黄培志－心肺复苏

1、Cardiopulmonary ResuscitationPeizhi HuangZhongshan Hospital1Diagnosis of cardiac and respiratory arrest Traditional methods : 1. Carotid pulse check by lay rescuers 2. Loss of consciousness 3. Pupil dilation 4. Respiratory arrest2 Guideline 2000Elimination of the pulse check for lay rescuersEvaluate

2、 for signs of circulation in 10 seconds breathing , coughing , movement in response to rescue breath3 Assess for a pulseTime is too longerAccurate rate 75 %Sensibitity 90%Specificity 60%4Rate of false- positive(40%) Results Pulseless Pulse Mistakenly loss the saving opportunity5Rate of false-negativ

3、e (10 %) Results Pulse Pulseless Unnecessarily do CPR6 Electrocardiogram changes of Cardiac arrest Ventricular fibrillationA flat line or only atrial wavePulseless Electrical Activity, PEA7 The chain of Survival Early access Early CPR Early Defibrillation Early advanced life support * patient with C

4、oma （ immediately do CPR ， not clear obstructed airways at first） 8Basic Life Support - the first ABCDAirway ABreathing BCirculation CDefibrillation D9 AirwayTilt the head backwardsLift the jaw Open the mouthClearing obstructed airways from choking Subdiaphragmatic abdominal thrust (Heimlich maneuve

5、r)10 BreathingMouth to mouth or mouth to noseMouth to oropharyngeal tube Mouth to shieldMouth to mask(compressing the cricoid cartilage in order to decrease gastric distention and prevent gastric reflu)Bag-mask ventilation challenged endotracheal intubation resuscitations “gold standard”11Circulatio

6、n external chest compression High-frequency（100 compressions per min） aortic pressure myocardial perfusion pressure cardiac outputs rise survival rate Reduce interrupted compression ( compression ventilation ratio simplified to 15:2)Compression-only CPR: unwilling or unable to perform mouth to mouth

7、 or cardiogenic cardiac arrest12Circulation Compression-only CPRResearch suggests: Survival rate with compression-only CPR in first 612 minutes is 40.8% Survival rate with chest compression add artificial ventilation is 34.1% , because artificial ventilation may be result in respiratory alkalosis. 1

8、3 Mechanism of external chest compression Chest pump - sequential increased and decreased pressure in the thoracic cavity - valves maintaining forward direction of flowCardiac pump -sequential filling and emptying of cardiac chambers -valves maintaining forward direction of flow14 CirculationThump v

9、ersion from 20-25 cm high to chestCough Version in 10-15 secondIntermittent abdominal compression-cardiopulmonary resuscitation（IAC-CPR)Activated compression-decompression（ACD-CPR)PhasedChest and Abdominal ACD-CPR （Life-stick Resuscitation） increase mean pressure，coronary and cerebral perfusion pres

10、sure，left ventricular and cerebral blood flow15Automated external defibrillator - AED Ventricular fibrillation : may be used by 200J*3 times) or 200J、200-300J、300J If polymorphic ventricular tachycardia can not be clearly distinguished from ventricular fibrillation (VF), treatment would refer to be

11、as VF Atrial fibrillation :100-200J synchronized Atrial flutter or supraventricular tachycardia 50- 100J synchronized Ventricular tachycardia 100J synchronized16 Biphasic waveform defibrillation A compensated defibrillation for the second time in limited timeLow-energy levels（150J correspond to 200-

12、300J）Reduce the myocardial injury 17 Advanced Life Support - the second ABCDEndotracheal intubation (A)Mechanical ventilation and oxygen therapy (B)Intravenous injection (C)electrocardiogram and blood pressure monitoring, resuscitation drug , open chest cardiac compression (C)Differential diagnosis

13、(D)18 Confirmation of Endotracheal tube placement Mark estimated depthBreath sounds by auscultation at 5 locus Thorax rise as inspirationincrease of SaO2Steam in canal of artificial ventilation deviceUse a specific technique or device to prevent tube dislodgment19Mechanical ventilationLow tidal volu

14、me 6-7ml/kg（400-600ml）Hyper ventilation High airway pressure and endogenous PEEP Intracranial hypertension; High tidal volume DistensionToo low tidal volume hypoxia and CO2 retention 20 Epinephrine EN -(1)-adrenergic receptor stimulating Peripheral arterial vasoconstriction(not cerebral and coronary

15、 arterioles) mean arterial pressure myocardial and cerebral blood flow 21Epinephrine EN -(2)Recommended dosage : 1.0mg(0.01-0.02mg/kg ) iv every 3-5 minutes, then 1mg + GS 250ml iv gtt, 1g/min3-4g/min, or 1mg、3mg、5mg ivCompared high dosage: 0. 1-0.2mg/kgHigh dosage (0.2mg/kg) may be harmfulEndotrach

16、eal administration: NS 20ml + 22.5 time recommended doseIntracardiac injection: only in heart operation or chest trauma22VasopressinAct by direct stimulation of smooth muscle V1 receptors vasoconstrictionNo increased myocardial oxygen consumptionHalf-life is 10 20 minute, longer than ENApplicable to

17、 VF or prolonged cardiac arrest, and with PEA（pulseless electrical activity）or with asystoleEffective in patients who remain in cardiac arrest after treatment with epinephrineUsage: 40IU iv 23 Amiodarone(1)Persistent VT or VF after defibrillation and epinephrine in cardiac arrestHemodynamically stab

18、le VTpolymorphic VT wide-complex tachycardiaVentricular rate control of rapid atrial arrhythmias with impaired LV function when digitalis ineffective24 Amiodarone(2)Initially 300mg iv diluted in 20-30 ml in cardiac arrestInitial dose of 150mg iv（ over 10 min), followed by 1 mg/min infusion for 6 h,

19、then 0.5mg/minSupplementary 150mg iv repeatedly for recurrent or resistant arrhythmias or hemodynamically unstable VT Maximum total dose: 2g24hadverse effects：hypotension and bradycardia 25Magnesium sulfateTorsades de pointes Arrhythmias caused by magnesium deficiencyLoading dose :12g /50-100ml iv (

20、over 5-60 minutes)Followed by an infusion of 0.5-1.0g/h26Sodium Bicarbonate（1）Only after the confirmed interventions are ineffectivePreexisting metabolic acidosis, hyperkalemia, tricyclic or phenobarbitone overdose Protracted arrest or long resuscitative efforts27Sodium Bicarbonate（2）Acid-base balan

21、ce : chest compressions ROSC adequate alveolar ventilation and restoration of tissue perfusionCO2 more freely diffusible than HCO3 - into myocardial and cerebral cells intracellular acidosisInitial dosage： 5%NaHCO3 1mEq /kg iv gtt ( 1ml0.6mEq )28 Etiological factors （5Hs，5Ts) HypovolemiaHypoxiaHydro

22、gen ion (acidosis)Hyperkalemia or HypokalemiaHyperthermia or HypothermiaTablets (drug)Tamponade Tension PneumothoraxThrombosis coronaryThrombosis pulmonary29 Optimal response to resuscitationAwakeResponsiveBreathing spontaneouslyrestoration of spontaneous circulation (ROSC)30 Prolong Life SupportPos

23、tresuscitation care - Prevent and treatment SIRS and MODSorgans function supportCerebral resuscitation31 Postresuscitation syndromeReperfusion failureReperfusion injuryCerebral intoxication from ischemic metabolitesCoagulopathy32 Postresuscitation syndrome - 4 phases Cardiovascular dysfunction in th

24、e hours after ROSC in 24 hoursSIRS leads to MODS over 1 to 3 daysSerious infection occurs and the patient declines rapidlyDeath 33 DopamineA potent adrenergic receptor agonist and a strong peripheral dopamine receptor agonist. Effects are dose-dependent: 5 20gminkgLow-dose (2 4 gminkg) is no longer used for acute oliguric renal failure, because occasionally diuresis no improve renal glomerular filtration rate.Middle dosa