心肺 复苏.ppt

心脏性猝死与心肺复苏SuddencardiacdeathandCardiopulmonaryResuscitation,北京大学第一医院心内科洪涛,猝死的定义,发病到死亡的时间死亡原因基础健康状况,非心脏原因心脏原因,猝死的病因,猝死的流行病学,每年自然死亡的10%左右属于猝死80左右的猝死属心脏性心血管疾病所致死亡有50左右属猝死50%80心脏性猝死者有冠心病证据8%10%冠心病人以心脏性猝死为首发症状,AgeGenderGeneticbasisHypertensionLeftventricularhypertrophyElevatedserumcholesterol,心脏性猝死的危险因素(1),心脏性猝死的危险因素(2),GlucoseintoleranceCigarettesmoking(*)HeartrateandheartratevariabilityDietaryfactorsPhysicalactivityEmotionalstress,心脏性猝死的危险因素(2),IncreaseinplateletadhesivenessDecreaseinVFthresholdAccelerationofheartrateIncreaseinbloodpressureInductionofcoronaryspasmDecreaseinO2-carryingcapacityNicotine-inducedcatecholaminerelease,心脏性猝死的危险因素(2),GlucoseintoleranceCigarettesmoking(*)HeartrateandheartratevariabilityDietaryfactorsPhysicalactivityEmotionalstress,心脏性猝死的病因-1,Ischemicheartdiseasecoronaryatherosclerosisanomalousoriginofcoronaryarteriescoronaryarteryspasmhypoplasticcoronaryarterycoronaryarterydissectioncoronaryarteritissmallvesseldisease,心脏性猝死的病因-2,Cardiomyopathiesidiopathicdilatedcardiomyopathyhypertrophiccardiomyopathyhypertensivecardiomyophthyrightventricularcardiomyopathy,心脏性猝死的病因-3,InfiltrativeandinflammatoryheartdiseaseMyocarditisSarcoidosisAmyloidosisHemochromatosis,心脏性猝死的病因-4,ValvularheartdiseaseAorticstenosisAorticregurgitationMitralvalveprolapseInfectiveendocarditis,心脏性猝死的病因-5,CongenitalheartdiseaseTetralogyofFallotTranspositionofthegreatvesselsEbsteinsanomalyPulmonaryvascularobstructivediseaseCongenitalaorticstenosis,心脏性猝死的病因-6,PrimarilyelectricalabnormalitiesLongQTsyndromeWolff-Parkinson-WhitesyndromeCongenitalheartblockIdiopathicventricularfibrillationBrugadasyndrome（RBBB、ST抬高、猝死）Pokkuridisease（东南亚男性夜间猝死综合征）,心脏性猝死的病因-7,Drug-inducedandothertoxicagentsAntiarrythmicdrugs(classesIa、Ic、III)ErythromycinTricyclicantidepressantsPhosphodiesteraseinhibitorsCocaineAlcohol,心脏性猝死的病因-8,ElectrolyteabnormalitiesHypokalemiaHypomagnesemiaHypercalcemiaAnorexianervosaandbulimiaLiquidproteindietingdiuretics,心脏性猝死的非特异性前驱症状,ChestpainDyspneaFatiguePalpitation,心脏性猝死的临床表现,意识突然丧失大动脉搏动消失心音消失呼吸异常直至停止苍白、紫绀、末梢循环衰竭瞳孔对光反射消失、瞳孔散大,心脏性猝死的ECG表现,室颤或无搏室速心室静止（室性停搏）电机械分离,“chainofsurvival”concept,EarlyaccessEarlyCPREarlydefibrillationEarlyadvancedcardiaclifesupport,Algorithmforbasiclifesupport,Checkresponsiveness,Shakeandshout,Openairway,Headtilt/chinlift,Checkbreathing,Look,listenandfeel,Ifbreathing:recoveryposition,breathe,2effective,assesscirculation,CirculationpresentContinuerescuebreathing,Checkcirculationeveryminute,NocirculationCompresschest,Algorithmforadvancedcardiaclifesupport,Cardiacarrest,Precordialthumpifappropriate,BLSalgorithmifappropriat,Attachdefibrillatormonitor,Assessrhythm,Checkpulse,VF/VT,Defibrillate3asnecessary,CPR1min,NonVF/VT,CPR3min*1minifimmediatelyafterdefibrillation,Correctreversiblecauses,心肺复苏,Callfirst-Callfast,心肺复苏,心前区叩击FirstABCDAirway开放气道清除口腔分泌物、异物（Heimlichmaneuver）判断有无自主呼吸,心肺复苏,FirstABCDBreath建立呼吸：口对口、口对鼻、507呼吸频率：1012次/分潮气量：8001200ml10ml/kg(7ml/kg,O2)操作要点观察指标,心肺复苏,FirstABCDChestcompression恢复循环：胸部（心脏）按压部位频率按压/放松时间比按压幅度与人工呼吸的配合5:115:2操作要点观察指标作用机理,心肺复苏_InterposedAbdominalCounterpulsationDuringCPR(IACCPR),心肺复苏,FirstABCDDefibrillation影响电流大小的因素：电能、胸部阻抗（电极的大小和位置、耦合剂、已除颤的次数和间隔、体形、呼吸的时相、对电极板施加的压力）同步与非同步除颤,VT/VF的处理,ABC继续CPR,除颤200J，200-300J，360J,VT/VF持续或复发,恢复自主循环,电机械分离,室性停搏,继续CPR气管插管开放静脉,肾上腺素1mg,每3-5分钟重复,30-60秒内除颤360J,VT/VF持续或复发者,每次给药后30-60秒内除颤360J,心前区叩击,2-5mg/3-5min,1-3-5mg/3min,0.1mg/kg/3-5min,可重复数次,评价生命体征，维持气道通畅，维持呼吸，维持血压、心率,考虑抗心律失常药,室性停搏的处理,继续CPR气管插管开放静脉两个以上导联确认停搏,除外可能的诱因,考虑起搏治疗,尽早与药物同时使用才有效,肾上腺素1mg/3-5min,阿托品1mg/3-5min极量0.03-0.04mg/kg,原有高钾者应给碳酸氢钠1mEq/kg,已知原有碳酸氢钠有效的酸中毒三环类抗抑郁药过量药物过量需碱化尿液时,碳酸氢钠1mEq/kg,电-机械分离的处理,继续CPR气管插管开放静脉Doppler测血流速，UCG，动脉测压,除外可能的诱因低血容量通气不足心包填塞张力性气胸低体温巨大肺栓塞三环类/洋地黄/阻滞剂/钙拮抗剂等药过量高钾酸中毒大面积AMI,肾上腺素1mg/3-5min,心动过缓时阿托品1mg/3-5min，总量0.03-0.04mg/kg,碳酸氢钠1mEq/kg,已知原有碳酸氢钠有效的酸中毒三环类抗抑郁药过量药物过量需碱化尿液时,心肺复苏,建立心电监护和静脉通道ABCD的合并症骨折气胸肝、脾、胃破裂误吸及吸入性肺炎,心肺复苏,SecondABCDAirway气管插管保持气道通畅Breath评价通气是否恰当，必要时机械通气,心肺复苏,SecondABCDCirculation必要时继续心脏按压、除颤维持静脉通道维持足够血容量，保持血流动力学稳定DifferentialDiagnosis寻找基础病因寻找可逆的诱因并排除之,心肺复苏-复苏过程中的常用药物,CatecholaminesepinephrinenorepinephrinephenylepinephrinedopaminedobutamineAntiarrythmicagentsSodiumbicarbonateCalciumchloride,心肺复苏,复苏成功的指标自主心跳恢复瞳孔变化、光反射意识状况改善肌张力改善自主呼吸恢复出现吞咽动作,CPR的终止,心脏死亡：经1015分钟积极、恰当的CPR仍未恢复自主心跳及外周灌注，经30分钟BLS和ALS而无心脏电活动脑死亡：持续深昏迷、无自主呼吸及循环、无反射、瞳孔散大且对光反射消失提示脑死亡，但尚无公认、统一标准,低体温、巴比妥盐过量、触电者应适当延长CPR时间,心肺复苏,脑复苏避免低氧、低血压神志很快恢复的:维持PaO2100130mmHg心肺复苏后神志仍不清:冬眠疗法、冰帽降温速尿2040mg或甘露醇250mlQ8hDF510mgQ8h,心肺复苏,脑复苏脑水肿：methylprednisolone:60100mgdexamethasone:1220mgQ6h躁动者：安定10mgQ6h其它：钙拮抗剂、自由基清除剂、莨菪类、ATP、辅酶A等,Life-threateningproblemspostarrest,AcuterenalfailureBowelinfarctionInfectionAdultrespiratorydistresssyndromesepsis,复苏成功后的患者处理,EstablishingtheunderlyingcardiacpathologyHistoryandphysicalexaminationSerialenzymesandECGchangesEchocardiographyCardiaccatheterizationRadionuclidestudies,magneticresonanceimaging,cardiacbiopsy,复苏成功后的患者处理,ExcludepotentiallyreversiblecausesofVFTransientmyocardialischemicepisodePrinzmetalsanginaProarrhythmiceffectofantiarrhythmicagentsandotherdrugsElectrolyteabnormalitiesHypoxiaAcutecongestiveheartfailure,高危患者的二级预防,BetablockersAngiotensin-convertingenzymeinhibitorsClassIantiarrhythmicdrugsSotalol(classIIIwithbeta-blockingeffect)Amiodarone,高危患者的二级预防,Implantablecardioverterdefibrillator(1)Post-MI:ResuscitatedVT/VF,Spontaneoussustainedhaemodynamicallynon-toleratedVTPost-MI:PrimarypreventionEF40%,non-sustainedVTclinical,sustainedventriculararrhythmiasatEPSBrugadasyndrome:SecondarypreventionBrugadasyndrome:Symptomaticforsyncope/VT,高危患者的二级预防,Impl