特殊情况下的CPR.ppt

CPR in Special Situations 特殊情况下的CPR,福建医科大学附属协和医院麻醉科 翁险峰,ACLS in the Perioperative Period 围术期高级心脏生命支持,Causes of cardiac arrest + 心跳骤停的原因 1) intraoperative hemorrhage 术中出血 2) pre-existent cardiac pathology 原有的心脏疾患 3) hypoxia, both at intubation or extubation 插管或拔管时缺氧.,a different milieu of pathophysiology 病理生理的不同之处,Hypovolemia, as a cause of myocardial ischemia, is far more common than transmural infarction from plaque rupture.术中低血容量导致的心肌缺血远多于透壁心梗。 The most common cardiac dysrrythmia during general and neuraxial anesthesia is bradycardia followed by asystole (45%).全麻和椎管内麻醉中最常见的心律失常是心动过缓之后的心跳停止。 The other life threatening cardiac rhythms are severe tachydysrrhythmias including ventricular tachycardia（VT), ventricular fibrillation (VF 14%), and pulseless electrical activity (PEA 7%).其它威胁生命的心律失常是严重的频速型心律失常，包括室性心动过速，室颤，和无脉性电活动。,hyperventilation is almost invariably associated with worsened survival 过度通气常与糟糕的生存预后相关,in a low flow state the duration of increased intrathoracic pressure is proportional to the ventilation rate and inversely proportional to blood pressure, coronary and cerebral perfusion胸内压的增加与通气频率成正比，与血压及冠脉、脑血管灌注成反比。 Recent versions of the ACLS guidelines have recommended lower levels of ventilatory support.近期的高级生命支持指南推荐低水平的通气支持。 Ventilation at 20 breaths a minute is associated with significantly lower survival than ventilation at 12 breaths/minute. 每分钟20次的通气频率与每分钟12次通气频率相比，生存率低,Cardioversion心脏复律,Immediate cardioversion is indicated for a patient with serious signs & symptoms related to the tachycardia or if ventricular rate is 150 bpm伴有严重症状的心动过速或心室率 150次/分，是立即心脏复律的指征。 Always be prepared to externally pace patients who are being cardioverted, as some will convert into a very bradycardic rhythm.对心脏复律的患者应准备好体外起搏，这是由于一些患者会出现严重的心动过缓。,Avoiding cardiac arrest requires successfully managing acute anemia, hypoxemia, and all contributing factors to cardiac output: preload, contractility, and afterload.要避免心跳骤停，应处理好急性贫血、低氧血症及与心输出量有关的心脏前负荷、心肌收缩力、心脏后负荷。,Common Causes of ACLS events in the perioperative setting Anesthetic 药物原因,Intravenous anesthetic overdose静脉麻醉药过量 Inhalation anesthetic overdose吸入麻醉药过量 Neuraxial block with high level sympathectomy 椎管内麻醉平面过高的交感神经阻滞 Local anesthetic systemic toxicity局麻药毒性反应 Malignant hyperthermia恶性高热 Drug administration errors给药错误,Respiratory呼吸原因,Hypoxemia 低氧血症 Auto PEEP 内源性呼气末正压 Acute Bronchospasm 急性支气管痉挛,Cardiovascular心血管原因,Vasovagal reflex 血管迷走反射 Hypovolemic and/or hemorrhagic shock低血容量 和/或 出血性休克 Tension Pneumothorax 张力性气胸 Anaphylactic Reaction 过敏反应 Transfusion Reaction 输血反应 Acute Electrolyte Imbalance (high K)急性电解质失衡（高钾） Severe Pulmonary Hypertension 严重肺动脉高压 Increased intraabdominal pressure 腹内压增高 Pacemaker failure 起搏器故障 Prolonged Q-T syndrome 长Q-T综合征 Acute Coronary Syndrome 急性冠脉综合征 Pulmonary Embolism 肺栓塞 Gas embolism 气体栓塞 Oculocardiac reflexes 眼心反射 Electroconvulsive therapy 电休克治疗,Recognizing cardiac arrest in the OR 识别手术室内的心跳骤停,EKG with pulseless rhythm (V-tach, V-fib)无脉心电活动（室速、室颤） Loss of pulse X 10 seconds 无心跳10秒 Loss of end-tidal CO2 无呼末二氧化碳 Loss of plethysmograph （无动脉容积波形）,BLS/ACLS in the OR Some key points to remember . . .,CPR for patients under general anesthesia need not be preceded by “Annie! Annie! Are you okay?”全麻下的CPR无需呼唤患者 Instruct appropriate personnel to start effective CPR.恰当的人员开始有效的CPR Discontinue the anesthetic and surgery停止麻醉药和外科手术 Call for help, defibrillator呼叫帮助，除颤 Bag mask ventilation if ETT not in place followed by immediate endotracheal intubation if feasible FiO2 = 1.0未气管插管者先面罩通气随后立即气管插管， FiO2 = 1.0,BLS/ACLS in the OR Some key points to remember . . .,Dont stop CPR unnecessarily! Capnography is a more reliable indicator of ROSC than carotid or femoral arterial pulse palpation.不要无故停止CPR! 二氧化碳波形图在提示自主循环恢复方面比触摸颈动脉或股动脉更可信。 Capnograph to confirm advance airway positioning and effective CPR 二氧化碳波形图可用来证实高级气道位置及CPR的有效性。 Hand ventilate rate 8 -10, VT to chest rise, TI one second with 100% oxygen assess for obstruction, if none, institute mechanical ventilation. If obstruction, suction, fiberoptic bronchoscopy, consider exchanging the airway. Continue CPR.手动呼吸8-10次/分，够胸廓抬起的潮气量，吸气时间1秒，使用100%氧处理气道梗阻，建立机械通气，如果有气道梗阻，吸引，纤支镜检查，考虑更换气管，继续CPR Open all IVs to wide open 开放粗大静脉通路,Anaphylaxis is a rare but important cause of circulatory collapse in the perioperative period. 过敏反应虽然少见，但却是围术期循环衰竭的重要原因。 While there is a wide range of minor allergic reactions, hypotension, tachycardia and bronchospasm can be more easily followed by vasogenic shock when the offending agent is administered as a rapid intravenous bolus, the most common route of drug administration during anesthesia. 当引起过敏的药快速通过静脉路给予时，可能出现低血压、心动过速和支气管痉挛，随后出现血管性休克。,The preponderance of anaphylaxis in perioperative patients is caused by a small number of drugs. 多数的围术期患者的过敏反应是很少的一些药物引起的 Anaphylactic shock has been identified as a coexisting or major indeterminate factor for dysrhythmic cardiac arrest during anesthesia occurring in 2.2 to 22.4 per 10,000 anesthetics with 3% to 4% of them being life threatening.过敏性休克与麻醉中因严重心律失常心跳骤停有关，发生率2.2-22.4/10000麻醉病例，其中34%威胁生命,Neuroaxial Anesthesia,Various hypotheses have been put forward over the years, invoking unrecognized respiratory depression, excessive sedation concurrent with high block, under appreciation of both the direct and indirect circulatory consequences of a high spinal anesthetic, and failure to rescue with airway management and drugs.近年来出现各种假设，包括未及时发现的呼吸抑制，过多的镇静药物伴高平面的阻滞，脊麻药物用量过多导致的循环变化，未能正确的处理呼吸和循环。,Treatment of Cardiac Arrest Associated with Neuraxial Anesthesia 椎管内麻醉相关心跳骤停的处理,Discontinue anesthetic or sedation infusion停止麻醉药或镇静药的输注 Ventilate with 100% Oxygen, intubate trachea 100%浓度氧气通气，气管插管 Begin CPR if patient has significant bradycardia or is pulseless 10sec 患者有严重的心动过缓或无脉时间超过10秒即开始CPR Treat bradycardia with 1mg Atropine 阿托品1mg处理心动过缓 Treat with at least 1 mg epinephrine IV (up to)给予至少1mg肾上腺素静注，最高可用到0.1mg/kg Consider concurrent treatment with 40u vasopressin 可考虑同时给予40u血管加压素,Differential Diagnosis for perioperative PEA or Asystole: 8H & 8T,Hypoxia 低氧Trauma创伤/hypovolemia低血容量 Hypovolemia低血容量Tension Pneumothorax张力性气胸 Hyper-vagal 迷走反射 Thrombosis of Coronary 冠脉栓塞 Hydrogen Ion 酸中毒Tamponade 心脏压塞 Hyperkalemia 高钾血症Thrombus in Pulmonary Artery 肺动脉栓塞 Malignant Hyperthermia 恶性高热Long QT syndrome 长QT综合征 Hypothermia低温 Toxins (anaphylaxis)中毒（过敏反应） Hypoglycemia 低血糖Pulmonary HTN 肺动脉高压,Cardiac Arrest Associated With Asthma 与哮喘相关的心跳骤停,Since the effects of auto-PEEP in an asthmatic patient with cardiac arrest are likely quite severe, a ventilation strategy of low respiratory rate and tidal volume is reasonable.哮喘心跳骤停患者内源性PEEP可能很严重，因此低呼吸频率和小潮气量是合理的。 During arrest a brief disconnection from the bag mask or ventilator may be considered, and compression of the chest wall to relieve air-trapping can be effective.可考虑将面罩或呼吸机短暂脱开，胸外按压可有效减轻空气滞留。,For all asthmatic patients with cardiac arrest, and especially for patients in whom ventilation is difficult, the possible diagnosis of a tension pneumothorax should be considered and treated. 哮喘心跳骤停患者，尤其通气困难者，应考虑到可能存在张力性气胸并给予处理。,Cardiac Arrest Associated With Pregnancy,孕妇心跳骤停 第一反应 启动孕妇心心跳骤停复苏团队 记录心跳骤停发生时间 将孕妇置于仰卧位 开始心脏按压，手的位置在胸骨上略高于通常位置,寻找并处理可能的原因 B 出血/DIC E 栓塞：冠脉/肺/羊水 A 麻醉药 U 宫缩无力 C 心脏疾病（心梗/缺血/主动脉夹层/心肌病） H 高血压/先兆子痫/子痫 O 其他：鉴别诊断 P 胎盘早剥/前置胎盘 S 脓毒血症,Airway气道 Bag-mask ventilation with 100% oxygen before intubation is especially important in pregnancy.在气管插管前面罩呼吸囊100%氧气特别重要 Intubation with an endotracheal tube or supraglottic airway should be performed only by experienced providers if possible.如果可能应由有经验者进行气管插管或声门上气道,Circulation循环 Current recommended drug dosages for use in resuscitation of adults should also be used in resuscitation of the pregnant patient.现有推荐用于成人复苏的药物同样适用于孕妇的复苏,Defibrillation除颤 Although there is a small risk of inducing fetal arrhythmias, cardioversion and defibrillation on the external chest are considered safe at all stages of pregnancy.尽管有较小的风险导致胎儿心律失常，胸外的心脏复律和除颤被认为在各孕期的孕妇是安全的。,Cardiac Arrest Associated With Life-Threatening Electrolyte Disturbances 电解质失衡相关的心跳骤停,Hyperkalemia高钾血症,Stabilize myocardial cell membrane: 稳定心肌细胞膜 Calcium chloride氯化钙 (10%): 5 to 10 mL (500 to 1000 mg) IV over 2 to 5 minutes or calcium gluconate葡萄糖酸钙 (10%): 15 to 30 mL IV over 2 to 5 minutes,Shift potassium into cells: 促使钾转移至细胞内 Sodium bicarbonate碳酸氢钠: 50 mEq IV over 5 minutes Glucose plus insulin葡萄糖加胰岛素: mix 25 g (50 mL of D50) glucose and 10 U regular insulin and give IV over 15 to 30 minutes Nebulized albuterol 雾化沙丁胺醇: 10 to 20 mg nebulized over 15 minutes,Promote potassium excretion: 促进钾的排出 Diuresis利尿: furosemide 速尿40 to 80 mg IV Kayexalate降钾树脂: 15 to 50 g plus sorbitol per oral or per rectum Dialysis 透析,Hypokalemia can produce ECG changes such as U waves, T-wave flattening, and arrhythmias (especially if the patient is taking digoxin), particularly ventricular arrhythmias, which, if left untreated, deteriorate to PEA or asystole.低钾血症ECG表现为U波、T波低平、心律失常（尤其正在使用地高辛的患者），尤其是室性心律失常，未处理可恶化为无脉性电活动 或心跳静止。 Disturbances in sodium level are unlikely to be the primary cause of severe cardiovascular instability.血钠的失衡不太可能是严重心血管循环不稳定的初始原因。,Hypermagnesemia高镁血症,Hypermagnesemia is defined as a serum magnesium concentration 2.2 mEq/L (normal: 1.3 to 2.2 mEq/L). Neurological symptoms of hypermagnesemia include muscular weakness, paralysis, ataxia, drowsiness, and confusion. Hypermagnesemia can produce vasodilation and hypotension. 高镁血症是指血清镁浓度超过2.2 mEq/L（正常值为 1.3 to 2.2 mEq/L）。高镁血症的神经症状包括：肌无力、麻痹、共共济失调、昏昏欲睡、神志恍惚。高镁血症可导致血管扩张和低血压。,Hypermagnesemia高镁血症,Extremely high serum magnesium levels may produce a depressed level of consciousness, bradycardia, cardiac arrhythmias, hypoventilation, and cardiorespiratory arrest.极度的高镁血症可使神志消失、心动过缓、心律失常、低通气、心跳呼吸骤停。 Administration of calcium (calcium chloride 10% 5 to 10 mL or calcium gluconate 10% 15 to 30 mL IV over 2 to 5 minutes) may be considered during cardiac arrest associated with hypermagnesemia对于与高镁血症相关的心跳骤停，可给予钙剂（10%氯化钙5 to 10 mL 或10%葡萄糖酸钙15 to 30 mL IV 2-5分钟）,Hypomagnesemia低镁血症,Hypomagnesemia can be associated with polymorphic ventricular tachycardia, including torsades de pointes, a pulseless form (polymorphic) of ventricular tachycardia. 低镁血症与多形性室速有关，包括尖端扭转、无脉室速。 For cardiotoxicity and cardiac arrest, IV magnesium 1 to 2 g of MgSO4 bolus IV push is recommended.对心跳骤停者，静注硫酸镁1-2g，心要时静脉追加。,Local Anesthetic Toxicity局麻药毒性,Consider 1.5 mL/kg of 20% long-chain fatty acid emulsion(长链脂肪乳） as an initial bolus, repeated every 5 minutes until cardiovascular stability is restored. 考虑1.5ml/kg 20%长链脂肪乳作为首剂量，然后每5分钟重复一次直到心血管功能稳定,Cyanide氰化物,Based on the best evidence available, a treatment regimen of 100% oxygen and hydroxocobalamin, with or without sodium thiosulfate, is recommended. 使用纯氧及静注维生素B12，合用或不用硫代硫酸钠。,Cardiac Arrest Associated With Trauma 创伤相关的心跳骤停,While CPR in the pulseless trauma patient has overall been considered futile, several reversible causes of cardiac arrest in the context of trauma are correctible and their prompt treatment could be life-saving. 对大多数无脉性创伤患者CPR是无效的，但一些可逆因素导致的心跳骤停是可治疗，立即处理是可以救命的。These include hypoxia, hypovolemia, diminished cardiac output secondary to pneumothorax or pericardial tamponade, and hypothermia.这些包括低氧、低血容量、继发于张力性气胸或心包压塞的低心排血量、低温。,When multisystem trauma is present or trauma involves the head and neck, the cervical spine must be stabilized. A jaw thrust should be used instead of a head tilt chin lift to establish a patent airway. 当出现多器官系统创伤或创伤包括了头颈，必须保持颈椎的稳定。在开放气道时应下推前颌取代头部倾斜抬下颌。 If breathing is inadequate and the patients face is bloody, ventilation should be provided with a barrier device, a pocket mask, or a bag-mask device while maintaining cervical spine stabilization. 如果通气不足且患者面部出血，在保持颈椎稳定性的同时，应提供面罩通气。 Stop any visible hemorrhage using direct compression and appropriate dressings. If the patient is completely unresponsive despite rescue breathing, provide standard CPR and defibrillation as indicated.使用直接按压或恰当的敷料来止血。如果患者对呼吸救治无反应，应进行常规的CPR和除颤。,After initiation of BLS care, if bag-mask ventilation is inadequate, an advanced airway should be inserted while maintaining cervical spine stabilization. If insertion of an advanced airway is not possible and ventilation remains inadequate, experienced providers should consider a cricothyrotomy. 面罩通气、高级气道、环甲膜切开,A unilateral decrease in breath sounds during positivepressure ventilation should prompt the rescuer to consider the possibility of pneumothorax, hemothorax, or rupture of the diaphragm.正压通气时单侧呼吸音减弱，救治者应想到气胸、血胸、横膈破裂的可能。 When the airway, oxygenation, and ventilation are adequate, evaluate and support circulation. Control ongoing bleeding where possible and replace lost volume if the losses appear to have significantly compromised circulating blood volume. Cardiac arrest resuscitation will likely be ineffective in the presence of uncorrected severe hypovolemia.当气道、供氧、通气足够时，评估支持循环。控制出血、输液，低血容量时心肺复苏很可能是无效的。,Treatment of PEA requires identification and treatment of reversible causes, such as severe hypovolemia, hypothermia, cardiac tamponade, or tension pneumothorax.处理无脉性电活动需要鉴别并处理可逆原因，如严重的低血容量、低温、心脏压塞或张力性气胸。 Development of bradyasystolic rhythms often indicates the presence of severe hypovolemia, severe hypoxemia, or cardiorespiratory failure.心动过缓进展到心跳停止常代表严重低血容量、严重低氧血症或心肺衰竭。 Ventricular fibrillation (VF) and pulseless ventricular tachycardia