心肺复苏指南解读课件

,第,页,再问路在何方,心肺复苏指南,再问路在何方,心肺复苏是一个世界性难题,在不同人群中的研究表明 ，,OHCA,的生存率在,6.7%-8.4%,Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-ofhospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2010;3:6381,心肺复苏是一个世界性难题在不同人群中的研究表明 ，OHCA的,现代心肺复苏的发展,1960 1970 1980 1990 2000 2010 2015 2020,胸外按,压,人,工呼吸,除颤,脑复苏,国际复苏联合会,第三次修订,CPR,指南,第四次修订,？,现代心肺复苏的发展 1960 1970 1980,关于心肺复苏的诸多困惑,如何识别心脏骤停,施救顺序,按压频率,按压深度,按压通气比,电除颤,高级生命支持,ROSC,后 治疗,关于心肺复苏的诸多困惑 如何识别心脏骤停,如何识别,01,?,1980 1990 2000 2010 2015 2020,心脏骤停,听，看，感,觉,评价无反应,没有呼吸或呼吸不正常,如何识别01 ?1980 1990 2000,02,抢救顺序,2005 2010 2015 2020,A,B C,C A B,? ? ?,02抢救顺序2005 2010,03,按压频率,(,次,/,分,),1960 1970 1980 1990 2000 2010 2015 2020,60-80,80,80-100,100,?,100-120,03按压频率(次/分)1960 1970 1980,04,按压深度,(cm),5-6,4-5,5,2005 2010 2015 2020,?,04按压深度(cm)5-64-552005,05,按压通气比,1980 1990 2000 2010 2015 2020,5:2,15:2,30:2,?,05按压通气比1980 1990 2000,06,电除颤,360J,，,360J,，,360J,单向波,100-200-300-360J,双向波,120 - 150 - 200 -,更,高,?,1980 1990 2000 2010 2015 2020,06电除颤360J，360J，360J 单向波100-200,07,高级生命支持,1970,1980,1990,2000,2010,2015,肾上腺素阿托品 利多卡因,外周静脉肾上腺素大剂量,1mg,肾上腺素每隔,3-5min,推注,1,次、加压素,?,2020,1mg,肾上腺素每隔,3-5min,推注,1,次,07高级生命支持1970198019902000201020,07,复苏后 综合治疗,心脏骤停的机制?,血流动力学,亚低温治疗,07复苏后 综合治疗心脏骤停的机制?,如何提高心肺复苏成功率？,如何提高心肺复苏成功率？,2015,年,11,月,7,日，本人有幸参加了由美国心脏协会（,AHA,）在奥兰,多举,行的,2015,科学年会,2015年11月7日，本人有幸参加了由美国心脏协会（AHA）,生存链,AHA,成人生存链,生存链AHA成人生存链,及早识别并启动应急反应系统,及早识别并启动应急反应系统,及早识别并启动应急反应系统,Given the low risk of harm and the potential benefit of such notifications, it may be reasonable for communities to incorporate, where available, social media technologies that summon rescuers who are willing and able to perform CPR and are in close proximity to a suspected victim of OHCA (ClassIIb, LOE B-R),01,对社区来说，利用社会媒体技术，帮助在院外疑似发生心脏骤停的患者呼叫附近有愿意帮助并有能力实施心肺复苏的施救者是有一定合理性的,(II b B-R),及早识别并启动应急反应系统Given the low ris,02,及早识别并启动应急反应系统,调度员应指导未经训练的非专业施救者对心脏骤停的成人患者进行单纯胸外按压,(Hands-Only),式心肺复苏 （,I,C-LD,）,We recommend that dispatchers should provide chest compressiononly CPR instructions to callers for adults with suspected OHCA (Class I, LOE C-LD),02及早识别并启动应急反应系统 调度员应指导未经训练的非,调度员电话指导路人,OHCA,心肺复苏,Ringh M,，美国,Ringh,M, Rosenqvist M, Hollenberg J, et al. Mobile-phone dispatch of,lay persons,for CPR in out-of-hospital cardiac arrest. N Engl J Med. 2015;372(24):2316-2325.,本研究共纳入,1080,例,OHCA,患者，研究结果显示由,911,调度员电话指导路人心肺复苏可提高路人,CPR,实施率及,CPR,的成功率,调度员电话指导路人OHCA心肺复苏Ringh M, Rose,心肺复苏指南解读课件,即时高质量心肺复苏,即时高质量心肺复苏,01,施救顺序,加强业务技术学习,01施救顺序加强业务技术学习,心肺复苏顺序ABC,vs.,CAB ：一项前瞻随机实验研究,瑞士,Stephan Marsch等,瑞士一项包括,316,名患者的研究发,现患者心脏骤停到完成第一组循环,(30:2),，,CAB,组相比,ABC,组用,时更短,(,48 10,vs.63, 17,;,P 0.0001,),。,Marsch S, Tschan F, Semmer NK, Zobrist R, Hunziker PR, Hunziker S. ABC versus CAB for cardiopulmonary resuscitation: a prospective, randomized simulator-based trial. Swiss Med Wkly. 2013;143:w13856. doi: 10.4414/smw.2013.13856.,心肺复苏顺序ABC vs. CAB ：一项前瞻随机实验研究,按压深度,02,During manual CPR, rescuers should perform chest compressions to a depth of at least 2 inches or 5 cm for an averageadult, while avoiding excessive chest compression depths (greater than 2.4 inches or 6 cm) (Class I, LOE C-LD),在徒手心肺复苏过程中，施救者应以至少,2,英寸（,5,厘米）的深度对普通成人实施胸部按压，同时避免胸部按压深度过大（大于,2.4,英寸,6,厘米,）（,I,C-LD,）,按压深度02During manual CPR, rescu,较深的胸外按压,对心脏 骤停患者有更大的副作用?,芬兰,Hellevuo H,等,Hellevuo H, Sainio M, Nevalainen R, Huhtala H, Olkkola KT, Tenhunen J, Hoppu S. Deeper chest compression - more complications for cardiac arrest patients? Resuscitation. 2013;84:760765. doi: 10.1016/j.resuscitation.2013.02.015.,本研究纳入,170,例患者，,通过尸检、,CT,、胸部,X,线等方法得出发生,医源性损伤的,平均按压深度,63mm,与未损伤的平均深度,55mm,有显著差异,(P=0.002),；按压深度的峰值,86mm,与,73mm,造成医源性损伤有显著差异,(P=0.001),较深的胸外按压对心脏 骤停患者有更大的副作用?,按压频率,03,In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100/min to 120/ min (Class IIa, LOE C-LD),对于心脏骤停的成年患者，施救者以每分钟,100,至,120,次的速率进行胸外按压较为合理,(IIa C-LD),按压频率03In adult victims of card,心脏骤停后按压频率与预后的关系,北美，,Idris Ah,等,北美的一项多中心研究发现，,ROSC,率在,CPR,按压频率达到,125,次,/,分时最高，频率继续增加则,ROSC,率呈下降趋势。,Idris AH, Guffey D, Pepe PE, Brown SP, Brooks SC, Callaway CW, Christenson J, Davis DP, Daya MR, Gray R, Kudenchuk PJ, Larsen J, Lin S, Menegazzi JJ, Sheehan K, Sopko G, Stiell I, Nichol G, Aufder -heide TP; Resuscitation Outcomes Consortium Investigators. Chest compression rates and survival following out-of-hospital cardiac arrest. Crit Care Med.2015;43:840848. doi: 10.1097 / CCM.0000000000000824.,心脏骤停后按压频率与预后的关系北美的一项多中心研究发现，RO,按压通气比,Consistent with the 2010 Guidelines, it is reasonable for rescuers to provide a compression-to-ventilation ratio of 30:2 for adults in cardiac arrest (Class IIa, LOE C-LD),04,与,2010,年指南保持一致，施救者对成人心脏骤停患者进行,30,：,2,的按压通气比是合理的,(IIa C-LD),按压通气比Consistent with the 2010,胸壁回弹,加强业务技术学习,05,It is reasonable for rescuers to avoid leaning on the chest between compressions to allow full chest wall recoil for adults in cardiac arrest (Class IIa, LOE C-LD),施救者应避免在按压间隙倚靠在患者胸上，以便每次按压后使胸廓充分回弹,(,IIa C-LD,),胸壁回弹加强业务技术学习05It is reasonable,06,In adult cardiac arrest, total preshock and postshock pauses in chest compressions should be as short as possible (ClassI, LOE C-LD),In adult cardiac arrest with an unprotected airway, it may be reasonable to perform CPR with the goal of a chest compression fraction as high as possible, with a target of at least 60% (Class IIb, LOE C-LD),施救者应尽可能减少胸外按压中断的次数和时间，尽可能增加每分钟胸外按压的次数,对于没有高级气道接受心肺复苏的心脏骤停成人患者，实施心肺复苏的目标应该是尽量提高胸部按压在整个心肺复苏中的比例，目标比例为至少,60%,尽可能减少按压中断次数,06In adult cardiac arrest, tot,在,ROC PRIMED,试验中除颤前后停顿时间对院外可电击心律患者生存率的影响,加拿大，,Idris Ah,等,Sheldon Cheskes, Robert H. Schmicker , P Richard Verbeek et al; Resuscitation Outcomes Consortium (ROC) investigators. The impact of peri-shock pause on survival from out-of-hospital shockable cardiac arrest during the Resuscitation Outcomes Consortium PRIMED trial. Resuscitation. 2014;85:336342. doi: 10.1016/j. resuscitation.2013.10.014.,本研究共纳入了,2919,例患者，结果,指出缩短除颤前后停顿时间与显著增加生存率有关,在ROC PRIMED试验中除颤前后停顿时间对院外可电击心律,快速除颤,快速除颤,先除颤,OR,先心肺复苏,For witnessed adult cardiac arrest when an AED is immedi-ately available, it is reasonable that the defibrillator be usedas soon as possible (Class IIa, LOE C-LD). For adults with unmonitored cardiac arrest or for whom an AED is not immediately available, it is reasonable that CPR be initiated while the defibrillator equipment is being retrieved and applied andthat defibrillation, if indicated, be attempted as soon as the device is ready for use (Class IIa, LOE B-R),当可以立即取得,AED,时，对于有目击的成人心脏骤停，应尽快使用除颤器。若成人在未受监控的情况下发生心脏骤停或不能立即取得,AED,时，应该在他人前往获取以及准备,AED,的时候开始心肺复苏，而且视患者情况，应在设备可供使用后尽快尝试进行除颤（,IIa B-R,）,先除颤 OR 先心肺复苏For witnessed adul,基础及高级急救医疗服务,EMS,急救团队到达后尽快转运至急诊室,/,导管室,基础及高级急救医疗服务EMS急救团队到达后尽快转运至急诊室/,血管活性药物,01,Gueugniaud PY, David JS, Chanzy E et al. Vasopressin and epinephrine vs. epinephrine alone in cardiopulmonary resuscitation. N Engl J Med. 2008;359:2130. doi:10.1056/NEJMoa0706873.,Vasopressin in combination with epinephrine offers no advantage as a substitute for standard-dose epinephrine in cardiac arrest (Class IIb, LOE B-R),联合使用加压素和肾上腺素，替代标准剂量的肾上腺素治疗心脏骤停时没有优势,(IIb B-R),血管活性药物01Gueugniaud PY, David J,02,ETCO2,预测复苏失败,Axelsson C, Karlsson T, Axelsson AB, Herlitz J. Mechanical active compression-decompression cardiopulmonary resuscitation (ACD-CPR) versus manual CPR according to pressure of end tidal carbon dioxide (P(ET)CO2) during CPR in out-of-hospital cardiac arrest (OHCA). Resuscitation.,2009;80:10991103. doi: 10.1016/j.resuscitation.2009.08.006.,ETCO 2 monitoring may be considered to evaluate the quality of chest compressions, but specific values to guide therapy have not been established in children (Class IIb, LOE C-LD),对于插管患者，如果经,20,分钟心肺复苏后，二氧化碳波形图检测的,ETCO 2,仍不能达到,10,毫米汞柱以上，可将此作为决定停止复苏的多模式方法中的一个因素，但不能单凭此点就做决定（,IIb C-LD,）,02ETCO2预测复苏失败Axelsson C, Karls,急诊冠脉造影,Coronary angiography should be performed emergently(rather than later in the hospital stay or not at all) for OHCApatients with suspected cardiac etiology of arrest and ST elevation on ECG (Class I, LOE B-NR).,对于疑似心源性心脏骤停，且心电图,ST,段抬高的院外心脏骤停患者，应急诊实施冠状动脉血管造影（,I B-NR,）,03,急诊冠脉造影Coronary angiography sho,急诊冠脉造影,Emergency coronary angiography is reasonable for select(eg, electrically or hemody -namically unstable) adult patientswho are comatose after OHCA of suspected cardiac origin but without ST elevation on ECG (Class IIa, LOE B-NR).,对于选定的（如心电或血流动力学不稳定的）成人患者，若在院外发生疑似心源性心脏骤停而昏迷，且无心电图,ST,段抬高的情况，实施紧急冠状动脉血管造影是合理的（,IIa B-NR),03,急诊冠脉造影Emergency coronary angio,急诊冠脉造影,Coronary angiography is reasonable in postcardiac arrest patients for whom coronary angiography is indicated regardless of whether the patient is comatose or awake (Class IIa,LOE C-LD),对于需要冠状动脉血管造影的心脏骤停后患者，无论其是否昏迷，都应当实施冠状动脉血管造影,(IIa C-LD),03,急诊冠脉造影Coronary angiography is,比较心脏骤停后行冠脉造影与未行冠脉造影的存活患者的临床表现和预后的差别,美国，,Waldo SW,等,Waldo SW, Armstrong EJ, Kulkarni A, Hoffmayer K, Kinlay S, Hsue P, Ganz P, McCabe JM. Comparison of clinical characteristics and outcomes of cardiac arrest survivors having versus not having coronary angiography.Am J Cardiol. 2013;111:12531258. doi: 10.1016/j.amjcard.2013.01.267.,通过建立,logistic,回归和风险比例模型统计,2008,年,-2012,年,110,例心脏骤停患者，其中,84,例行冠脉造影，结果指出拒绝急诊冠脉造影的患者死亡率是增加的,比较心脏骤停后行冠脉造影与未行冠脉造影的存活患者的临床表现和,高级生命支持及骤停后护理,高级生命支持及骤停后护理,血液动力学目标,Gaieski DF, Band RA, Abella BS,et al. Early goal-directed hemodynamic optimization com-bined with therapeutic hypothermia in comatose survivors of out-of-hospital cardiac arrest. Resuscitation. 2009;80:418424. doi: 10.1016/j.resuscitation.2008.12.015.,01,Avoiding and immediately correcting hypotension (systolic blood pressure less than 90 mm Hg, MAP less than 65 mm Hg)during postresuscitation care may be reasonable (Class IIb,LOE C-LD),在心脏骤停后救治中，应该避免和立即矫正低血压（收缩压低于,90,毫米汞柱，平均动脉压低于,65,毫米汞柱）,(IIb C-LD),血液动力学目标Gaieski DF, Band RA, Ab,目标温度管理,02,We recommend that comatose (ie, lack of meaningful response to verbal commands) adult patients with ROSC after cardiac arrest have TTM (Class I, LOE B-R for VF/pVT OHCA;Class I, LOE C-EO for non-VF/pVT (ie, “nonshockable”) andin-hospital cardiac arrest),We recommend selecting and maintaining a constant temperature between 32C and 36C during TTM (Class I,LOE B-R),It is reasonable that TTM be maintained for at least 24 hours after achieving target temperature (Class IIa, LOE C-EO),所有在心脏骤停后恢复自主循环的昏迷（即对语言指令缺乏有意义的反应）的成年患者都应采用,TTM,，目标温度选定在,32 C,到,36 C,之间，并至少维持,24,小时,目标温度管理02We recommend that coma,以团队形式实施心肺复苏,For adult patients,RRT or MET systems can be effective in reducing the incidence of cardiac arrest,particularly in general care wards (IIa C),对于成年患者，快速反应小组（,RRT,）或紧急医疗团队（,MET,）能够有效减少院内心脏骤停的发生，尤其是在普通病房效果更明显,(IIa C),而在,2010,年指南中仅建议针对,CA,高风险,的患者,建立有效的反应系统，而,在,2015,年的指南中则建议专业的,RRT,或,MET,介,入,以团队形式实施心肺复苏 For adult patie,救治的地区化,A regionalized approach to OHCA resuscitation that inciudes the use of cardiac resuscitation centers may be considered(IIb C),与,2015,年的指南重申了,2010,年指南中提出的将,OHCA,患者转运至区域性心肺复苏中心进行治疗的建议（,IIb C,）,救治的地区化A regionalized approach,Kajino K, Iwami T, Daya M, Nishiuchi T, Hayashi Y, Kitamura,T, Irisawa,T, Sakai T, Kuwagata Y, Hiraide A, Kishi M, Yamayoshi,S. Impact,of transport to critical care medical centers on outcomes,after out-of-hospital,cardiac arest. Resuscitation. 2010;81:549554.,doi:10.1016/j. resuscitation.2010.02.008,.,OHCA,患者转运至心肺复苏中心对其预后的影响,Kentaro Kajino 日本,这项包括,10383,名,OHCA,患者的观察性研究发现，相比在非心肺复苏中心接受治疗，转运至心肺复苏中心的患者具有更高的,1,个月生存率和更好的神经功能预后,Kajino K, Iwami T, Daya M, Nis,心肺复苏中心应具备的条件,应,该,24h,具有急诊,PCI,的能,力,每,年都进行一定数量目标温度管理,能,够坚持复苏方案的持续质量改进，包括：,衡 量,、基准确定、反馈和程序改良,等,心肺复苏中心应具备的条件应该24h具有急诊PCI的能力,小结,小结,敢问路在何方,路在脚下,敢问路在何方,谢谢观赏,谢谢观赏,