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1、概 述：,心肺复苏 Cardiopulmonary Resuscitation, CPR CPR 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。,Cardiac Arre
2、st 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 EMD pulseless electrical activity PEA,CPR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。,触摸
4、颈动脉波动 （两指沿喉向外滑入沟内） 要求：10秒钟内完成,复苏方法CPR,Airway Breathing Circulation,Airway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,拍 背 法,呼吸道异物的处理： 口腔、咽部异物：头低侧卧位取出 气管内异物：拍背法或Heimlich手法,头低侧卧位,Breathing口对口人工呼吸,仰头抬颏手法：保持气道通畅的同时夹住病 人的鼻翼防止漏气。 潮气量：吹入8001200毫升。能看到胸廓抬举，能听到病人有呼气声。 吹气持续1.5秒，呼气约1.5秒。 首先吹气两次 单人操作：每吹气2次行心脏
5、按摩15次。 双人操作：首先吹气两次，每5秒钟吹入一次，频率为12次/分。,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的成功率高。,II. Adv
6、anced life support ALS 后续生命支持,特点: Medical staff with primary equipment SpotAmbulance Hospital 任务: Acquire more efficient ventilation and circulation Maintain sufficient oxygen delivery / blood perfusion to vital organs,ALS 的CPR 技术,Airway Endotracheal intubation Breathing anesthesia bag bag-valve-mas
7、k ventilation (FiO2 0.4) Circulation Chest compression ECG: Defibrillation iv access: Drugs,Airway control 气道管理,Endotracheal intubation气管插管 The optimal technique for controlling the airway and ventilating the lungs during CPR Efficient ventilation and protect the airway from aspiration. Alternative/
8、temporary devices Mask Pharyngeal airway Esophageal-tracheal combitube (ETC) Laryngeal mask airway (LMA),LMA,Intubation,Breathing-通气,Anesthesia bag (self-inflating, one way valve) Bag-valve-mask ventilation Automatic transport ventilators (ATVs). High FiO2 : 0.4 1.0 Tidal Volume (Vt): 400 600 ml/adu
9、lt,确保气道通畅 有效的通气,Tracheal intubation and ventilator The best LMA and anesthesia bag OK bag-valve mask system not bad,Circulation 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 bicarbonate other agents: atropine, lidocaine, calcium chloride, dopamine etc. Recover spontaneous circulati
10、on Gain good blood pressure and organ perfusion,除颤方法,Early ECG monitor to discover VF Precordial thump 心前区重击 The first set of three sequence DC shocks: 1. 200 J minimal myocardial damage, adequate to achieve success in most recoverable situations; decreases the thoracic impedance, thus increasing th
11、e amount of energy from the second DC shock. 2. 200 J 3. 360 J If 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-diastol
12、ic filling pressure and thus improves coronary perfusion. -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 administ
13、ered via the tracheal route are unpredictable.,肾上腺素的剂量,标准剂量 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
14、剂量: 0.1 mg/kg, q3-5 min Alternative doses are considered acceptable 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, abolish
15、es reentrant excitation by inducing complete block in reentrant 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
16、shock. repeated in a dose of 1.5 mg/kg in 3 to 5 minutes, with a 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 defibrillat
17、ory shocks at 360 J, bretylium can be given in a dose of 5 mg/kg, 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,
18、hyperkalemia, or hypomagnesemia may permit shocks to restore a sustained 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 us
19、ed to treat refractory VT or VF.,Sodium bicarbonate (NaHCO3 ),NaHCO3 should not be used routinely in the treatment of cardiac arrest Just 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 given
20、followed at 10-minute intervals by 0.5 mmol/kg. Of course, if a base deficit 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)
21、 in mmol of HCO3- solution 1 ml of 5% NaHCO3 = 0.6 mmol HCO3- 1 mmol HCO3 =1.7 ml of 5% NaHCO3 for example: give 1 mmol/kg to 60kg patient, 601.7ml 100ml 5% NaHCO3,The dosage of bicarbonate based upon base deficit,Sodium bicarbonate should not be administered without considering that:,It does not im
22、prove ability to defibrillate the heart. It shifts the oxyhaemoglobin dissociation 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
23、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 contractility: 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.
24、 Arrhythmias: All arrhythmias are potentiated by disturbances in blood/gas or potassium homeostasis.,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
25、 h should follow any episode of circulatory arrest. If respiratory failure occurs, a period of artificial 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
26、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 lateral 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
27、adequate CPP Hct in the low normal range to optimize DO2 Tissue hydration and blood biochemistry should be maintained as normal An increase in body temperature increases CMRO2 and should be avoided. Depth of coma should be assessed regularly.,脑损伤的特殊治疗,过度通气: PaCO2 of 4 kPa helps to minimize increases
28、 in ICP secondary to cerebral oedema. with the aid of muscle relaxants or cerebral depressants. A head-up tilt assists cerebral venous drainage. 脱水: Mannitol (0.25 g.kg-1 initially) is often used. When CVP is high, frusemide may be more appropriate. 激素:There is no evidence that steroids are benefici
29、al after cardiac arrest. CNS 抑制: Thiopentone and diazepam are often used, large loading doses are contraindicated. 钙拮抗剂: The role of these drugs after cardiac arrest still awaits clarification.,CPR 的终止,CPR should be continued until there is no doubt that the patient will fail to recover. Future cerebral function cannot be predicted accurately during CPR and suspicion of brain damage is no justification for terminating resuscitation. Good recovery has taken place after 1 - 2 h of continuous CPR.,Summary,小 结,