學(xué)會(huì)講座心肺復(fù)蘇

GuidelinesWritingGroupChairsMichaelR.Sayre,MD貴陽醫(yī)學(xué)院附院麻醉科曾慶繁2010年AHA心肺復(fù)蘇指南介紹In1960Kouwenhoven

14病人心跳驟停閉式胸部心臟按壓存活

closedchestcardiacmassagein1962單向直流電除顫direct-currentmonophasicwaveformdefibrillationIn1966AmericanHeartAssociation(AHA)firstCPRGuidelines199520002005

1960------------2010

Kouwenhoven

2010心肺復(fù)蘇50周年356位專家來自29個(gè)國家

歷時(shí)36個(gè)月討論2010InternationalConsensusConferenceRobertA.Berg

UniversityofPennsylvaniaProfessorofAnesthesiologyandCriticalCareMedicine,DivisionChief,PediatricCriticalCare心臟驟停的幾種節(jié)律

Cardiacarrestcanbecausedby5rhythms室顫VF室速(無脈)VT無脈性電活動(dòng)PEA心博停止asystole.無脈性心動(dòng)過緩Three-PhaseModelofResuscitation02468101214161820ArrestTime(min)CirculatoryPhaseElectricalPhaseMetabolicPhase0100%MyocardialATPWeisfeldtML,BeckerLB.JAMA2002:288:3035-8rapiddefibrillationgoodchestcompressionslittlewecando

室顫無脈性室速

VF/PulselessVT及早按壓chestcompressions(CC)及早除顫earlyDefibrillation(DF)Earlyrecognition

cardiacarrest及早識(shí)別心跳驟停

不檢查脈搏

Notcheckforapulse

降低脈搏檢查的重要性

Minimizetheimportanceofpulsechecks脈搏2005(Old):“Look,listen,andfeel”NO:“Look,Listen,FeelforBreathing”*

呼吸2010(New):取消“看、聽和感覺呼吸”程序*

外行急救

layrescuer

1.突然暈倒suddenlycollapse2.意識(shí)消失Unresponsive3.無呼吸或無正常呼吸notbreathing4.Seizure.

心臟驟停cardiacarrestAChangeFromA-B-CtoC-A-B“Adults”Childreninfants(excludingthenewlyborn)復(fù)蘇步驟VF-CA:

中心血液中富含氧窒息性心臟驟停-通氣!

關(guān)鍵:CCC心腦C-A-B及早開始按壓關(guān)鍵ForgetCPR,GiveCCRInstead心腦復(fù)蘇新概念

CardiocerebralResuscitation忘了CPR代之CCR簡化成人基本生命支持:CCC+DF胸外按壓速率：

每分鐘至少100次*2005（舊）：以每分鐘大約100次的速率按壓。2010（新）：以每分鐘至少100次按壓的速率進(jìn)行胸外按壓較為合理.(快!不間斷)

胸外按壓幅度*2010（新）：應(yīng)將成人胸骨按下至少5厘米2005（舊）：應(yīng)將成人胸骨按下大約4至5厘米。電擊治療ELECTRICALTHERAPIESAEDUseinChildrenNowIncludesInfants2010(New):<1yearofage.2005(Old):NotuseofAEDsforinfants<1yearofage.CPR

<3min除顫立即CPR(不檢查脈搏/心律分析)ADVANCEDCARDIOVASCULARLIFESUPPORT監(jiān)測(cè)PETCO2:1.確定氣管導(dǎo)管位置

2.監(jiān)測(cè)CPR有效性

3.檢查心跳恢復(fù)

CPR質(zhì)量藥物NewMedicationProtocols2010(New):阿托品不常規(guī)用于PEA/心搏停止

2005(Old):阿托品用于高級(jí)心血管生命支持

心搏停止緩慢PEA

可用阿托品心動(dòng)過速tachycardia規(guī)律的單型寬QRS心動(dòng)過速

腺苷(rhythmisregular)2010(New)adenosine只用于規(guī)則的窄QRS的折返性室上速2005(Old):不規(guī)律的寬QRS心動(dòng)過速不用腺苷(maycausedegenerationoftherhythmtoVF)心動(dòng)過緩Bradycardia癥狀性不穩(wěn)定心動(dòng)過緩變時(shí)性藥物輸注atropinewhileawaitingapacerorifpacingwasineffective.chronotropicdruginfusions2010(New)2005(Old):避免過度通氣AvoidingHyperventilation10-12次/minPETCO2:35-40mmHgPaCO2:40-45mmHg.ACLSCardiacArrestAlgorithmPost–CardiacArrestCareTable1.MultipleSystemApproachtoPost–CardiacArrestCareVentilationHemodynamicsCardiovascularNeurologicalMetabolic●CO2監(jiān)測(cè)直接動(dòng)脈:心臟監(jiān)測(cè):神經(jīng)學(xué)檢查:乳酸監(jiān)測(cè)確定氣管插管MAP>65mmHg心律失常再發(fā)及治療昏迷腦損傷保證灌注昏迷:插管SBP≥90mmHg不預(yù)防性抗心律失常藥判斷預(yù)后K>3.5mEq/L調(diào)節(jié)通氣:治療低血壓去除心律失常原因?qū)φZ言刺激反應(yīng)避免低鉀(心律失常)PETCO2:Fluidbolus12-leadECG/瞳孔光反射尿量,血清肌酐35–40mmHgDopamine5–10mcgACSSTEMIQT角膜反射發(fā)現(xiàn)ARFPaco2:Norepinephrine治療急性冠脈綜合征自主眼球活動(dòng)等容euvolemia40–45mmHgEpinephrineAspirin/heparin動(dòng)嘴嗆咳自主呼吸腎替代治療脈搏氧血?dú)?.1–0.5mcg/kg.miPCIor腦電圖:replacement降低FIO2

fibrinolysis驚厥血糖監(jiān)測(cè)SpO2≥94%

抗驚厥治療治療低血糖<80mgPaO2-100mmHg

昏迷者中心溫度監(jiān)測(cè):高血糖:控制在Pao2/FIO2300

降低腦損傷改善預(yù)后144–180mg/dL機(jī)械通氣:

預(yù)防高熱:>37.7°CLocalinsulinprotocolsVT6-8mL/kg

VentilationHemodynamicCardiovascularNeurologicalMetabolicChestX-ray:

心臟超聲:治療性低溫:確定氣道

檢查室壁運(yùn)動(dòng)ColdIVfluidbolus30mL/kgAvoidHypotonicFluis檢查CA原因并發(fā)癥

心肌病Surfaceorendovascularincreaseedemapneumonitis

心肌頓抑coolingfor32°C–34°C(cerebraledema)pulmonaryedema

TreatMyocardialStunning:24hours

FluidstooptimizevolumeAfter24hours

Dobutamine5–10mcg/kgslowrewarming0.25°C/hr

動(dòng)脈氣囊反博(IABP)CT

鎮(zhèn)靜肌松

控制寒戰(zhàn)

機(jī)控呼吸(非同步)

謝謝!CentralNervousSystem

braininjury

Clinicalmanifestations:comaSeizuresMyoclonusneurocognitivedysfunction(memorydeficitstopersistentvegetativestate)braindeath.SeizureManagementEEGshouldbemonitoredfrequentlyorcontinuouslyincomatosepatientsafterROSC(ClassI)NeuroprotectiveDrugsmoleculareventshourstodaysafterROSCtherapeuticwindow

neurodegeneration.PrognosticationofNeurologicalOutcomePooroutcomeisdefinedasDeathpersistentunresponsivenessinabilitytoundertakeindependentactivitiesafter6monthsNeurologicalAssessmentPhysicalexamination<24hoursaftercardiacarrest:NOsignsmot