placed on the use of primary coronary intervention in appropriate cases &#40;including comatose patients&#41; with sustained recovery of spontaneous circulation after CA&#46;</p></li><li class="elsevierStyleListItem" id="lsti0490"><span class="elsevierStyleLabel">-</span><p id="par0640" class="elsevierStylePara elsevierViewall">Revision is made of the recommendation referred to blood glucose control&#58; in adults with sustained recovery of spontaneous circulation after CA&#44; blood glucose values of &#62;10<span class="elsevierStyleHsp" style=""></span>mmol&#47;l &#40;&#62;180<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; should be treated&#44; though avoiding hypoglycemia&#46;</p></li><li class="elsevierStyleListItem" id="lsti0495"><span class="elsevierStyleLabel">-</span><p id="par0645" class="elsevierStylePara elsevierViewall">Utilization of therapeutic hypothermia also in comatose CA survivors initially associated to rhythms both amenable and not amenable to defibrillation&#46; It is recognized that there is less evidence in favor of such use after CA involving rhythms not amenable to defibrillation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0500"><span class="elsevierStyleLabel">-</span><p id="par0650" class="elsevierStylePara elsevierViewall">Recognition that many of the accepted predictors of poor prognosis in comatose CA survivors are not reliable&#44; particularly if the patient has been subjected to therapeutic hypothermia&#46;</p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0655" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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        5 => array:2 [
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          "titulo" => "Prevention of in-hospital cardiac arrest &#40;CA&#41;"
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        6 => array:2 [
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          "titulo" => "Resuscitation in the hospital"
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        7 => array:2 [
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          "titulo" => "Immediate actions in the case of patients collapsing in hospital"
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        8 => array:2 [
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          "titulo" => "Start of CPR in the hospital"
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        9 => array:2 [
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          "titulo" => "Simplified advanced life support algorithm"
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          "titulo" => "Cardiopulmonary resuscitation techniques and devices"
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        11 => array:2 [
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          "titulo" => "Post-resuscitation care"
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        12 => array:2 [
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          "titulo" => "Prognosis"
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        13 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Non-heart beating donors and reference centers in cardiac arrest"
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          "identificador" => "sec0055"
          "titulo" => "Summary of the changes since the guides of 2005"
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    "fechaRecibido" => "2011-03-06"
    "fechaAceptado" => "2011-03-11"
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            0 => "Cardiac arrest"
            1 => "Resuscitation"
            2 => "Advanced life support"
            3 => "Post-resuscitation"
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            0 => "Parada cardiaca"
            1 => "Resucitaci&#243;n"
            2 => "Soporte vital avanzado"
            3 => "Posresucitaci&#243;n"
            4 => "Pron&#243;stico"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We present some of the most important developments in advanced life support incorporating the new international recommendations for resuscitation 2010&#46; The study highlights aspects related to prevention and early detection of in-hospital cardiac arrest&#44; resuscitation in the hospital&#44; the new advanced life support algorithm&#44; the techniques and devices for cardiopulmonary resuscitation&#44; post-resuscitation care&#44; assessment of the prognosis of patients who survive initially&#44; and specific aspects of non-beating heart organ donation and the creation of cardiac arrest referral centers&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se presentan a continuaci&#243;n algunas de las novedades m&#225;s importantes en soporte vital avanzado que incorporan las nuevas recomendaciones internacionales en resucitaci&#243;n de 2010&#46; Se destacan los aspectos relacionados con la prevenci&#243;n y detecci&#243;n precoz de la parada cardiaca intrahospitalaria&#44; la resucitaci&#243;n en el hospital&#44; el nuevo algoritmo de soporte vital avanzado&#44; las t&#233;cnicas y dispositivos de resucitaci&#243;n cardiopulmonar&#44; los cuidados posresucitaci&#243;n&#44; la valoraci&#243;n del pron&#243;stico de los pacientes que sobreviven inicialmente a la parada y aspectos espec&#237;ficos relativos a la donaci&#243;n de &#243;rganos a coraz&#243;n parado y la creaci&#243;n de centros de referencia de parada cardiaca&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; P&#233;rez-Vela JL&#44; et al&#46; Novedades en soporte vital avanzado&#46; Med Intensiva&#46; 2011&#59;35&#58;373&#8211;87&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Respiratory frequency &#40;rpm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8804;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#8211;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#8211;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#8211;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oxygen saturation &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85&#8211;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90&#8211;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Temperature &#40;&#176;C&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8804;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#46;1&#8211;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#46;1&#8211;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;1&#8211;37&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#8211;38&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;38&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Heart rate &#40;bpm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8804;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#8211;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51&#8211;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#8211;110&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">111&#8211;130&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;130&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="8" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Systolic blood pressure &#40;separate evaluation&#41;</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sedation score &#40;independent&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#8211;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diuresis &#40;ml in 4<span class="elsevierStyleHsp" style=""></span>h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80&#8211;119&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">120&#8211;800&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;800&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab8749.png"
              ]
            ]
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          "notaPie" => array:1 [
            0 => array:2 [
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara">Sedation score&#58;</p> <p class="elsevierStyleNotepara">0&#58; Awake&#47;alert</p> <p class="elsevierStyleNotepara">1&#58; Asleep&#44; responds to stimuli</p> <p class="elsevierStyleNotepara">2&#58; Mild&#58; occasionally drowsy&#44; easily awakened</p> <p class="elsevierStyleNotepara">3&#58; Moderate&#58; often drowsy&#44; easy to awaken but cannot keep awake</p> <p class="elsevierStyleNotepara">4&#58; Severe&#58; difficult to awaken</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Modified early warning score&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Vital signs to evaluate&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ventilation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hemodynamics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cardiovascular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neurological&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metabolic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tracheal intubation if possible&#44; in comatoseCapnography&#58;Confirm airwayAdjust ventilationPetCO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#8776;<span class="elsevierStyleHsp" style=""></span>35&#8211;40PaCO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#8776;<span class="elsevierStyleHsp" style=""></span>40&#8211;45<span class="elsevierStyleHsp" style=""></span>mmHgChest Rx&#58;Confirm airwayDetect causes or complications of cardiac arrest&#44; e&#46;g&#46;&#44; lung edemaPulsioximetry&#47;gases&#58;Maintain adequate oxygenation and adjust FiO<span class="elsevierStyleInf">2</span>Sat pO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>94&#37;PaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#8776;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mmHgMechanical ventilation&#58;Minimize acute lung damage and potential oxygen toxicityTidal volume 6&#8211;8<span class="elsevierStyleHsp" style=""></span>ml&#47;kgAdjust minute volume for indicated PaCO<span class="elsevierStyleInf">2</span> and PetCO<span class="elsevierStyleInf">2</span>Adjust FiO<span class="elsevierStyleInf">2</span> for indicated SatpO<span class="elsevierStyleInf">2</span> and SaO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Blood pressure monitorization&#47;assess arterial catheterMaintain MBP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>65 or SBP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>90<span class="elsevierStyleHsp" style=""></span>mmHgTreatment hypotension&#58;FluidsDopamine 5&#8211;10<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;minNoradrenalin 0&#46;1&#8211;0&#46;5<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;minAdrenalin 0&#46;1&#8211;0&#46;5<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cardiac monitorization&#58;<span class="elsevierStyleHsp" style=""></span>Detect and treat arrhythmias<span class="elsevierStyleHsp" style=""></span>No prophylactic antiarrhythmic drugs<span class="elsevierStyleHsp" style=""></span>Assess reversible causes12-lead ECG&#47;troponin&#58;<span class="elsevierStyleHsp" style=""></span>Detect ACS&#47;AMI with ST elevation<span class="elsevierStyleHsp" style=""></span>Assess QT-intervalTreatment ACS&#58;<span class="elsevierStyleHsp" style=""></span>Aspirin&#47;heparin<span class="elsevierStyleHsp" style=""></span>Transfer to center with options for primary coronary intervention<span class="elsevierStyleHsp" style=""></span>Consider primary coronary intervention&#47;fibrinolysisEchocardiogram to detect global stunning&#44; segment disorders&#44; structural myocardiopathy problemsTreatment of myocardial stunning&#58;<span class="elsevierStyleHsp" style=""></span>Fluids<span class="elsevierStyleHsp" style=""></span>Inotropic agents<span class="elsevierStyleHsp" style=""></span>Counterpulsation balloon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Serial explorations&#58;<span class="elsevierStyleHsp" style=""></span>To define coma&#44; brain damage and prognosis<span class="elsevierStyleHsp" style=""></span>Response to verbal instructions&#47;stimuli<span class="elsevierStyleHsp" style=""></span>Pupil and corneal reflexes and eye movements<span class="elsevierStyleHsp" style=""></span>Cough&#44; respirationEEG monitorization if comatoseAntiseizure drugs in case of crisisCore temperature if comatose&#58;<span class="elsevierStyleHsp" style=""></span>Prevent hyperpyrexia &#40;<span class="elsevierStyleItalic">T</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>37&#46;7<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;<span class="elsevierStyleHsp" style=""></span>Induce therapeutic hypothermia in absence of contraindications<span class="elsevierStyleHsp" style=""></span>After 24<span class="elsevierStyleHsp" style=""></span>h&#44; slow warming &#40;0&#46;25<span class="elsevierStyleHsp" style=""></span>&#176;C&#47;h&#41;Brain CT&#46; Discard primary intracranial processesSedation&#47;muscle relaxation&#46; Control shivers&#44; restlessness&#44; and adjust to mechanical ventilation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Serial lactate determinations to assess adequate perfusionPotassium to avoid hypokalemia &#40;which favors arrhythmias&#41;<span class="elsevierStyleHsp" style=""></span>Maintain K<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3&#46;5 mEq&#47;lDiuresis&#47;creatinine&#58;<span class="elsevierStyleHsp" style=""></span>Maintain euvolemiaRenal replacement therapy if necessary<span class="elsevierStyleHsp" style=""></span>Detect acute renal failureBlood glucose&#58; detect hyper-&#47;hypoglycemia<span class="elsevierStyleHsp" style=""></span>Treat hypoglycemia<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>80<span class="elsevierStyleHsp" style=""></span>mg&#47;dl<span class="elsevierStyleHsp" style=""></span>Treat hyperglycemia to reach blood glucose<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>180<span class="elsevierStyleHsp" style=""></span>mg&#47;dl<span class="elsevierStyleHsp" style=""></span>Use insulin protocolsAvoid hypotonic fluids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Multisystemic approach to post-cardiac arrest management&#46;</p>"
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      "titulo" => "References"
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ISSN: 21735727
Original language: English
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