特殊情况下的CPR资料课件

CPR in Special Situations特殊情况下的CPR福建医科大学附属协和医院麻醉科 翁险峰ACLS in the Perioperative Period围术期高级心脏生命支持Causes of cardiac arrest+心跳骤停的原因1)intraoperative hemorrhage术中出血2)pre-existent cardiac pathology原有的心脏疾患3)hypoxia,both at intubation or extubation插管或拔管时缺氧.a different milieu of pathophysiology病理生理的不同之处病理生理的不同之处n nHypovolemia,as a cause of myocardial ischemia,is far Hypovolemia,as a cause of myocardial ischemia,is far more common than transmural infarction from plaque more common than transmural infarction from plaque rupture.rupture.术中低血容量导致的心肌缺血远多于透壁心梗。术中低血容量导致的心肌缺血远多于透壁心梗。n nThe most common cardiac dysrrythmia during general The most common cardiac dysrrythmia during general and neuraxial anesthesia is bradycardia followed by and neuraxial anesthesia is bradycardia followed by asystole(45%).asystole(45%).全麻和椎管内麻醉中全麻和椎管内麻醉中最常见最常见的心律失常是的心律失常是心动过缓之后的心跳停止心动过缓之后的心跳停止心动过缓之后的心跳停止心动过缓之后的心跳停止。n nThe other life threatening cardiac rhythms are severe The other life threatening cardiac rhythms are severe tachydysrrhythmias including ventricular tachydysrrhythmias including ventricular tachycardiatachycardia（VT),ventricular fibrillation(VF 14%),and VT),ventricular fibrillation(VF 14%),and pulseless electrical activity(PEA 7%).pulseless electrical activity(PEA 7%).其它威胁生命的心其它威胁生命的心律失常是严重的频速型心律失常，包括室性心动过速，室律失常是严重的频速型心律失常，包括室性心动过速，室颤，和无脉性电活动。颤，和无脉性电活动。hyperventilation is almost invariablyhyperventilation is almost invariablyassociated with worsened survivalassociated with worsened survival过度通气常与糟糕的生存预后相关过度通气常与糟糕的生存预后相关n nin a low flow state the duration of increased intrathoracic in a low flow state the duration of increased intrathoracic pressure is proportional to the ventilation rate and pressure is proportional to the ventilation rate and inversely proportional to blood pressure,coronary and inversely proportional to blood pressure,coronary and cerebral perfusioncerebral perfusion胸内压的增加与通气频率成正比，与血胸内压的增加与通气频率成正比，与血压及冠脉、脑血管灌注成反比。压及冠脉、脑血管灌注成反比。n nRecent versions of the ACLS guidelines have Recent versions of the ACLS guidelines have recommended lower levels of ventilatory support.recommended lower levels of ventilatory support.近期的近期的高级生命支持指南推荐低水平的通气支持。高级生命支持指南推荐低水平的通气支持。n nVentilation at 20 breaths a minute is associated with Ventilation at 20 breaths a minute is associated with significantly lower survival than ventilation at 12 significantly lower survival than ventilation at 12 breaths/minute.breaths/minute.每分钟每分钟2020次的通气频率与每分钟次的通气频率与每分钟1212次通次通气频率相比，生存率低气频率相比，生存率低Cardioversion心脏复律n nImmediate cardioversion is indicated for a patient with Immediate cardioversion is indicated for a patient with serious signs&symptoms related to the tachycardia or if serious signs&symptoms related to the tachycardia or if ventricular rate is 150 bpmventricular rate is 150 bpm伴有严重症状的心动过速或伴有严重症状的心动过速或心室率心室率 150 150次次/分，是立即心脏复律的指征。分，是立即心脏复律的指征。n n Always be prepared to externally pace patients who are Always be prepared to externally pace patients who are being cardioverted,as some will convert into a very being cardioverted,as some will convert into a very bradycardic rhythm.bradycardic rhythm.对心脏复律的患者应准备好体外起搏，对心脏复律的患者应准备好体外起搏，这是由于一些患者会出现严重的心动过缓。这是由于一些患者会出现严重的心动过缓。n nAvoiding cardiac arrest requires successfully managing Avoiding cardiac arrest requires successfully managing acute anemia,hypoxemia,and all contributing factors to acute anemia,hypoxemia,and all contributing factors to cardiac output:preload,contractility,and afterload.cardiac output:preload,contractility,and afterload.要避要避免心跳骤停，应处理好急性贫血、低氧血症及与心输出量免心跳骤停，应处理好急性贫血、低氧血症及与心输出量有关的心脏前负荷、心肌收缩力、心脏后负荷。有关的心脏前负荷、心肌收缩力、心脏后负荷。Common Causes of ACLS events in the perioperative Common Causes of ACLS events in the perioperative setting Anesthetic setting Anesthetic 药物原因药物原因n nIntravenous anesthetic overdoseIntravenous anesthetic overdose静脉麻醉药过量静脉麻醉药过量n nInhalation anesthetic overdoseInhalation anesthetic overdose吸入麻醉药过量吸入麻醉药过量n nNeuraxial block with high level sympathectomy Neuraxial block with high level sympathectomy 椎椎管内麻醉平面过高的交感神经阻滞管内麻醉平面过高的交感神经阻滞n nLocal anesthetic systemic toxicityLocal anesthetic systemic toxicity局麻药毒性反应局麻药毒性反应n nMalignant hyperthermiaMalignant hyperthermia恶性高热恶性高热n nDrug administration errorsDrug administration errors给药错误给药错误Respiratory呼吸原因n nHypoxemia Hypoxemia 低氧血症低氧血症n nAuto PEEP Auto PEEP 内源性呼气末正压内源性呼气末正压n nAcute Bronchospasm Acute Bronchospasm 急性支气管痉挛急性支气管痉挛Cardiovascular心血管原因n nVasovagal reflex Vasovagal reflex 血管迷走反射血管迷走反射n nHypovolemic and/or hemorrhagic shockHypovolemic and/or hemorrhagic shock低血容量低血容量 和和/或或 出血性休克出血性休克n nTension Pneumothorax Tension Pneumothorax 张力性气胸张力性气胸n nAnaphylactic Reaction Anaphylactic Reaction 过敏反应过敏反应n nTransfusion Reaction Transfusion Reaction 输血反应输血反应n nAcute Electrolyte Imbalance(high K)Acute Electrolyte Imbalance(high K)急性电解质失衡（高急性电解质失衡（高钾）钾）n nSevere Pulmonary Hypertension Severe Pulmonary Hypertension 严重肺动脉高压严重肺动脉高压n nIncreased intraabdominal pressure Increased intraabdominal pressure 腹内压增高腹内压增高n nPacemaker failure Pacemaker failure 起搏器故障起搏器故障n nProlonged Q-T syndrome Prolonged Q-T syndrome 长长Q-TQ-T综合征综合征n nAcute Coronary Syndrome Acute Coronary Syndrome 急性冠脉综合征急性冠脉综合征n nPulmonary Embolism Pulmonary Embolism 肺栓塞肺栓塞n nGas embolism Gas embolism 气体栓塞气体栓塞n nOculocardiac reflexes Oculocardiac reflexes 眼心反射眼心反射n nElectroconvulsive therapy Electroconvulsive therapy 电休克治疗电休克治疗Recognizing cardiac arrest in the OR识别手术室内的心跳骤停n nEKG with pulseless rhythm(V-tach,V-fib)无脉心电活动（室速、室颤）n nLoss of pulse X 10 seconds 无心跳10秒n nLoss of end-tidal CO2 无呼末二氧化碳n nLoss of plethysmograph（无动脉容积波形）BLS/ACLS in the OR Some key points to remember.n nCPR for patients under general anesthesia need not be CPR for patients under general anesthesia need not be preceded by preceded by“Annie!Annie!Are you okay?Annie!Annie!Are you okay?”全麻下的全麻下的CPRCPR无需呼唤患者无需呼唤患者n nInstruct appropriate personnel to start effective CPR.Instruct appropriate personnel to start effective CPR.恰当恰当的人员开始有效的的人员开始有效的CPRCPRn nDiscontinue the anesthetic and surgeryDiscontinue the anesthetic and surgery停止麻醉药和外科停止麻醉药和外科手术手术n nCall for help,defibrillatorCall for help,defibrillator呼叫帮助，除颤呼叫帮助，除颤n nBag mask ventilation if ETT not in place followed by Bag mask ventilation if ETT not in place followed by immediate endotracheal intubation if feasible FiO2=1.0immediate endotracheal intubation if feasible FiO2=1.0未气管插管者先面罩通气随后立即气管插管，未气管插管者先面罩通气随后立即气管插管，FiO2=1.0FiO2=1.0BLS/ACLS in the OR Some key points to remember.n nDonDon t stop CPR unnecessarily!Capnography is a more t stop CPR unnecessarily!Capnography is a more reliable indicator of ROSC than carotid or femoral arterial reliable indicator of ROSC than carotid or femoral arterial pulse palpation.pulse palpation.不要无故停止不要无故停止CPR!CPR!二氧化碳波形图在提二氧化碳波形图在提示自主循环恢复方面比触摸颈动脉或股动脉更可信。示自主循环恢复方面比触摸颈动脉或股动脉更可信。n nCapnograph to confirm advance airway positioning and Capnograph to confirm advance airway positioning and effective CPR effective CPR 二氧化碳波形图可用来证实高级气道位置二氧化碳波形图可用来证实高级气道位置及及CPRCPR的有效性。的有效性。n nHand ventilate rate 8-10,VT to chest rise,TI one Hand ventilate rate 8-10,VT to chest rise,TI one second with 100%oxygen second with 100%oxygen assess for obstruction,if assess for obstruction,if none,institute mechanical ventilation.If obstruction,none,institute mechanical ventilation.If obstruction,suction,fiberoptic bronchoscopy,consider exchanging suction,fiberoptic bronchoscopy,consider exchanging the airway.Continue CPR.the airway.Continue CPR.手动呼吸手动呼吸8-108-10次次/分，够胸廓抬分，够胸廓抬起的潮气量，吸气时间起的潮气量，吸气时间1 1秒，使用秒，使用100%100%氧氧处理气道梗阻，处理气道梗阻，建立机械通气，如果有气道梗阻，吸引，纤支镜检查，考建立机械通气，如果有气道梗阻，吸引，纤支镜检查，考虑更换气管，继续虑更换气管，继续CPRCPRn nOpen all IVs to wide open Open all IVs to wide open 开放粗大静脉通路开放粗大静脉通路n nAnaphylaxis is a rare but important cause of circulatory Anaphylaxis is a rare but important cause of circulatory collapse in the perioperative period.collapse in the perioperative period.过敏反应虽然少见，过敏反应虽然少见，但却是围术期循环衰竭的重要原因。但却是围术期循环衰竭的重要原因。n nWhile there is a wide range of minor allergic reactions,While there is a wide range of minor allergic reactions,hypotension,tachycardia and bronchospasm can be hypotension,tachycardia and bronchospasm can be more easily followed by vasogenic shock when the more easily followed by vasogenic shock when the offending agent is administered as a rapid intravenous offending agent is administered as a rapid intravenous bolus,the most common route of drug administration bolus,the most common route of drug administration during anesthesia.during anesthesia.当引起过敏的药快速通过静脉路给予当引起过敏的药快速通过静脉路给予时，可能出现低血压、心动过速和支气管痉挛，随后出现时，可能出现低血压、心动过速和支气管痉挛，随后出现血管性休克。血管性休克。n nThe preponderance of anaphylaxis in perioperative The preponderance of anaphylaxis in perioperative patients is caused by a small number of drugs.patients is caused by a small number of drugs.多数的围多数的围术期患者的过敏反应是很少的一些药物引起的术期患者的过敏反应是很少的一些药物引起的n nAnaphylactic shock has been identified as a coexisting Anaphylactic shock has been identified as a coexisting or major indeterminate factor for dysrhythmic cardiac or major indeterminate factor for dysrhythmic cardiac arrest during anesthesia occurring in 2.2 to 22.4 per arrest during anesthesia occurring in 2.2 to 22.4 per 10,000 anesthetics with 3%to 4%of them being life 10,000 anesthetics with 3%to 4%of them being life threateningthreatening.过敏性休克与麻醉中因严重心律失常心跳骤过敏性休克与麻醉中因严重心律失常心跳骤停有关，发生率停有关，发生率2.2-22.4/100002.2-22.4/10000麻醉病例，其中麻醉病例，其中3 34%4%威威胁生命胁生命Neuroaxial Anesthesian nVarious hypotheses have been put forward over the Various hypotheses have been put forward over the years,invoking unrecognized respiratory depression,years,invoking unrecognized respiratory depression,excessive sedation concurrent with high block,under excessive sedation concurrent with high block,under appreciation of both the direct and indirect circulatory appreciation of both the direct and indirect circulatory consequences of a high spinal anesthetic,and consequences of a high spinal anesthetic,and failure to failure to rescuerescue with airway management and drugs.with airway management and drugs.近年来出现近年来出现各种假设，包括未及时发现的呼吸抑制，过多的镇静药物各种假设，包括未及时发现的呼吸抑制，过多的镇静药物伴高平面的阻滞，脊麻药物用量过多导致的循环变化，未伴高平面的阻滞，脊麻药物用量过多导致的循环变化，未能正确的处理呼吸和循环。能正确的处理呼吸和循环。Treatment of Cardiac Arrest Associated with Neuraxial Anesthesia椎管内麻醉相关心跳骤停的处理n nDiscontinue anesthetic or sedation infusionDiscontinue anesthetic or sedation infusion停止麻醉药或停止麻醉药或镇静药的输注镇静药的输注n nVentilate with 100%Oxygen,intubate trachea 100%Ventilate with 100%Oxygen,intubate trachea 100%浓度浓度氧气通气，气管插管氧气通气，气管插管n nBegin CPR if patient has significant bradycardia or is Begin CPR if patient has significant bradycardia or is pulseless 10sec pulseless 10sec 患者有严重的心动过缓或无脉时间超过患者有严重的心动过缓或无脉时间超过1010秒即开始秒即开始CPRCPRn nTreat bradycardia with 1mg Atropine Treat bradycardia with 1mg Atropine 阿托品阿托品1mg1mg处理心动处理心动过缓过缓n nTreat with at least 1 mg epinephrine IV(up to)Treat with at least 1 mg epinephrine IV(up to)给予至少给予至少1mg1mg肾上腺素静注，最高可用到肾上腺素静注，最高可用到0.1mg/kg0.1mg/kgn nConsider concurrent treatment with 40u vasopressin Consider concurrent treatment with 40u vasopressin 可可考虑同时给予考虑同时给予40u40u血管加压素血管加压素Differential Diagnosis for perioperative PEA or Asystole:8H&8TH Hypoxia ypoxia 低氧低氧T Traumarauma创伤创伤/hypovolemia/hypovolemia低血容量低血容量H Hypovolemiaypovolemia低血容量低血容量T Tension Pneumothoraxension Pneumothorax张力性气胸张力性气胸H Hyper-vagal yper-vagal 迷走反射迷走反射 T Thrombosis of Coronary hrombosis of Coronary 冠脉栓塞冠脉栓塞H Hydrogen Ion ydrogen Ion 酸中毒酸中毒T Tamponade amponade 心脏压塞心脏压塞H Hyperkalemia yperkalemia 高钾血症高钾血症T Thrombus in Pulmonary Artery hrombus in Pulmonary Artery 肺动脉栓肺动脉栓塞塞MMalignant alignant H Hyperthermia yperthermia 恶性高热恶性高热Long QLong QT T syndrome syndrome 长长QTQT综合综合征征H Hypothermiaypothermia低温低温 T Toxins(anaphylaxis)oxins(anaphylaxis)中毒（过敏反应）中毒（过敏反应）H Hypoglycemia ypoglycemia 低血糖低血糖Pulmonary HPulmonary HT TN N 肺动脉高压肺动脉高压Cardiac Arrest Associated With Asthma与哮喘相关的心跳骤停n nSince the effects of auto-PEEP in an asthmatic Since the effects of auto-PEEP in an asthmatic patient with cardiac arrest are likely quite severe,patient with cardiac arrest are likely quite severe,a ventilation strategy of low respiratory rate and a ventilation strategy of low respiratory rate and tidal volume is reasonable.tidal volume is reasonable.哮喘心跳骤停患者内哮喘心跳骤停患者内源性源性PEEPPEEP可能很严重，因此低呼吸频率和小潮气可能很严重，因此低呼吸频率和小潮气量是合理的。量是合理的。n nDuring arrest a brief disconnection from the bag During arrest a brief disconnection from the bag mask or ventilator may be considered,and mask or ventilator may be considered,and compression of the chest wall to relieve air-compression of the chest wall to relieve air-trapping can be effective.trapping can be effective.可考虑将面罩或呼吸机可考虑将面罩或呼吸机短暂脱开，胸外按压可有效减轻空气滞留。短暂脱开，胸外按压可有效减轻空气滞留。n nFor all asthmatic patients with cardiac arrest,and especially for patients in whom ventilation is difficult,the possible diagnosis of a tension pneumothorax should be considered and treated.哮喘心跳骤停患者，尤其通气困难者，应考虑到可能存在张力性气胸并给予处理。Cardiac Arrest AssociatedWith Pregnancy孕妇心跳骤停第一反应启动孕妇心心跳骤停复苏团队记录心跳骤停发生时间将孕妇置于仰卧位开始心脏按压，手的位置在胸骨上略高于通常位置 寻找并处理可能的原因B 出血/DICE 栓塞：冠脉/肺/羊水A 麻醉药U 宫缩无力C 心脏疾病（心梗/缺血/主动脉夹层/心肌病）H 高血压/先兆子痫/子痫O 其他：鉴别诊断P 胎盘早剥/前置胎盘S 脓毒血症n nAirway气道气道n nBag-mask ventilation with 100%oxygen before Bag-mask ventilation with 100%oxygen before intubation is especially important in pregnancy.intubation is especially important in pregnancy.在气管插管前面罩呼吸囊在气管插管前面罩呼吸囊100%100%氧气特别重要氧气特别重要n nIntubation with an endotracheal tube or Intubation with an endotracheal tube or supraglottic airway should be performed only by supraglottic airway should be performed only by experienced providers if possible.experienced providers if possible.如果可能应由如果可能应由有经验者进行气管插管或声门上气道有经验者进行气管插管或声门上气道n nCirculation循环循环n nCurrent recommended drug dosages for use in resuscitation of adults should also be used in resuscitation of the pregnant patient.现有推荐用于成人复苏的药物同样适用于孕妇的复苏n nDefibrillation除颤除颤n nAlthough there is a small risk of inducing fetal arrhythmias,cardioversion and defibrillation on the external chest are considered safe at all stages of pregnancy.尽管有较小的风险导致胎儿心律失常，胸外的心脏复律和除颤被认为在各孕期的孕妇是安全的。Cardiac Arrest Associated WithCardiac Arrest Associated With Life-Threatening Life-Threatening Electrolyte DisturbancesElectrolyte Disturbances电解质失衡相关的心跳骤停电解质失衡相关的心跳骤停Hyperkalemia高钾血症 Stabilize myocardial cell membrane:Stabilize myocardial cell membrane:稳定心肌细胞膜稳定心肌细胞膜n n Calcium chlorideCalcium chloride氯化钙氯化钙(10%):5 to 10 mL(500(10%):5 to 10 mL(500 to 1000 mg)IV over 2 to 5 minutes or calcium to 1000 mg)IV over 2 to 5 minutes or calcium gluconategluconate葡萄糖酸钙葡萄糖酸钙(10%):15 to 30 mL IV over(10%):15 to 30 mL IV over 2 to 5 minutes2 to 5 minutesShift potassium into cells:促使钾转移至细胞内n nSodium bicarbonate碳酸氢钠:50 mEq IV over 5 minutesn n Glucose plus insulin葡萄糖加胰岛素:mix 25 g(50 mL of D50)glucose and 10 U regular insulin and give IV over 15 to 30 minutesn n Nebulized albuterol 雾化沙丁胺醇:10 to 20 mg nebulized over 15 minutesPromote potassium excretion:Promote potassium excretion:促进钾的排出促进钾的排出n n DiuresisDiuresis利尿利尿:furosemide:furosemide 速尿速尿40 to 80 mg IV 40 to 80 mg IV n n Kayexalate Kayexalate降钾树脂降钾树脂:15 to 50 g plus sorbitol per:15 to 50 g plus sorbitol per oral or per rectumoral or per rectumn n Dialysis Dialysis 透析透析n nHypokalemia can produce ECG changes such as U Hypokalemia can produce ECG changes such as U waves,T-wave flattening,and arrhythmias(especially if waves,T-wave flattening,and arrhythmias(especially if the patient is taking digoxin),particularly ventricular the patient is taking digoxin),particularly ventricular arrhythmias,which,if left untreated,deteriorate to PEA arrhythmias,which,if left untreated,deteriorate to PEA or asystole.or asystole.低钾血症低钾血症ECGECG表现为表现为U U波、波、T T波低平、心律失波低平、心律失常（尤其正在使用地高辛的患者），尤其是室性心律失常，常（尤其正在使用地高辛的患者），尤其是室性心律失常，未处理可恶化为无脉性电活动未处理可恶化为无脉性电活动 或心跳静止。或心跳静止。n nDisturbances in sodium level are unlikely to be the Disturbances in sodium level are unlikely to be the primary cause of severe cardiovascular instabilityprimary cause of severe cardiovascular instability.血钠的血钠的失衡不太可能是严重心血管循环不稳定的初始原因。失衡不太可能是严重心血管循环不稳定的初始原因。Hypermagnesemia高镁血症高镁血症n nHypermagnesemia is defined as a serum magnesium Hypermagnesemia is defined as a serum magnesium concentration 2.2 mEq/L(normal:1.3 to 2.2 mEq/L).concentration 2.2 mEq/L(normal:1.3 to 2.2 mEq/L).Neurological symptoms of hypermagnesemia include Neurological symptoms of hypermagnesemia include muscular weakness,paralysis,ataxia,drowsiness,and muscular weakness,paralysis,ataxia,drowsiness,and confusion.Hypermagnesemia can produce vasodilation confusion.Hypermagnesemia can produce vasodilation and hypotension.and hypotension.高镁血症是指血清镁浓度超过高镁血症是指血清镁浓度超过2.2 2.2 mEq/LmEq/L（正常值为（正常值为 1.3 to 2.2 mEq/L1.3 to 2.2 mEq/L）。高镁血症的神经）。高镁血症的神经症状包括：肌无力、麻痹、共共济失调、昏昏欲睡、神志症状包括：肌无力、麻痹、共共济失调、昏昏欲睡、神志恍惚。高镁血症可导致血管扩张和低血压。恍惚。高镁血症可导致血管扩张和低血压。Hypermagnesemia高镁血症高镁血症n nExtremely high serum magnesium levels may produce a Extremely high serum magnesium levels may produce a depressed level of consciousness,bradycardia,cardiac depressed level of consciousness,bradycardia,cardiac arrhythmias,hypoventilation,and cardiorespiratory arrhythmias,hypoventilation,and cardiorespiratory arrest.arrest.极度的高镁血症可使神志消失、心动过缓、心律失极度的高镁血症可使神志消失、心动过缓、心律失常、低通气、心跳呼吸骤停。常、低通气、心跳呼吸骤停。n nAdministration of calcium(calcium chloride 10%5 to 10 Administration of calcium(calcium chloride 10%5 to 10 mL or calcium gluconate 10%15 to 30 mL IV over 2 to mL or calcium gluconate 10%15 to 30 mL IV over 2 to 5 minutes)may be considered during cardiac arrest 5 minutes)may be considered during cardiac arrest associated with hypermagnesemiaassociated with hypermagnesemia对于与高镁血症相关对于与高镁血症相关的心跳骤停，可给予钙剂（的心跳骤停，可给予钙剂（10%10%氯化钙氯化钙5 to 10 mL 5 to 10 mL 或或10%10%葡萄糖酸钙葡萄糖酸钙15 to 30 mL IV 2-515 to 30 mL IV 2-5分钟）分钟）Hypomagnesemia低镁血症低镁血症n nHypomagnesemia can be associated with polymorphic Hypomagnesemia can be associated with polymorphic ventricular tachycardia,including torsades de pointes,a ventricular tachycardia,including torsades de pointes,a pulseless form(polymorphic)of ventricular tachycardia.pulseless form(polymorphic)of ventricular tachycardia.低镁血症与多形性室速有关，包括尖端扭转、无脉室速。低镁血症与多形性室速有关，包括尖端扭转、无脉室速。n nFor cardiotoxicity and cardiac arrest,IV magnesium 1 to For cardiotoxicity and cardiac arrest,IV magnesium 1 to 2 g of MgSO2 g of MgSO4 4 bolus IV push is recommended.bolus IV push is recommended.对心跳骤停对心跳骤停者，静注硫酸镁者，静注硫酸镁1-2g1-2g，心要时静脉追加。，心要时静脉追加。Local Anesthetic Toxicity局麻药毒性n nConsider 1.5 mL/kg of 20%long-chain fatty acid emulsion(长链脂肪乳）as an initial bolus,repeated every 5 minutes until cardiovascular stability is restored.n n考虑1.5ml/kg 20%长链脂肪乳作为首剂量，然后每5分钟重复一次直到心血管功能稳定Cyanide氰化物n nBased on the best evidence available,a treatment regimen of 100%oxygen and hydroxocobalamin,with or without sodium thiosulfate,is recommended.n n使用纯氧及静注维生素B12，合用或不用硫代硫酸钠。Cardiac Arrest Associated With Trauma创伤相关的心跳骤停创伤相关的心跳骤停nWhile CPR in the pulseless trauma patient has overall been considered futile,several reversible causes of cardiac arrest in the context of trauma are correctible and their prompt treatment could be life-saving.对大多数无脉性创伤患者CPR是无效的，但一些可逆因素导致的心跳骤停是可治疗，立即处理是可以救命的。These include hypoxia,hypovolemia,diminished cardiac output secondary to pneumothorax or pericardial tamponade,and hypothermia.这些包括低氧、低血容量、继发于张力性气胸或心包压塞的低心排血量、低温。nWhen multisystem trauma is present or trauma involves the head and neck,the cervical spine must be stabilized.A jaw thrust should be used instead of a head tilt chin lift to establish a patent airway.当出现多器官系统创伤或创伤包括了头颈，必须保持颈椎的稳定。在开放气道时应下推前颌取代头部倾斜抬下颌。nIf breathing is inadequate and the patients face is bloody,ventilation should be provided with a barrier device,a pocket mask,or a bag-mask device while maintaining cervical spine stabilization.如果通气不足且患者面部出血，在保持颈椎稳定性的同时，应提供面罩通气。nStop any visible hemorrhage using direct compression and appropriate dressings.If the patient is completely unresponsive despite rescue breathing,provide standard CPR and defibrillation as indicated.使用直接按压或恰当的敷料来止血。如果患者对呼吸救治无反应，应进行常规的CPR和除颤。nAfter initiation of BLS care,if bag-mask ventilation is inadequate,an advanced airway should be inserted while maintaining cervical spi