如何处理术中心跳骤停课件

如何处理术中心跳骤停？一、什么情况下要CPR？需要CPRECG:杂波或ABP：测不出or45/20mmHg室性心律室扑室颤心脏没有射血或很少–CPRCirculation–mechanismofexternalChestCompressionCARDIACARREST-出手要快-胸外按压

AntegradesystemicarterialbloodflowcontinuesaftercardiacarrestuntilthepressuregradientbetweentheaortaandrightheartstructuresreachequilibriumAsimilarprocessoccursduringcardiacarrestwithantegradepulmonarybloodflowbetweenthepulmonaryarteryandtheleftatriumLessfillddmorefilledthevenouscapacitancevesselsbecomeincreasinglydistended犹豫：俯卧位侧卧位CardiopulmonaryResuscitation:BasicandAdvancedLifeSupport.In:RonaldD.Miller,eds.Miller’sAnesthesia.8thed.2013:3182-3217.SteenS,LiaoQ,PierreL,etal:Thecriticalimportanceofminimaldelaybetweenchestcompressionsandsubsequentdefibrillation:Ahaemodynamicexplanation,Resuscitation58:249,2003Circulation–mechanismofexternalChestCompressioncardiacpumpandthoracicpumpmechanismsCardiopulmonaryResuscitation:BasicandAdvancedLifeSupport.In:RonaldD.Miller,eds.Miller’sAnesthesia.8thed.2013:3182-3217.BIS8：008：309：009：30舒芬太尼10ug，罗库溴铵10ｍg丙泊酚2.8ug/ml，喉罩瑞芬太尼400~500ug/h，右美托咪定0.4ug/kg/h，丙泊酚2.8ug/ml晶体：500ml羟乙基淀粉：500ml401209：009：3540120EtCO238mmHg–28--16mmHg胸外心脏按压麻黄碱6mg–间羟胺1mg

–肾上腺素100ug–300ug缺氧引起的心跳停止–脑复苏最困难气道安全第一麻醉导致的死亡气道是第一位麻醉病人要高度重视气道气道三原则插得进，插不进怎么办留得住，留不住怎么办二进宫，二进宫怎么办二、ABCCAB2010AHAGuidelinesforCPRandECCC-A-BversusA-B-CC-A-BversusA-B-CCPRsequencewithchestcompressionsratherthanbreathstominimizethetimetoinitiationofchestcompressionsComparisonoftimesofinterventionduringpediatricCPRmaneuversusingABCandCABsequences:arandomizedtrial.Resuscitation.2012;83:1473–1477Verificationofchangesinthetimetakentoinitiatechestcompressionsaccordingtomodifiedbasiclifesupportguidelines.AmJEmergMed.2013;31:1248–1250.ABCversusCABforcardiopulmonaryresuscitation:aprospective,randomizedsimulator-basedtrial.SwissMedWkly.2013;143:w13856CPR最怕的结局-昏迷不醒脑复苏的黄金时间：≤5minCARDIACARREST-出手要快-胸外按压

AntegradesystemicarterialbloodflowcontinuesaftercardiacarrestuntilthepressuregradientbetweentheaortaandrightheartstructuresreachequilibriumAsimilarprocessoccursduringcardiacarrestwithantegradepulmonarybloodflowbetweenthepulmonaryarteryandtheleftatriumLessfillddmorefilledthevenouscapacitancevesselsbecomeincreasinglydistendedSteenS,LiaoQ,PierreL,etal:Thecriticalimportanceofminimaldelaybetweenchestcompressionsandsubsequentdefibrillation:Ahaemodynamicexplanation,Resuscitation58:249,2003DefibrillationSurvivalinvictimsofVF/pVTishighestwhenbystandersdeliverCPRanddefibrillationisattemptedwithin3to5minutesofcollapse2015AHAGuidelinesUpdateforCardiopulmonaryResuscitationandEmergencyCardiovascularCareShockEnergyforDefibrillationBiphasic:120-200Jifunknown,usemaximumavailable.Secondandsubsequentdosesshouldbeequivalent,andhigherdosesmaybeconsidered.•Monophasic:360JC-A-B-D求救！Help！团队手术间内：人员多，设备齐C胸外按压A-B口咽，喉罩，插管，控制通气D除颤100~120次/min按压深度5cmCardiacoutputduringCPRwitheffective,uninterruptedchestcompressionis25%to30%ofthenormalspontaneouscirculation.CardiopulmonaryResuscitation:BasicandAdvancedLifeSupport.In:RonaldD.Miller,eds.Miller’sAnesthesia.8thed.2013:3182-3217.

Pushfast.PushhardQuantitativewaveformcapnography–IfPETCO2<10mmHg,attempttoimproveCPRquality.ABP：90/20mmHg2015AHAGuidelinesUpdateforCardiopulmonaryResuscitationandEmergencyCardiovascularCareIntra-arterialpressure–Ifrelaxationphase(diastolic)pressure<20mmHg,attempttoimproveCPRquality.chestcompression-relaxationratioapproaches50:50CardiopulmonaryResuscitation:BasicandAdvancedLifeSupport.In:RonaldD.Miller,eds.Miller’sAnesthesia.8thed.2013:3182-3217.Venousbloodreturnstothethoraxatverylowpressuresduringcardiacarrest.Modestincreasesinintrathoracicpressure,asmightoccurwithoverzealousventilationduringCPR,willimpairvenousreturnandnegativelyimpactsystemic,coronary,andcerebralperfusionandalsoreducethechancesofreturnofspontaneouscirculation按压100~120/min,深度：5cm王二熊大熊二张三李四第一组：1,2,3……….30,通气2次第二组：1,2,3……….30,通气2次第三组：1,2,3……….30,通气2次第四组：1,2,3……….30,通气2次第五组：1,2,3……….30,通气2次暂停ECGVentilationAfterAdvancedAirwayPlacementPositivepressureventilationincreasesintrathoracicpressureandmayreducevenousreturnandcardiacoutput,especiallyinpatientswithhypovolemiaorobstructiveairwaydisease.Inanimalmodels,slowerventilationrates(6to12breathsperminute)areassociatedwithimprovedhemodynamicparametersandshort-termsurvival2010AHAGuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascularCareVentilationAfterAdvancedAirwayPlacementBecausecardiacoutputislowerthannormalduringcardiacarrest,theneedforventilationisreduced8-10次/min2010AHAGuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascularCareEpinephrine肾上腺素Theseα-adrenergiceffectsofepinephrinecanincreasecoronaryperfusionpressureandcerebralperfusionpressureduringCPR.Thevalueandsafetyoftheβ-adrenergiceffectsofepinephrinearecontroversialbecausetheymayincreasemyocardialworkandreducesubendocardialperfusion.2015AHAGuidelinesUpdateforCardiopulmonaryResuscitationandEmergencyCardiovascularCare1mgIV/IO3-5minStandardDoseEpinephrineVersusHigh-DoseEpinephrineHighdosesofepinephrinearegenerallydefinedasdosesintherangeof0.1to0.2mg/kgHigh-doseepinephrineisnotrecommendedforroutineuseincardiacarrestThesetrialsdidnotdemonstrateanybenefitforhigh-doseepinephrineoverstandard-doseepinephrineforsurvivaltodischargewithagoodneurologicrecoveryTherewas,however,ademonstratedROSCadvantagewithhighdoseepinephrine-缓兵之计2015AHAGuidelinesUpdateforCardiopulmonaryResuscitationandEmergencyCardiovascularCareEpinephrineVersusVasopressin加压素Vasopressinisanonadrenergicperipheralvasoconstrictorthatalsocausescoronaryandrenalvasoconstriction.2015AHAGuidelinesUpdateforCardiopulmonaryResuscitationandEmergencyCardiovascularCareVasopressinandOtherAgentsAffectingtheRenalConservationofWater.InLaurenceL.Brunton.eds.G&GthePharmacologicalBasisofTherapeutics.9thed.2006:771-788.EpinephrineVersusVasopressinAsingleRCTenrolling336patientscomparedmultipledosesofstandard-doseepinephrinewithmultipledosesofstandarddosevasopressin(40unitsIV)intheemergencydepartmentafterOHCA.ThetrialhadanumberoflimitationsbutshowednobenefitwiththeuseofvasopressinforROSCorsurvivaltodischargewithorwithoutgoodneurologicoutcome.Vasopressinoffersnoadvantageasasubstituteforepinephrineincardiacarrest2015AHAGuidelinesUpdateforCardiopulmonaryResuscitationandEmergencyCardiovascularCareEpinephrineVersusVasopressin+EpinephrineAnumberoftrialshavecomparedoutcomesfromstandarddoseepinephrinetothoseusingthecombinationofepinephrineandvasopressin.Thesetrialsshowednobenefitwiththeuseoftheepinephrine/vasopressincombinationforsurvivaltohospitaldischargewithCerebralPerformanceCategoryscoreof1or2in2402patients,nobenefitforsurvivaltohospitaldischargeorhospitaladmissionin2438patients,andnobenefitforROSCVasopressinincombinationwithepinephrineoffersnoadvantageasasubstituteforstandard-doseepinephrineincardiacarrest2015AHAGuidelinesUpdateforCardiopulmonaryResuscitationandEmergencyCardiovascularCareAtropine阿托品Atropinesulfatereversescholinergic-mediateddecreasesinheartrateandatrioventricularnodalconduction.NoprospectivecontrolledclinicaltrialshaveexaminedtheuseofatropineinasystoleorbradycardicPEAcardiacarrest.Lower-levelclinicalstudiesprovideconflictingevidenceofthebenefitofroutineuseofatropineincardiacarrest.Thereisnoevidencethatatropinehasdetrimentaleffects不利作用duringbradycardicorasystoliccardiacarrest.2010AHAGuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascularCareAtropine阿托品AvailableevidencesuggeststhatroutineuseofatropineduringPEAorasystoleisunlikelytohaveatherapeuticbenefit(ClassIIb,LOEB).Forthisreasonatropinehasbeenremovedfromthecardiacarrestalgorithm.2010AHAGuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascularCareSodiumBicarbonate碳酸氢钠Tissueacidosisandresultingacidemia酸血症duringcardiacarrestandresuscitationaredynamicprocessesresultingfromnobloodflowduringarrestandlowbloodflowduringCPR.Restorationofoxygencontentwithappropriateventilationwithoxygen,supportofsometissueperfusionandsomecardiacoutputwithhigh-qualitychestcompressions,thenrapidROSCarethemainstaysofrestoringacid-basebalanceduringcardiacarrest.2010AHAGuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascularCareSodiumBicarbonate碳酸氢钠BicarbonatemaycompromiseCPPbyreducingsystemicvascularresistanceInonehumanstudyROSCdidnotoccurunlessaCPP15mmHgwasachievedduringCPRKetteF,etal.Buffersolutionsmaycompromisecardiacresuscitationbyreducingcoronaryperfusionpresssure.JAMA.1991;266:2121–2126ParadisNA,etal.FeingoldM,NowakRM.Coronaryperfusionpressureandthereturnofspontaneouscirculationinhumancardiopulmonaryresuscitation.JAMA.1990;263:1106–1113.CalciumStudiesofcalciumduringcardiacarresthavefoundvariableresultsonROSC,andnotrialhasfoundabeneficialeffectonsurvivaleitherinoroutofhospital.Routineadministrationofcalciumfortreatmentofin-hospitalandout-of-hospitalcardiacarrestisnotrecommended2010AHAGuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascularCareVF/pVT：AmiodaroneAmiodaroneIV/IOdose:Firstdose:300mgbolus.Seconddose:150mg.2015AHAGuidelinesUpdateforCardiopulmonaryResuscitationandEmergencyCardiovascularCareLidocaineEarlystudiesinpatientswithacutemyocardialinfarctionfoundthatlidocainesuppressedprematureventricularcomplexes期外心室综合波andnonsustained非持续性VT,rhythmsthatwerebelievedtopresage前兆VF/pVT.Laterstudiesnotedadisconcertingassociationbetweenlidocaineandhighermortalityafteracutemyocardialinfarction,possiblyduetoahigherincidenceofasystoleandbradyarrhythmias;theroutinepracticeofadministeringprophylacticlidocaineduringacutemyocardialinfarctionwasabandoned.Thereisinadequateevidencetosupporttheroutineuseoflidocaineaftercardiacarrest.2015AHAGuidelinesUpdateforCardiopulmonaryResuscitationandEmergencyCardiovascularCareMagnesiumSulfate硫酸镁Twoobservationalstudies290,291showedthatIVmagnesiumsulfatecanfacilitateterminationoftorsadesdepointes扭转性室速(irregular/polymorphicVTassociatedwithprolongedQTinterval).Magnesiumsulfateisnotlikelytobeeffectiveinterminatingirregular/polymorphicVTinpatientswithanormalQTinterval.2010AHAGuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascularCareMagnesiumSulfateThreeRCTsdidnotidentifyasignificantbenefitfromuseofmagnesiumcomparedwithplaceboamongpatientswithVFarrestintheprehospital,intensivecareunit,andemergencydepartmentsetting,respectively.Thus,routineadministrationofmagnesiumsulfateincardiacarrestisnotrecommended(ClassIII,LOEA)unlesstorsadesdepointesispresent.2010AHAGuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascularCareReturnofSpontaneousCirculation(ROSC)1.Pulseandbloodpressure2.AbruptsustainedincreaseinPETCO2(typically40mmHg)3.Spontaneousarterialpressurewaveswithintra-arterialmonitoringTreatableCausesofCardiacArrest:TheH’sandT’sH’sT’sHypoxiaSpO2100%Toxins术中突发Hypovolemia没出血1000液体血压平稳Tamponade(cardiac)无外伤Hydrogenion(acidosis)血气？Tensionpneumothorax无肺大泡气道压不高Hypo-/hyperkalemia血气？Thrombosis,pulmonary有可能，需要血气Hypothermia体温探头正常Thrombosis,coronary有可能，需要12导联心电图处理呼吸内科急会诊心内科急会诊血气分析心电图室12导联心电图TreatableCausesofCardiacArrest:TheH’sandT’sH’sT’sHypoxiaSpO2100%Toxins术中突发Hypovolemia没出血1000液体血压平稳Tamponade(cardiac)无外伤Hydrogenion(acidosis)7.24Tensionpneumothorax无肺大泡气道压不高Hypo-/hyperkalemia3.6Thrombosis,pulmonaryPaO2435mmHgHypothermia体温正常Thrombosis,coronaryECG不考虑Post–CardiacArrestCare

-CardiovascularCareHemodynamicGoalsSBP≥90mmHgMAP≥65mmHg2015AHAGuidelinesUpdateforCardiopulmonaryResuscitationandEmergencyCardiovascularCarePost–CardiacArrestCare

-TargetedTemperatureManagementTargetedTemperatureManagementthetermtargetedtemperaturemanagement(TTM)hasbeenadoptedtorefertoinducedhypothermiaaswellastoactivecontroloftemperatureatanytarget2015AHAGuidelinesUpdateforCardiopulmonaryResuscitationandEmergencyCardiovascularCareTargetedTemperatureManagementForpatientswithVF/pVTOHCA,combinedoutcomedatafrom1randomizedand1quasi-randomizedclinicaltrialreportedincreasedsurvivalandincreasedfunctionalrecoverywithinducedhypothermiato32ºCto34ºCMildtherapeutichypothermiatoimprovetheneurologicoutcomeaftercardiacarrest.NEnglJMed.2002;346:549–556.Treatmentofcomatosesurvivorsofout-of-hospitalcardiacarrestwithinducedhypothermia.NEnglJMed.2002;346:557–5632015AHAGuidelinesUpdateforCardiopulmonaryResuscitationandEmergencyCardiovascularCareTargetedTemperatureManagementWerecommendthatcomatose(ie,lackofmeaningfulresponsetoverbalcommands)adultpatientswithROSCaftercardiacarresthaveTTMWerecommendselectingandmaintainingaconstanttemperaturebetween32ºCand36ºCduringTTM2015AHAGuidelinesUpdateforCardiopulmonaryResuscitationandEmergencyCardiovascularCareTargetedTemperatureManagementHighertemperaturesmightbepreferredinpatientsforwhomlowertemperaturesconveysomerisk(eg,bleeding)Lowertemperaturesmightbepreferredwhenpatientshaveclinicalfeaturesthatareworsenedathighertemperatures(eg,seizures,cerebraledema)2015AHAGuidelinesUpdateforCardiopulmonaryResuscitationandEmergencyCardiovascularCarePost–CardiacArrestCare

-OtherNeurologicCareSeizureManagementAnEEGforthediagnosisofseizureshouldbepromptlyperformedandinterpreted,andthenshouldbemonitoredfrequentlyorcontinuouslyincomatosepatientsafterROSCThesameanticonvulsantregimens抗癫痫药物方案forthetreatmentofstatusepilepticus癫痫持续状态causedbyotheretiologiesmaybeconsideredaftercardiacarrest2015AHAGuidelinesUpdateforCardiopulmonaryResuscitationandEmergencyCardiovascularCarePost–CardiacArrestCare

-RespiratoryCareVentilationMaintainingthePaCO2withinanormalphysiologicalrange,takingintoaccountanytemperaturecorrection,maybereasonableNormocarbia(end-tidalCO230–40mmHgorPaCO235–45mmHg)maybeareasonablegoal2015AHAGuidelinesUpdateforCardiopulmonaryResuscitationandEmergencyCardiovascularCareVentilationahigherPaCO2maybepermissibleinpatientswithacutelunginjuryorhighairwaypressures.mildhypocapniamightbeusefulasatemporizingmeasurewhentreatingcerebraledema,buthyperventilationmightcausecerebralvasoconstriction.2015AHAGuidelinesUpdateforCardiopulmonaryResuscitationandEmergencyCardiovascularCareOxygenationitisreasonabletodecreasetheFiO2whenoxyhemoglobinsaturationis100%,providedtheoxyhemoglobinsaturationcanbemaintainedat94%orgreater2015A