《心肺脑复苏》课件

1、心 肺 脑 复 苏 外科学第八章 第四节概 述：心肺复苏 Cardiopulmonary Resuscitation, CPRCPR 是针对呼吸，心跳停止所采用的抢救措施，即以人工呼吸代替患者的自主呼吸，以心脏挤压形成暂时人工循环并诱发心脏的自主搏动。心肺脑复苏Cardiopulmonary Cerebral Resuscitation, CPCR从心跳停止到细胞坏死的时间以脑神经细胞最短（46分钟）。因此，维持脑组织的灌流是心肺复苏的重点，一开始就应积极防治脑神经细胞的损害，力争脑功能的完全恢复。故现以将心肺复苏扩展为心肺脑复苏 CPCR。复苏术的基本目标：增加和维持重要器官（脑、心）的氧供

2、。Cardiac Arrest 心跳骤停无效的心输出量四种形式:(1). Ventricular fibrillation VF(2). Ventricular tachycardia VT(3). Asystole(4). Electromechanical dissociation EMDpulseless electrical activity PEACPR的步骤初期复苏（Basic Life Support, BLS）后期复苏（Advanced Life Support, ALS）复苏后处理（Post-resuscitation Treatment, PRT）决定因素时间（迅速）方法（

3、有效）条件（院内或院外）I. 初期复苏 BLS（心肺复苏CPR本课重点）特点：在无任何特殊器械的条件下徒手操作，时间是成功的关键（普及训练BLS技术有重要意义）。任务：迅速识别判定呼吸、心跳停止，并通过CPR技术支持病人的呼吸和循环。心跳停止: 心脏停搏 心室纤颤、无脉搏室速或电-机械分离等CPR步骤判定（Assessment）复苏（Resuscitation）判定心跳骤停的方法大动脉搏动消失意识消失自主呼吸停止或出现濒死喘息瞳孔散大或皮肤粘膜灰白与发绀最简捷的方法： 先喊一声，再摸一下，同时已经观察到呼吸和皮肤。迅速判定心跳骤停后立即开始CPR操作。复苏方法CPRAirwayBreathin

4、gCirculationAirway确保呼吸道通畅是急救时最重要的首步措施也是最常犯的错误举例舌后坠的处理：仰头抬颏手法Circulation胸外心脏按摩病人体位：必须水平仰卧位，背下垫上硬板，以保证按压的有效性。抢救者手的位置胸骨中线的中下三分之一交界处两掌相叠，手指可伸直或相互交叉锁住。两臂伸直，肘关节固定，肩手垂直有效的心脏挤压可以触及颈动脉或股动脉的搏动频率：80100次/分深度：3.85.1cm（Two Inches）BLS的结果在CPR过程中，如果肤色好转，瞳孔立即缩小并有对光反射者，预后良好。BLS为ALS赢得了时间，创造了条件。心跳停止4分钟开始BLS，8分钟开始ALS的成功率

5、高。II. Advanced life support ALS后续生命支持特点:Medical staff with primary equipmentSpotAmbulance Hospital任务:Acquire more efficient ventilation and circulationMaintain sufficient oxygen delivery / blood perfusion to vital organsALS 的CPR 技术AirwayEndotracheal intubationBreathing anesthesia bagbag-valve-mask v

6、entilation (FiO2 0.4)CirculationChest compressionECG: Defibrillationiv access: DrugsAirway control气道管理Endotracheal intubation气管插管The optimal technique for controlling the airway and ventilating the lungs during CPREfficient ventilation and protect the airway from aspiration.Alternative/temporary dev

7、icesMaskPharyngeal airwayEsophageal-tracheal combitube (ETC)Laryngeal mask airway (LMA)LMAIntubationBreathing-通气Anesthesia bag (self-inflating, one way valve)Bag-valve-mask ventilation Automatic transport ventilators (ATVs). High FiO2 : 0.4 1.0Tidal Volume (Vt): 400 600 ml/adult确保气道通畅有效的通气Tracheal i

8、ntubation and ventilatorThe bestLMA and anesthesia bagOKbag-valve mask systemnot badCirculation 循环继续胸外按压ECG 和 除颤器开放静脉 和 药物治疗adrenaline (epinephrine)sodium bicarbonateother agents: atropine, lidocaine, calcium chloride, dopamine etc.Recover spontaneous circulationGain good blood pressure and organ pe

9、rfusion除颤方法Early ECG monitor to discover VFPrecordial thump 心前区重击The first set of three sequence DC shocks:1. 200 Jminimal myocardial damage, adequate to achieve success in most recoverable situations; decreases the thoracic impedance, thus increasing the amount of energy from the second DC shock.2.

10、 200 J3. 360 JIf all three initial defibrillation attempts (200 J, 200J, 360 J) are unsuccessful, the prospects of recovery are poor.肾上腺素的作用adrenergic receptor stimulant effects. causes peripheral vasoconstriction, raises SVR, raises the end-diastolic filling pressure and thus improves coronary perf

11、usion. -adrenergic stimulant activity chronotropic and inotropic activity of the myocardium.Make the defibrillation efficiency肾上腺素的给药途径1 mg 静脉注射如果静脉还没开通， 2-3 mg 经气管注入 This route is definitely second best as the pharmacodynamics of drugs administered via the tracheal route are unpredictable. 肾上腺素的剂量标

12、准剂量 1.0 mg (10 ml of a 1:10,000). This dose should be repeated every 3 to 5 minutes, as long as cardiac arrest persists to assure sustained blood flow benefit.另外的剂量疗法:中等剂量: 2 to 5 mg, q3 -5 min逐步增加剂量: 1 mg, 3 mg, 5 mg at 3-minute intervals高剂量: 0.1 mg/kg, q3-5 minAlternative doses are considered acce

13、ptable and possibly helpful if an initial trial with standard doses is not effective.利多卡因Anti-fibrillatory action 抗颤作用:Decreases ventricular automaticity, suppresses reentrant circuits due to boundary currents in acute ischemia, abolishes reentrant excitation by inducing complete block in reentrant

14、pathways, and elevates the VF threshold. Also enhance intraoperative ventricular defibrillation in cardiac surgery, permitting defibrillation with fewer shocks of lower energy and current. initial dose is 1.5 mg/kg, followed by a 360-J shock. repeated in a dose of 1.5 mg/kg in 3 to 5 minutes, with a

15、 total loading dose of 3 mg/kg. Lidocaine, like epinephrine and atropine, can be injected into the tracheobronchial tree via an endotracheal tube,Bretylium 溴苄铵If VF persists or recurs despite lidocaine treatment followed by defibrillatory shocks at 360 J, bretylium can be given in a dose of 5 mg/kg,

16、 followed by a 360-J shock. If VF remains, a second dose of 10 mg/kg can be given in 5 minutes followed by another shock. If necessary, a third dose of 10 mg/kg can be given, followed by another shock.电解质紊乱Correction of hypokalemia, hyperkalemia, or hypomagnesemia may permit shocks to restore a sust

17、ained conversion.Magnesium plays a critical role in maintenance of a stable cardiac rhythm. Hypomagnesemia should be suspected and treated when refractory VT or VF is present.Magnesium sulfate 1 to 2 g over 1 to 2 minutes can be used to treat refractory VT or VF. Sodium bicarbonate (NaHCO3 )NaHCO3 s

18、hould not be used routinely in the treatment of cardiac arrestJust for a pre-existing metabolic acidosis is present, or a severe documented metabolic acidosis develops during the arrest. An initial dose of 1 mmol/kg can be givenfollowed at 10-minute intervals by 0.5 mmol/kg. Of course, if a base def

19、icit is documented on blood gas analysis the drug can be given based upon that measurement.Monitoring both arterial and mixed-venous blood gases and pH will lead to more rational antacid therapy. Base deficit/4 body weight (kg) in mmol of HCO3- solution1 ml of 5% NaHCO3 = 0.6 mmol HCO3-1 mmol HCO3 =

20、1.7 ml of 5% NaHCO3for example: give 1 mmol/kg to 60kg patient, 601.7ml 100ml 5% NaHCO3The dosage of bicarbonatebased upon base deficit Sodium bicarbonate should not be administered without considering that:It does not improve ability to defibrillate the heart.It shifts the oxyhaemoglobin dissociati

21、on curve and inhibits the release of oxygen.It causes hyperosmolality and hypernatraemia.It produces paradoxical cerebrospinal fluid acidosis.It exacerbates central venous acidosis.III. 复苏后治疗- PRT恢复自主循环在 ICU, CCU，监测多项生命体征维持循环和呼吸在稳定状态good perfusion for vital organs治疗脑损伤 心血管系统Poor myocardial contracti

22、lity:Dopamine 2-10 g.kg-1.min-1 by infusion is the treatment of choice.Hypovolaemia:The optimal preload for the failing heart should be ensured by the cautious administration of colloid as guided by the CVP.Arrhythmias:All arrhythmias are potentiated by disturbances in blood/gas or potassium homeost

23、asis. 呼吸系统Lung dysfunction:inhalation of vomit, lung contusion, fractured ribs and pneumothorax. Pulmonary oedema:heart failure and after head injury, drowning or smoke inhalation. Oxygen therapy for 24 h should follow any episode of circulatory arrest. If respiratory failure occurs, a period of art

24、ificial ventilation is required. All patients should have a chest X-ray and blood gas analysis after resuscitation.中枢神经系统有效的 CPR 可以防止脑损伤, 但不能防止对脑功能的抑制。 如果及时开始有效的复苏并且持续到恢复了适当的自主循环（CO），病人的意识应当很快地恢复清醒。 病人尚未恢复意识的原因:低心输出量脑损伤 复苏延迟了 低氧血症导致的心跳骤停.脑损伤的一般治疗The tracheal tube should be left in situ or in the lat

25、eral position (The unconscious patient whose trachea is not intubated). Epileptiform fits(癫痫发作), which increase CMRO2, may be treated safely with anticonvulsants. BP in the normal range to ensure adequate CPPHct in the low normal range to optimize DO2Tissue hydration and blood biochemistry should be maintained as normalAn increase in body temperature increases CMRO2 and should be avoided. Depth of coma should be assessed regularly.脑损伤的特殊治