特殊情况下的复苏术精品课件

Special Resuscitation Situations 特殊情況下的復甦術 長庚醫院 急診醫學科 邱德發 Advanced Challenges in Resuscitation 1 Advanced Challenges in Resuscitation 1. 致命的電解質異常 2. 毒藥物造成之心血管急症 3. 緊急心臟照護的特殊挑戰 低體溫 溺水 瀕死性氣喘 過敏性反應 外傷併心臟停止 懷孕併心臟停止 電擊及雷擊 2 Advanced Challenges in Resuscitation w致命的電解質異常 血鉀、血鈉、血鎂及血鈣的太高或太低 w毒藥物造成之心血管急症 以藥物引起症狀及急救流程為導向 w緊急心臟照護的特殊挑戰 瀕死性氣喘 (Near-Fatal Asthma) 過敏性反應(Anaphylaxis) 3 致命的電解質異常 w造成心臟停止或降低急救成效 w在檢驗數值出來前即採取急救措施 w以高血鉀最易致命 4 高血鉀 w血鉀 5.0 mEq/L w pH 0.1 U serum K+ 0.3 mEq/L 5 高血鉀原因 Drugs (K+-sparing diuretics, ACEI, NSAIDs, K supplements) ESRD Muscle breakdown (rhabdomyolysis) Metabolic acidosis Pseudohyperkalemia Hemolysis Tumor lysis syndrome Diet (rarely sole cause) Hypoaldosteronism (Addison disease, hyporeninemia) Type 4 renal tubular acidosis Other: hyperkalemic periodic paralysis 6 高血鉀 w 症狀:全身無力(由下肢往上漸進式發生) ，呼吸衰竭 w 心電圖變化 T波變高 P波變平 PR延長 QRS波變寬 S波變深 idioventricular rhythm sine waves VF、心跳停止 7 處置 w 輕症(5-6)以利尿劑、離子交換樹脂 或血液透析來移除鉀 w 中症(6-7)加上NaHCO3 、Glucose + insulin、Albuterol噴霧治療 w 重症(7)再加上CaCl2 8 低血鉀 w血鉀 145 mEq/L w症狀: 口渴、意識不清、無力、躁動、 局部神經症狀、抽搐、昏迷 13 處置 減少水份流失、補水 w 低血容:補生理食鹽水 w 缺水量 =體重 x 0.5 x (血鈉 - 140) /140 體重 x 0.4 x (血鈉 - 140) /140 70公斤男性，血鈉160，缺水量 ? L w 血鈉 0.5-1.0 mEq/h ( 2.2 mEq/L w最常見原因: 腎衰竭 w其它原因: 攝取過多 內臟破裂仍持續進食 18 高血鎂 w 神經症狀 : 肌無力、麻痺、運動失調 、嗜睡、意識混亂 w 腸胃症狀:噁心、嘔吐 w 心血管症狀:血管擴張、緩脈、換氣不 足、心肺停止 19 高血鎂 心電圖變化 w PR、 QT 延長 w QRS 變寬 w P波電位變小 w T波變高 w Complete AV block、Asystole 20 處置 w補鈣離子 CaCl2 ( 5 to 10 mEq IV ) 可避免致命性心律不整 w移除血鎂 血液透析 腎及心血管功能正常 IV N /S + furosemide w減少攝取 21 低血鎂 w血鎂 10.5 mEq/L or Ca2+ 4.8 mg/dL w Primary hyperparathyroidism and malignancy account for 90% cases. 28 高血鈣 -症狀 Total serum Ca 12 to 15 mg/dL w Neuro. S/S: depression, weakness, fatigue, ,confusion (at lower levels) hallucination, disorientation, hypotonicity, coma (at higher levels) w Renal concentration of urine 29 高血鈣 -症狀 w CV S/S: variable 15 to 20 : myocardial depression Automaticity and ventricular systole is shortened Arrhythmias ( refractory period ) Digitalis toxicity is worsened Hypertension Many patients with hyperCa develop hypoK 30 高血鈣 -症狀 w GI S/S: dysphagia constipation peptic ulcers pancreatitis w Renal S/S: ability to concentrate urine dehydration diuresis (loss of Na, K, Mg, and P vicious circle of Ca reabsorption) 31 高血鈣 -心電圖變化 w QT變短 w PR and QRS 延長 w QRS voltage 變大 w T-wave變平、變寬 w Notching of QRS w AV block 32 處置 Symptomatic or 15 mg/dL w NS at 300 to 500 mL/h -維持尿量200 to 300 mL/h w After adequate rehydration: NS at 100 to 200 mL/h w Closely monitor K 10 mL) 1-5 mL over 5 minutes (嚴重有生命危險者) IVF 1-4 g/min SC 休克病患吸收差 Anaphylaxis 64 預防心跳停止的措施 - II w Antihistamines: diphenhydramine 25 mg IV or IM w H2 blockers: cimetidine 300 mg PO, IM, or IV w 等張溶液: NS 1-2 L甚至4L w albuterol ipratropium inhalation w Corticosteroids: 高劑量 IV or IM w Glucagon: 使用 -blockers者, 1-2 mg IM or IV Q5 min w 密切觀察24小時 Anaphylaxis 65 心跳停止時的措施 - 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