ICU医生与院内急救.ppt

1、ICU医生与院内急救,四川大学华西医院ICU 金晓东,CODE 199! CODE Blue!,一、前言,医院需要ICU吗？ 医院需要成立院内急救小组吗？,我院ICU现状,2005年共收治2025例患者 心肺复苏后转入者37例 其中在转运途中心跳骤停者3例(例痊愈) 在普通病房未能成功复苏者,医院现有状况,普通病房心肺复苏操作流程不规范 须请急会诊 须请麻醉科急会诊,我们的想法,应有一个小组对全院患者实施监控 由该小组判断患者该留治或转 尽可能避免“突然的心跳骤停” 该小组应由医师牵头组建 ICU医生参与院内急救的同时，还需决定病人是否转运及时机。,我们的想法,先进、良好、待用的特殊急救设备（

2、如便携式呼吸机、氧气瓶等）的及时到位。 确保转运过程的安全性、快速性。 从EMSS层面出发，尽量把ICU资源搬到院内急救，弥补院内急救相对薄弱的关键时机。,ICU的功能,集中严重心/肺/肾功能衰竭、创伤和其它各种严重有生命威胁的患者，便于严密观察病情变化和监护。 应用先进的医学诊断技术和生命支持疗法，如：复苏除颤、体内心脏起搏、气管插管、机械通气、心导管、腹透、血透等。,ICU的功能,ICU的医师和护士均受过特殊的训练，对严重疾病的紧急处理有特定的技术。 ICU具有生命支持的环境，包括床旁监护、生命支持设备和机械通气机等，组成一个特异的生理功能单元,二、基础设施配置与合理使用,良好齐全的急救设

3、备: 基本设备： 中心气源、中心负压、多功能病床、多功能插座、微泵、多参数监护系统、气管插管设备、手动辅助换气囊、呼吸机、雾化系统，心电图机、电除颤器、临时起搏器、纤支镜、冰机、CRRT系统 特殊设备 ： IABP、B超、血透机 ,院内急救面临的问题,目前院外急救已初具规模 院内急救? 没有相对固定的工作小组 没有相对完善的工作流程 没有全院各科室的积极配合 没有复苏后的积极反馈,院内急救效率下降！,应成立专业院内急救小组！,二、人员组成,Primary code team members： ICU physician (team leader) resident physicians Cri

4、tical care nurse respiratory therapists Administrative supervisor Lab personnel,.,Supplemental Team Members On-call anesthesiologist A spiritual care person is on call for codes,三、人员的素质要求,高水平的鉴别诊断能力 熟练掌握各类急救技术 组织协调能力 具有强健的体魄 能适应紧张的工作 有较高的业务素质 较强的责任感和无私奉献的精神,Education and Training,Physicians have rec

5、eived up-to-date training in ACLS protocols according to the American Heart Association. Basic life support (BLS) training for the health care provider and Heartsaver Plus, with satisfactory completion, are required every other year and are provided according to the AHA standards.,Education and Trai

6、ning,Employees involved in direct patient care are mandated to attend CPR programs and must demonstrate competency in CPR. Outpatient service staff must conform to the same standard of CPR education. Mouth-mask devices or resuscitation bags are available.,四、各级人员的职责,ICU Physician (team leader),Ultima

7、tely responsible for Code management. Determines when to discontinue efforts or establishes when patient is stable enough for transport. Communicates with the attending physician and family. improvement tool,Resident physician,Help with Code management Helps with CPR, defibrillation, or pacing. Cent

8、ral line placement Draws blood for ABGs and other labs. Dispenses the medications from the emergency cart to the RN and prepares IV solutions with medication additives for RN administration.,Critical care nurse （1）,Establishes the cardiac rhythm and defibrillates as quickly as possible if indicated.

9、 Administers medications as directed. May give epinephrine, atropine, and/or lidocaine as approved in the Emergency Measures protocol. Uses ACLS guidelines,Critical care nurse （2）,Helps with all aspects of the resuscitative effort. The critical care nurse and/or the responding physician are responsi

10、ble for managing the care of the patient, including ascertaining that proper chest compressions and ventilations are being performed. Brings I-STAT box and “difficult-to-incubate” box.,Respiratory therapist,Manages the airway, including bag-valve-mask breathing, intubation, and suctioning. Helps ove

11、rsee adequate oxygen delivery. Helps with CPR. Replaces the emergency cart. Brings an emergency cart and defibrillator to the arrest site, if one is not stationed in the area of the emergency. Runs I-STAT.,Administrative supervisor （1）,Role varies with circumstances. Helps with CPR as needed, especi

12、ally in non-clinical areas. Validates code team members are present and the physician/resident is giving direction. Assists with traffic control.,Administrative supervisor （2）,Assists with physician notification and family support. Assists staff/code team as needed. Helps troubleshoot difficult situ

13、ations. Makes arrangements for bed assignments.,设备的规范化管理,五定一随时： 抢救物资必须统一固定位置 固定专人管理 固定的物资管理模式 一定的物资储备量 定期检查 随时补充（平时禁止取用）,合理使用,疾病是个连续的病理过程，应强调作连续和动态地监测，孤立的、哪怕看来是“异常”的数据并不足以说明问题。 使用各种仪器对病人进行生理功能监测的结果是加强治疗的决策依据。 熟练地掌握使用方法。 对检测结果的解释要全面合理，要充分考虑每项监测的局限性和制约因素，注意研究同一系统不同指标间和不同系统间的联系，防止片面性。 发挥其先进性和优越性，注意局限性和不足，扬长避短。,五、ICU医生与专科医生的关系,专业化的ICU是完全独立的科室，ICU医师将全权负责病人的医疗工作。 ICU是高度开放的、与专科联系最广泛和密切的科室，因此专科医生应参与并协助ICU的治疗，向ICU医师提出要求和建议。 ICU医师也有义务将病情和治疗计划详细向专科医生沟通。,关于专科医师,专科医生对待急救小组切忌： 缺乏信任，指手划脚