欧洲急性心衰院前与早期处理共识课件

2015 HFAESCEuSEMSAEM建议：急性心衰的院前和医院管理,谢文源2015-12-30,CONTENTS,1.Deinition and epidemiology of acute heart failure 急性心衰的定义与流行病学特点,2.Prehospital and early management strategies in acute heart failure 急性心衰院前及早期治疗策略,3.Initial clinical evaluation and investigations早期评估和治疗,4. Deinition, initial management and monitoring of cardiogenic shock心源性休克诊疗的定义和要点,1.Deinition and epidemiology of acute heart failure,2.Prehospital and early management strategies in acute heart failure,3.Initial clinical evaluation and investigations,4. Deinition, initial management and monitoring of cardiogenic shock,CONTENTS,解决软件开发企业核心难题,2, Acute heart failure (AHF) is the term used to describe the rapid onset of, or acute worsening of symptoms and signs of HF, associated with elevated plasma levels of natriuretic peptides. 定义为：心力衰竭症状急性发作或加重，并伴有血浆脑利钠肽水平的升高。, Most of the patients with AHF present with normal or high blood pressure and with symptoms and/or signs of congestion rather than low cardiac output.与住院患者比较，急诊或院前 的特点在于，绝大多数患者的血压正常或升高，伴有肺淤血症状和体征，而不是低心输出量。,Deinition and epidemiology of acute heart failure,Deinition and epidemiology of acute heart failure,1.Deinition and epidemiology of acute heart failure,2.Prehospital and early management strategies in acute heart failure,3.Initial clinical evaluation and investigations,4. Deinition, initial management and monitoring of cardiogenic shock,CONTENTS,急救战线前移：As for acute coronary syndromes, the “time-to-treatment” concept may be important in patients with AHF. Hence, all AHF patients should receive appropriate therapy as early as possible. 和急性冠脉综合征一样，应秉承“及时治疗”理念治疗。所有急性心衰患者均应尽早接受适宜的治疗。,In the pre-hospital setting, AHF patients should benefit from:,Noninvasive monitoring, including pulse oximetry, blood pressure, respiratory rate, and a continuous ECG, instituted within minutes of patient contact and in the ambulance if possible.Oxygen therapy given based on clinical judgment unless oxygen saturation90% in which case oxygen therapy should be routinely administered.Non-invasive ventilation, in patients with respiratory distressMedical treatment should be initiated based on blood pressure and/or the degree of congestion using vasodilators and/or diuretics (i.e., furosemide)对于处于院前阶段的急性心衰患者，下列措施能带来治疗获益：（1）尽早开展无创监测（如急救车内），包括脉搏血氧饱和度、血压、呼吸频率及连续心电监测等；（2）若患者氧饱和度90%，氧疗法应纳入常规治疗，除此之外的情况均需根据临床诊断决定是否氧疗；（3）给予呼吸窘迫患者无创通气；（4）根据患者血压情况和/或充血程度决定是否给予药物治疗，一般考虑血管扩张剂、利尿剂；（5）尽快转诊至附近有完备心内科和/或CCU/ICU的大中型医院。,4,Prehospital and early management strategies in acute heart failure,1.Deinition and epidemiology of acute heart failure,2.Prehospital and early management strategies in acute heart failure,3.Initial clinical evaluation and investigations,4. Deinition, initial management and monitoring of cardiogenic shock,CONTENTS,A. Laboratory tests at presentation 实验室检查,F. Discharge from emergency department 出院标准,B. Oxygen therapy and/or ventilatory support 氧疗和机械通气支持,C. Early administration of intravenous diuretics and vasodilators利尿剂和血管扩张剂的早期应用,D. Drugs to be used cautiously in acute heart failure (excluding cardiogenic shock) 慎用药物,E. Management of Evidence Based Oral Therapies 循证口服药物治疗,Laboratory tests at presentation,1 A plasma natri-uretic peptide level (BNP, NT-proBNP or MR-proANP) should be measured in all patients with acute dyspnoea and suspected AHF, to help in the differen-tiation of AHF from non-cardiac causes of acute dyspnoea. 检测血浆脑利钠肽 水平，把 从非心原性的急性呼吸困难患者中鉴别开来。2 The following laboratory assessments should be performed at admission in the blood of all AHF patients: troponin, BUN (or urea), creatinine, electrolytes, glucose and complete blood count. 实验室检查：肌钙蛋白，（或尿素），肌酐，电解质，血糖和血常规。3 D-dimer is indicated in patients with suspicion of acute pul-monary embolism 二聚体在怀疑急性肺栓塞患者中应该进行检测。4 Routine arterial blood gas is not needed.常规血气分析是不需要的。（除非是氧合不能通过脉搏血氧饱和度监测、合并心源性休克的、合并急性肺水肿或既往有慢性阻塞性肺疾病史的患者）,Oxygen therapy and/orventilatory support,Early administration of intravenous diureticsand vasodilators,1.Initially, 2040mg intravenous furosemide can be consideredin all AHF patients；起始可给予急性心衰患者20mg至40mg呋塞米。2.When systolic BP is normal to high (110mmHg),intravenous vasodilator therapy might be given for symptomatic relief as an initial therapy. Alternatively, sublingual nitrates maybe considered. 若患者收缩压110mmHg，静注血管扩张剂可起到症状缓解作用，硝化甘油舌下含服可作为其替代治疗。,Drugs to be used cautiouslyin acute heart failure,Routine use of opioids in AHF patients is not recommended,不推荐将阿片类药物作为急性心衰常规用药；There is only a very limited place for sympathomimetics or vasopressors in patients with AHF excluding cardiogenic shock;they should be reserved for patients who have persistent signs of hypoperfusion despite adequate illing status.仅有少数急性心衰患者（不含心源性休克）需要拟交感神经药物或血管加压药物，此类情况多为输液充分的情况下仍然存在顽固性低灌注。,Management of Evidence Based Oral Therapies,Discharge from emergency department,Clinical condition can change dramatically within a few hours of ED arrival. Hence, clinical response to initial treatment is an important indicator of likely disposition.Indicators of good response to initial therapy that might be considered in discharge include: Resting HR95% in room air No or moderate worsening of renal function (chronic renal disease might be present Fast track discharge from ED should be considered in hospitals with chronic disease management programs, once the trigger for decompensation has been identiied and early management commenced Patients with de novo AHF should not be discharged home from ED,出院指标,1.初始治疗临床反应良好的指标如下（可出院）：（1）患者主诉病情改善；（2）静息心率100bpm；（3）无站立低血压；（4）尿量正常；（5）室内血氧饱和度95%；（6）无或中度肾功能恶化。2.急诊快速通道出院后应启动慢性疾病管理计划，一旦有失代偿征象立即治疗。3.新发急性心衰患者不能从急诊直接出院回家，需中间病房治疗。,1.Deinition and epidemiology of acute heart failure,2.Prehospital and early management strategies in acute heart failure,3.Initial clinical evaluation and investigations,4. Deinition, initial management and monitoring of cardiogenic shock,CONTENTS,Initial management and monitoring of cardiogenic shock,1 Cardiogenic shock is deined as hypotension(SBP2mmol/L, metabolic acidosis, SvO2200ml/15-30min) is recommended as the first line treatment if there is no sign of overt luid overload.如果患者无容量负荷，推荐溶