2015年心肺复苏

再问路在何方 2015 AHA 心肺复苏指南,滑县妇幼保健院 韩帅超,心肺复苏是一个世界性难题,现代心肺复苏的发展,1960 1970 1980 1990 2000 2010 2015 2020,胸外按压人工呼吸,除颤,脑复苏,国际复苏联合会,第三次修订,CPR指南,第四次修订,关于心肺复苏的诸多困惑,如何识别心脏骤停施救顺序按压频率按压深度按压通气比电除颤高级生命支持ROSC后 治疗,如何识别,01,1980 1990 2000 2010 2015 2020,心脏骤停,听，看，感觉 评价无反应,02,抢救顺序,03,按压频率(次/分),1960 1970 1980 1990 2000 2010 2015 2020,60-80,80,80-100,100,100-120,04,按压深度(cm),2005 2010 2015 2020,05,按压通气比,1980 1990 2000 2010 2015 2020,5:2,15:2,30:2,06,电除颤,360J，360J，360J,单向波100-200-300-360J,双向波120 - 150 - 200 -更高,1980 1990 2000 2010 2015 2020,07,高级生命支持,肾上腺素阿托品 利多卡因,外周静脉肾上腺素大剂量,1mg肾上腺素每隔3-5min推注1次、加压素,?,2020,1mg肾上腺素每隔3-5min推注1次,08,复苏后 综合治疗,心脏骤停的机制?血流动力学亚低温治疗,如何提高心肺复苏成功率？,生存链,AHA成人生存链,及早识别并启动应急反应系统,及早识别并启动应急反应系统,01,02,及早识别并启动应急反应系统,We recommend that dispatchers should provide chest compressiononly CPR instructions to callers for adults with suspected OHCA (Class I, LOE C-LD),911调度员电话指导路人OHCA心肺复苏Ringh M，美国,Ringh M, Rosenqvist M, Hollenberg J, et al. Mobile-phone dispatch of laypersons for CPR in out-of-hospital cardiac arrest. N Engl J Med. 2015;372(24):2316-2325.,即时高质量心肺复苏,01,施救顺序,加强业务技术学习,Marsch S, Tschan F, Semmer NK, Zobrist R, Hunziker PR, Hunziker S. ABC versus CAB for cardiopulmonary resuscitation: a prospective, randomized simulator-based trial. Swiss Med Wkly. 2013;143:w13856. doi: 10.4414/smw.2013.13856.,按压深度,Hellevuo H, Sainio M, Nevalainen R, Huhtala H, Olkkola KT, Tenhunen J, Hoppu S. Deeper chest compression - more complications for cardiac arrest patients? Resuscitation. 2013;84:760765. doi: 10.1016/j.resuscitation.2013.02.015.,02,在徒手心肺复苏过程中，施救者应以至少2英寸（5 厘米）的深度对普通成人实施胸部按压，同时避免胸部按压深度过大（大于 2.4 英寸 6 厘米 ）(I C-LD),During manual CPR, rescuers should perform chest compressions to a depth of at least 2 inches or 5 cm for an averageadult, while avoiding excessive chest compression depths (greater than 2.4 inches or 6 cm) (Class I, LOE C-LD),较深的胸外按压对心脏 骤停患者有更大的副作用? Resuscitation ,Hellevuo H et al.,芬兰学者Heidi Hellevuo等人通过尸检、CT、胸部X线的方法分析170名经CPR的成年患者胸部按压与医源性损伤的联系，得出发生医源性损伤的平均按压深度63mm与未损伤的平均深度55mm有显著差异(P=0.002)；按压深度的峰值86mm与73mm造成医源性损伤有显著差异(P=0.001)。,03,按压深度,按压频率,Idris AH, Guffey D, Pepe PE, Brown SP, Brooks SC, Callaway CW, Christenson J, Davis DP, Daya MR, Gray R, Kudenchuk PJ, Larsen J, Lin S, Menegazzi JJ, Sheehan K, Sopko G, Stiell I, Nichol G, Aufder -heide TP; Resuscitation Outcomes Consortium Investigators. Chest compression rates and survival following out-of-hospital cardiac arrest. Crit Care Med.2015;43:840848. doi: 10.1097 / CCM.0000000000000824.,对于心脏骤停的成年患者，施救者以每分钟 100 至 120 次的速率进行胸外按压较为合理(Class IIa, LOE C-LD),04,In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100/min to 120/ min (Class IIa, LOE C-LD),北美的一项多中心研究发现，ROSC率在CPR按压频率达到125次/分时最高，频率继续增加则ROSC率呈下降趋势。,心脏骤停后按压频率与预后的关系Crit Care Med, Idris Ah et al.,05,按压频率,Hellevuo H, Sainio M, Nevalainen R, Huhtala H, Olkkola KT, Tenhunen J, Hoppu S. Deeper chest compression - more complications for cardiac arrest patients? Resuscitation. 2013;84:760765. doi: 10.1016/j.resuscitation.2013.02.015.,按压通气比,Hinchey PR, Myers JB, Lewis R, De Maio VJ, Reyer E, Licatese D, Zalkin J, Snyder G; Capital County Research Consortium. Improved out-of-hospital cardiac arrest survival after the sequential implementation of 2005 AHA guidelines for compressions, ventilations, and induced hypothermia:the Wake County experience. Ann Emerg Med. 2010;56:348357. doi:10.1016/j.annemergmed.2010.01.036.,30:2,(Class IIa, LOE C-LD),06,胸壁回弹,加强业务技术学习,回弹充分 促进静脉回流和心肺血流,Glatz AC, Nishisaki A, Niles DE,et al. Sternal wall pressure comparable to leaning during CPR impacts intrathoracic pressure and haemodynamics in anaesthetized children during cardiac catheterization. Resuscitation. 2013;84:16741679. doi: 10.1016/j.resuscitation.2013.07.010.,回弹不充分 增加胸廓内压力，减少静脉回流、冠状动脉灌注压力和心肌血流，影响复苏存活率,07,08,尽可能减少胸外按压中断次数,(Class IIb, LOE C-LD),目标比例为至少60%,(Class I, LOE C-LD),Cheskes S, Schmicker RH, Verbeek PR,et al; Resuscitation Outcomes Consortium (ROC) investigators. The impact of peri-shock pause on survival from out-of-hospital shockable cardiac arrest during the Resuscitation OutcomesConsortium PRIMED trial. Resuscitation. 2014;85:336342. doi: 10.1016/j. resuscitation.2013.10.014.,快速除颤,先除颤 OR 先心肺复苏,OR,Huang Y, He Q, Yang LJ, Liu GJ, Jones A. Cardiopulmonary resuscitation (CPR) plus delayed defibrillation versus immediate defibrillation for out-of-hospital cardiac arrest. Cochrane Database Syst Rev.2014;9:CD009803. doi: 10.1002/14651858.CD009803.pub2.,01,02,PAD方案,基础及高级急救医疗服务,EMS急救团队到达后尽快转运至急诊室/导管室,药物应用,02,Gueugniaud PY, David JS, Chanzy E et al. Vasopressin and epinephrine vs. epinephrine alone in cardiopulmonary resuscitation. N Engl J Med. 2008;359:2130. doi:10.1056/NEJMoa0706873.,02,ETCO2预测复苏失败,02,PAD方案,高级生命支持及骤停后护理,血液动力学目标,(Class IIb, LOE C-LD),Gaieski DF, Band RA, Abella BS,et al. Early goal-directed hemodynamic optimization com-bined with therapeutic hypothermia in comatose survivors of out-of-hospital cardiac arrest. Resuscitation. 2009;80:418424. doi: 10.1016/j.resuscitation.2008.12.015.,01,目标温度管理,03,Nielsen N, Wetterslev J, Cronberg T et al; TTM Trial Investigators. Targeted temper