心肺复苏 中山大学 外科学.ppt

1,Cardiopulmonary Resuscitation (CPR) Jie-yu Fang Department of Anesthesia, The First Affiliated Hospital,fang_,2,CPR,BLS diagnosis A,B,C effectiveness CPR for children and infants ALS Advanced Life Support PLS scoring system,抢救过程可分为： 基本生命支持（Basic Life Support,BLS） A =Air Way 开放气道; B =Breathing 人工通气; C =Circulation 人工循环. 高级生命支持 （Advanced Cardiac Life Support,ACLS）,3,BACKGROUND,Approximately 700,000 cardiac arrests per year in Europe Survival to hospital discharge presently approximately 5-10% Bystander CPR vital intervention before arrival of emergency services Early resuscitation and prompt defibrillation (within 1-2 minutes) can result in 60% survival,4,What is Cardiac arrest?,Cardiac arrest is the cessation of normal circulation of the blood due to failure of the heart to contract effectively during systole. if the patient still has a pulse, respiratory arrest (the combined term cardiorespiratory arrest) is also used. lack of blood supply results in cell death from oxygen starvation. Cerebral hypoxia, or lack of oxygen supply to the brain, causes victims to lose consciousness and stop breathing. Cardiac arrest is a medical emergency that, if left untreated, invariably leads to death within seconds to minutes. The primary first-aid treatment for cardiac arrest is cardiopulmonary resuscitation.,5,Etiology,Coronary artery disease (CAD) is the predominant disease process associated with sudden cardiac death in the United States. In apparently healthy adults, cardiac arrest is often caused by ventricular fibrillation during myocardial infarction (heart attack). In children, cardiac arrest is typically caused by hypoxia from other causes such as near-drowning. With prompt treatment survival rates are high. Every fatal injury or illness ultimately terminates in cardiac arrest, which is a natural part of the processes of death.,6,Diagnosis,The state of cardiac arrest is diagnosed in an unconscious (unresponsive to vigorous stimulation) person who does not have a pulse . An ECG clarifies the exact diagnosis and guides treatment. but treatment should begin without awaiting an ECG.,7,cardiac arrest- four rhythms,Ventricular fibrillation 54.2% Ventricular standstill (asystole) 29.8% Electro-mechanical dissociation(EMD) 9.2% Ventricular tachycardia 1.5% There are 4 rhythms which result in a cardiac arrest. VF and VT are both responsive to a defibrillator and so are colloquially referred to as “shockable“ rhythms, whereas asystole and EMD are non-shockable.,8,Cardiopulmonary Resuscitation (CPR),Definition 是指对于早期心脏呼吸停止的病人，通过采取人工呼吸，人工循环，电除颤等方法帮助病人恢复自主心跳和自主呼吸的一种急救技术。,9,What is Electromechanical dissociation (EMD)-Pulseless electrical activity,Refers to organized electrical depolarization without mechanical contractions, (persistence of electrical activity in the heart but there is ineffective cardiac contraction). The primary mechanisms are cardiac rupture, acute tamponade, global ischemia, acute MI, obstructing by intracardiac tumor or thrombus, and chronic heart failure,hypovolemia, hypothermia, significant acidosis,medication overdose (tricyclic agents, digitalis, betblockers,calcium channel blockers).,10,Asystole,Asystole is the absence of electrical activity on ECG, with absent perfusion, BP, and pulse. Causes include severe generalized myocardial ischemia, ventricular rupture, and hyperpolarization of cardiac cell membranes in severe hyperkalemia (serum K+ 7 mEq/L) or hypermagnesemia.,11,Diagnosis,Cardiac arrest strikes immediately and without warning. Here are the signs: Unconscious- inadequate cerebral perfusion stopped breathing lack of circulation In many cases, lack of carotid pulse is the gold standard for diagnosing cardiac arrest, but lack of a pulse (particularly in the peripheral pulses) may be a result of other conditions (e.g. shock) If cardiac arrest occurs, begin CPR immediately for 1 min & call 120.,12,Common causes of cardiac arrest,13,Treatment of cardiac arrest,Basic Life Support (CPR) Continous of effective Basic Life Support remains important to maintain vital organ perfusion assure circulation of lifesaving drugs Advanced life support: treats cardiac arrest definitively with drugs, fluids, DC countershock or artificial pacemaker when appropriate,14,Treatment- Chain of Survival,Out-of hospital arrest,several organization promote the idea of “Chain of survival” Early recognition/access Early CPR Early defibrillation Early advanced care,及早进入急救程序 及早CPR 及早电除颤 及早进一步治疗,15,What is CPR?,Cardiopulmonary resuscitation (CPR) CPR is a combination of rescue breathing and chest compressions delivered to victims thought to be in cardiac arrest. When cardiac arrest occurs, the heart stops pumping blood. CPR can support a small amount of blood flow to the heart and brain to “buy time” until normal heart function is restored,16,Treatment of cardiac arrest -CPR,Basic life support (CPR) A: Airway B: Breathing C: Circulation D: defibrilation,17,Basic Life Support Airway,1. Clear the airway Quick inspection of the mouth and throat may reveal a blocked airway. the patient should be placed on his/her back on a firm surface. tilting the head, lifting the chin will lift the tongue away from the back of the mouth, opening the airway. In the possibility of a neck injury, lifting the chin or jaw may be enough to stabilise the airway; If foreign body is lodged in the oropharynx, the Heimlich maneuver is performed.,18,BLS-airway,19,Basic Life Support breathing,Proper check of the patients respiration : After opening the victims airway, breathing effort is checked, detecting any of the following signs: feeling the airflow on the cheek hearing the airflow feeling the chest rise and fall seeing the chest rise and fall,20,Basic Life Support breathing,This is done for 10 seconds. If the victim is breathing, he/she is placed on the side (in the recovery position). More time is now available to call for help. If the victim is absence of breathing effort, artificial respiration is commenced. mouth-to-mouth respiration may be used.,21,Basic Life Support breathing,mouth-to-mouth respiration The head of the patient is tilted backward. The rescuer closes the patients nose with one hand, while lifting the chin with her other hand to keep the mouth open Initially, two rescue breaths are given.,Conventional ventilation techniques during single-responder CPR require the lungs to be inflated twice in succession every 30 chest compressions.,22,Bag mask ventilator,23,Mechanical ventilation,A definitive airway will be established by the placement of an endotracheal tube which is attached to a mechanical ventilation.,24,Basic Life Support circulation,To check for a pulse place your fingers on the victims neck and slide them to the side until you find a groove in the neck above the carotid artery. Check for pulse for no more than ten seconds. Pulse can also be found in the wrists and the ankles, although in an emergency situation there is not usually time to check for pulse here. (In patients with a low blood pressure, the pulse may disappear in the wrists and ankles, and can only be felt in the neck or femoral arteries.) On infants it can be found on the inside of the upper arm.,25,Basic Life Support circulation,If there is no circulation: Begin chest compressions Chest compression is based on the assumption that cardiac compression allows the heart to maintain a pump function by sequential filling and emptying of its chambers, with competent valves maintaining forward direction of flow. The palm of one hand is placed Send a bystander to call for help using the emergency telephone number.,26,In some places, including the UK and the United States, some experts no longer advise laypersons to assess the carotid pulse because it wastes time and studies have shown it leads to an incorrect conclusion in up to 50% of cases. Instead they recommend looking for other visible signs of circulation. Health professionals are still advised to perform a carotid pulse check, taking no more than 10 seconds, whilst also checking the other signs of a circulation.,27,Begin chest compressions,Place the victim on their back on a firm surface. (a soft surface will render the compression completely useless). Kneel next to the victims chest. Remove, open or cut the patients excess clothes. (doing CPR through a thin clothing is acceptable). Place your hands directly above the sternum, one on top of the other, two fingers width (4-5cm) above the point where the lower ribs meet. To avoid injuring ribs, only the heel of your hand should touch the chest. (The American Heart Association suggests using the CPR landmark described as, “in the center of the chest, between the nipples“.) Shift your weight forward on your knees until your shoulders are directly over your hands.,28,Begin chest compressions:,Keeping your elbows locked straight, repeatedly bear down and then come up, bear down and come up. You must depress the chest of an average adult about 2 inches (4-5cm) with each compression. It is important to release completely after each chest compression. Compress the chest about 100 times every minute. To get the right speed and rhythm, count out loud as you do the compressions, saying “1, 2, 3, 4, 5, 1, 2, 3, 4, 5, 1, 2, 3, 4, 5“. Try to compress and release for equal periods of time. After each 30 compressions, give the victim 2 rescue breaths, p182 Return to the victims chest and put your hands in the correct position again. Repeat this cycle of 30 and 2 for a total of 3 times every minute.,29,When to stop? Continue until there is: breathing, coughing or movement or other signs of circulation return qualified help arrives and you are asked to stop (if a defibrillator arrives, its operation will have priority on the CPR). you are too exhausted to continue. It is also important to note that, particularly in elderly patients, crepitations 劈拍声 will often occur. Crepitations are the shattering碎裂 of bones in the rib cage and sternum. They can be both heard and felt. Do not discontinue CPR due to crepitations, although check your hand position if bone breakage appears to be excessive.,30,CPR,31,Effectiveness,CPR is almost never effective if started more than 15 minutes after collapse because permanent brain damage has probably already occurred. A notable exception is cardiac arrest occurring with exposure to very cold temperatures. There are cases where CPR, defibrillation, and advanced warming techniques have revived hypothermia victims after over 30 minutes. In respiratory arrest, when the victim still has a heartbeat, such as in drowning, choking, or drug overdose with opioids or sedatives, the Airway and Breathing part of CPR is relatively very effective. About 10% of those on which CPR has been performed will recover entirely.,32,Complication of chest compression,1. Gastric distention-due to breathing too forcefully and/or too quickly, causing air to enter the stomach. 2. broken ribs 3 Pneumothorax 4. Disease transmission, including herpes, HIV, Hepatitis, Mononucleosis, Influenza, Staph infection, and TB-due to inadequate or no protective mask. 5. Vomiting and possible aspiration into lungs.,33,Advanced Life Support,ALS- 1.Monitoring and Arrhythmia Rocognition,Attach a defibrillatormonitor Monitor the cardiac rhythm: Place the defibrillator paddles or self-adhesive electrode pads on the chest wall; one just below the right clavicle, the other at the left mid axillary line. Place monitoring electrodes on the limbs or trunk but well away from the defibrillation sites. After a shock has been delivered there is a possibility of spurious asystole being displayed if monitoring is continued through paddles and gel pads. If a non-shockable rhythm is displayed via paddles and gel pads after the first or second shocks, monitoring leads should be attached, and the rhythm confirmed.,34,Advanced Life Support,ALS- 2.defibrillation,Assess rhythm (check for pulse) Check for signs of a circulation, including the carotid pulse. Take no more than 10 s Assess the rhythm on the monitor as being: A shockable rhythm: Ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). A non shockable rhythm: Asystole or Pulseless Electrical Activity (PEA),35,ALS-defibrillation,VF:VT (a) Ensure that everybody is clear of the patient. Place the defibrillator paddles on the chest wall Use up to three sequential shocks, if required, of 200, 200 and 360 J with a monophasic defibrillator, observing the ECG trace after each shock for any changes in the rhythm. Use appropriate alternative levels with a biphasic defibrillator. The aim should be to administer up to three initial shocks. (b) If VF:VT persists after three shocks, perform 1 min of CPR (30:2).,36,(c) During CPR: Consider and correct reversible causes. If not already: Check electrodes, paddle position and contact. Secure and verify the airway, administer oxygen, obtain IV access. (Once the trachea has been intubated, chest compressions at a rate of 100 min_1 should continue uninterrupted, with ventilations performed at about 12 min_1 asynchronously) . Give 1 mg adrenaline IV. If venous access has not been established consider giving 23 mg adrenaline via the tracheal tube in a 1:10 000 solution. . The interval between the third and fourth shocks should not be more than 1 min. (d) Reassess the rhythm on the monitor. Check for signs of a circulation, including the carotid pulse, but only if the ECG waveform is compatible with cardiac output. (e) If the rhythm is non-VF:VT, follow the path of the algorithm.,37,38,(f) If VF:VT persists: Consider amiodarone in VF:VT refractory to three initial shocks. Attempt defibrillation with three further shocks at 360 J with a monophasic defibrillator or an equivalent energy for an alternative waveform defibrillator. . Give 1 mg adrenaline IV. The process of rhythm reassessment, delivery of three shocks and 1 min of CPR will take 23 min. One mg of adrenaline is given in each loop every 3 min. Repeat the cycle of three shocks and 1 min of CPR until defibrillation is achieved. (g) Each period of 1 min of CPR offers a new opportunity to check electrode:paddle positions and contact, secure and verify the airway, administer oxygen, obtain IV access, if not already done. . Consider the use of other medications (e.g., buffers).,39,Advanced Life Support,ALS,Non VF:VT asystole, pulseless electrical activity (a) Check for signs of a circulation, including the carotid pulse. (b) Perform 3 min of CPR (30:2), if the patient is in cardiac arrest. NB: If the non-VF:VT rhythm occurs after defibrillation,perform only 1 min of CPR before reassessing the rhythm and giving any drugs. (c) During CPR: Consider and correct reversible causes. If not already: Check electrodes, paddle position and contact Secure and verify the airway, administer oxygen, obtain IV access. (Once the trachea has been intubated, chest compressions should continue uninterrupted, with ventilations performed at 12 min_1 asynchronously) . Give 1 mg adrenaline IV. If venous access has not been established, consider giving 23 mg adrenaline via the tracheal tube in 1:10 000 solution.,40,(d) Reassess the rhythm after 3 min of CPR. Check for signs of a circulation, including the carotid pulse, but only if the ECG waveform is compatible with cardiac output. (e) If VF:VT, follow the path of the algorithm. (f) If non-VF:VT, perform 3 min of CPR (30:2). . Give 1 mg adrenaline IV. As the process will take 3 min, 1 mg of epinephrine (adrenaline) is given in each loop every 3 min. (g) Each period of 3 min of CPR offers a new opportunity to check electrode paddle positions and contact, secure and verify the airway, administer oxygen, obtain IV access, if not already done. (h) Consider the use of other medications (atropine, buffers) and pacing.,41,Advanced Life Support,ALS- medications,Consider the use of other measures (medications and pacing) (a) Antiarrhythmics There is incomplete evidence to make firm recommendation on the use of any antiarrhythmic drug. Amiodarone is the first choice in patients with VF:VT refractory to initial shocks. The initial dose is 300 mg diluted in 20 ml 5% dextrose given as an IV bolus. An additional 150 mg of amiodarone may be considered if VF:VT recurs. Consider the use of amiodarone after three - shocks, but do not delay subsequent shocks.,42,(b) Buffers Consider giving sodium bicarbonate (50 ml of an 8.4% solution) or an alternative buffer to correct a severe metabolic acidosis (pHB7.1). When blood analysis is not possible, it is reasonable to consider sodium bicarbonate or an alternative buffer after 2025 min of cardiac arrest. (c) Atropine A single dose of 3 mg of atropine, given as an IV bolus, should be considered for asystole and pulseless electrical activity (rateB60 beats min_1). (d) Pacing Pacing may play a valuable role in patients with extreme bradyarrhythmias, but its value in asystole has not been established, except in cases of trifascicular block where P waves are seen.,43,Sequence of actions,Consider:treat reversible causes. In any cardiac arrest patient, potential causes or aggravating factors for which specific treatment exists should be considered:(4H 4T) Hypoxia Hypovolaemia Hyper:hypokalaemia Hypothermia Tension pneumothorax Tamponade Toxic:therapeutic disturbances Thromboemboli,44,The guideline of CPR,45,Defibrillation,electro-mechanical dissociation, EMD,46,CPR on babies aged under 1 year,Open the airway. Remove any visible obstructions from the mouth and nose Breathing Attempt 5 initial rescue breaths Place 2 fingers in the middle of the chest and press down one third of the depth of the chest. After 30 chest compressions give 2 breaths Continue with cycles of 30 chest compression and 2 rescue breaths until emergency help arrives.,47,48,Advanced life support,Advanced Life Support D.药物治疗(Drugs) E.心电监护(ECG) F.心脏除颤(Fibrillation) Resuscitation success vs.Time no treatment 0% Dela