《心肺脑复苏》课件

1、心肺脑复苏课件心心 肺肺 脑脑 复复 苏苏 外科学外科学心肺脑复苏课件概概 述：述： 心肺复苏心肺复苏 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心

2、肺脑复苏 CPCR。 复苏术的基本目标：复苏术的基本目标： 增加和维持重要器官（脑、心）的氧供。增加和维持重要器官（脑、心）的氧供。心肺脑复苏课件Cardiac Arrest 心跳骤停心跳骤停 无效的心输出量无效的心输出量 四种形式四种形式: (1). Ventricular fibrillation VF (2). Ventricular tachycardia VT (3). Asystole (4). Electromechanical dissociation EMD pulseless electrical activity PEA心肺脑复苏课件 CPR的步骤的步骤 初期复苏（初期复

3、苏（Basic Life Support, BLS） 后期复苏（后期复苏（Advanced Life Support, ALS） 复苏后处理（复苏后处理（Post-resuscitation Treatment, PRT） 决定因素决定因素 时间（迅速）时间（迅速） 方法（有效）方法（有效） 条件（院内或院外）条件（院内或院外）心肺脑复苏课件I. 初期复苏初期复苏 BLS（心肺复苏（心肺复苏CPR本课重点）本课重点） 特点：特点： 在无任何特殊器械的条件下徒手操作，时间是成在无任何特殊器械的条件下徒手操作，时间是成功的关键（普及训练功的关键（普及训练BLS技术有重要意义）。技术有重要意义）。

4、任务：任务： 迅速识别判定呼吸、心跳停止，并通过迅速识别判定呼吸、心跳停止，并通过CPR技术技术支持病人的呼吸和循环。支持病人的呼吸和循环。 心跳停止心跳停止: 心脏停搏心脏停搏 心室纤颤、无脉搏室速或心室纤颤、无脉搏室速或电电-机械分离等机械分离等心肺脑复苏课件CPR步骤步骤 判定（判定（Assessment） 复苏（复苏（Resuscitation）心肺脑复苏课件判定心跳骤停的方法判定心跳骤停的方法 大动脉搏动消失大动脉搏动消失 意识消失意识消失 自主呼吸停止或出现濒死喘息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瞳孔散大或皮肤粘膜灰白与发绀最简捷的方法：最简捷的方法： 先喊

5、一声，再摸一下，同时已经观察到呼吸和皮肤。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迅速判定心跳骤停后立即开始CPR操作。操作。心肺脑复苏课件判判 定定要求简捷、迅速、果断要求简捷、迅速、果断1. Call for help2. Start Resuscitation as soon as possible120心肺脑复苏课件触摸颈动脉波动触摸颈动脉波动（两指沿喉向外滑入沟内）（两指沿喉向外滑入沟内）要求：要求：1010秒钟内完成秒钟内完成心肺脑复苏课件复苏方法复苏方法CPR Airway Breathing Circulation心肺脑复苏课件Airway确保呼

6、吸道通畅确保呼吸道通畅 是急救时最重要的首步措施是急救时最重要的首步措施 也是最常犯的错误也是最常犯的错误 举例举例心肺脑复苏课件舌后坠的处理：舌后坠的处理：仰头抬颏手法仰头抬颏手法心肺脑复苏课件拍拍 背背 法法呼吸道异物的处理：呼吸道异物的处理：口腔、咽部异物：头低侧卧位取出口腔、咽部异物：头低侧卧位取出气管内异物：拍背法或气管内异物：拍背法或Heimlich手法手法头低侧卧位头低侧卧位心肺脑复苏课件Breathing口对口人工呼吸口对口人工呼吸心肺脑复苏课件仰头抬颏手法：保持气道通畅的仰头抬颏手法：保持气道通畅的同时夹住病同时夹住病 人的鼻翼防止漏气。人的鼻翼防止漏气。潮气量：吹入潮气量：

7、吹入8001200毫升。能毫升。能看到胸廓抬举，能听到病人有呼看到胸廓抬举，能听到病人有呼气声。气声。吹气持续吹气持续1.5秒，呼气约秒，呼气约1.5秒。秒。首先吹气两次首先吹气两次单人操作：每吹气单人操作：每吹气2次行心脏按摩次行心脏按摩15次。次。双人操作：首先吹气两次，每双人操作：首先吹气两次，每5秒秒钟吹入一次，频率为钟吹入一次，频率为12次次/分。分。心肺脑复苏课件Circulation胸外心脏按摩胸外心脏按摩病人体位：必须水平仰病人体位：必须水平仰卧位，背下垫上硬板，卧位，背下垫上硬板，以保证按压的有效性。以保证按压的有效性。心肺脑复苏课件抢救者手的位置抢救者手的位置胸骨中线的中下

8、三分之一交界处胸骨中线的中下三分之一交界处心肺脑复苏课件两掌相叠，手指可伸两掌相叠，手指可伸直或相互交叉锁住。直或相互交叉锁住。心肺脑复苏课件两臂伸直，肘关节固定，肩手垂直两臂伸直，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有效的心脏挤压可以触及颈动脉或股动脉的搏动动脉的搏动频率：频率：80100次次/分分深度：深度：3.85.1cm（Two Inches）心肺脑复苏课件心肺脑复苏课件BLS的结果的结果 在在CPR过程中，如果肤色好转，瞳孔立过程中，如果肤色好转，瞳孔立即缩小并有对光反射者，预后良好。即缩小并有对光反射者，预后良好。 BLS为为ALS赢得了时间，创造了条件。赢得了时间

9、，创造了条件。 心跳停止心跳停止4分钟开始分钟开始BLS，8分钟开始分钟开始ALS的成功率高。的成功率高。心肺脑复苏课件II. Advanced life support ALS后续生命支持后续生命支持 特点特点: Medical staff with primary equipment SpotAmbulance Hospital 任务任务: Acquire more efficient ventilation and circulation Maintain sufficient oxygen delivery / blood perfusion to vital organs心肺脑复苏课

10、件ALS 的的CPR 技术技术 Airway Endotracheal intubation Breathing anesthesia bag bag-valve-mask ventilation (FiO2 0.4) Circulation Chest compression ECG: Defibrillation iv access: Drugs心肺脑复苏课件Airway control气道管理气道管理 Endotracheal intubation气管插管气管插管 The optimal technique for controlling the airway and ventilati

11、ng the lungs during CPR Efficient ventilation and protect the airway from aspiration. Alternative/temporary devices Mask Pharyngeal airway Esophageal-tracheal combitube (ETC) Laryngeal mask airway (LMA)心肺脑复苏课件LMAIntubation心肺脑复苏课件Breathing-通气通气 Anesthesia bag (self-inflating, one way valve) Bag-valve

12、-mask ventilation Automatic transport ventilators (ATVs). High FiO2 : 0.4 1.0 Tidal Volume (Vt): 400 600 ml/adult心肺脑复苏课件确保气道通畅确保气道通畅有效的通气有效的通气 Tracheal intubation and ventilator The best LMA and anesthesia bag OK bag-valve mask system not bad心肺脑复苏课件Circulation 循环循环 继续胸外按压继续胸外按压 ECG 和和 除颤器除颤器 开放静脉开放静

13、脉 和和 药物治疗药物治疗 adrenaline (epinephrine) sodium bicarbonate other agents: atropine, lidocaine, calcium chloride, dopamine etc. Recover spontaneous circulation Gain good blood pressure and organ perfusion心肺脑复苏课件除颤方法除颤方法 Early ECG monitor to discover VF Precordial thump 心前区重击心前区重击 The first set of three

14、 sequence DC shocks: 1. 200 J minimal myocardial damage, adequate to achieve success in most recoverable situations; decreases the thoracic impedance, thus increasing the 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) ar

15、e unsuccessful, the prospects of recovery are poor.心肺脑复苏课件肾上腺素的作用肾上腺素的作用 adrenergic receptor stimulant effects. causes peripheral vasoconstriction, raises SVR, raises the end-diastolic filling pressure and thus improves coronary perfusion. -adrenergic stimulant activity chronotropic and inotropic ac

16、tivity of the myocardium. Make the defibrillation efficiency心肺脑复苏课件肾上腺素的给药途径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 administered via the tracheal route are unpredictable. 心肺脑复苏课件肾上腺素的剂量肾上腺素的剂量 标准剂量 1.0 mg (10 ml of a 1:10,000).

17、 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 高剂量: 0.1 mg/kg, q3-5 min Alternative doses are considered acceptable and possibly helpful

18、if an initial trial with standard doses is not effective.心肺脑复苏课件利多卡因利多卡因 Anti-fibrillatory action 抗颤作用: Decreases ventricular automaticity, suppresses reentrant circuits due to boundary currents in acute ischemia, abolishes reentrant excitation by inducing complete block in reentrant pathways, and e

19、levates 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 shock. repeated in a dose of 1.5 mg/kg in 3 to 5 minutes, with a total loading

20、dose of 3 mg/kg. Lidocaine, like epinephrine and atropine, can be injected into the tracheobronchial tree via an endotracheal tube,心肺脑复苏课件Bretylium 溴苄铵 If VF persists or recurs despite lidocaine treatment followed by defibrillatory shocks at 360 J, bretylium can be given in a dose of 5 mg/kg, follow

21、ed 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.心肺脑复苏课件电解质紊乱电解质紊乱 Correction of hypokalemia, hyperkalemia, or hypomagnesemia may permit shocks to restore

22、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 used to treat refractory VT or VF. 心肺脑复苏课件Sodium bicarbonate (N

23、aHCO3 ) 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 followed at 10-minute intervals by 0.5 mmol/kg. Of cou

24、rse, 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.心肺脑复苏课件 Base deficit/4 body weight (kg) in mmol of HCO3- solution 1 ml of 5% NaHCO3 =

25、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% NaHCO3The dosage of bicarbonatebased upon base deficit 心肺脑复苏课件Sodium bicarbonate should not be administered without considering that:lIt does not improve ability to defibrillate the heart.lI

26、t shifts the oxyhaemoglobin dissociation curve and inhibits the release of oxygen.lIt causes hyperosmolality and hypernatraemia.lIt produces paradoxical cerebrospinal fluid acidosis.lIt exacerbates central venous acidosis.心肺脑复苏课件VF/VT ProtocolDefibrillate 360J. 30-60safter each dose of medicationPat

27、tern should bedrug-shock, drug-shockAdminister medicationsof probable benefit inpersistent or recurrent VF/VTDefibrillate 360J within 30-60 sEpinephrine 1 mg IV push,repeat every 3-5 minContinue CPRIntubate at onceObtain IV accessPersistent or recurrent VF/VTProvide medications appropriate for BP, h

28、eart rate, and rhythmAssess vital signsSupport airway Support breathingReturn of spontaneous circulationPEA or AsytoleRhythm after the 3 shocks?Defibrillate up to 3 times if needed for persistent VF/VT (200J. 200-300J. 360J)ABCsPerform CPR until defibrillator attachedVF/VT present on defibrillator心肺

29、脑复苏课件III. 复苏后治疗复苏后治疗- PRT 恢复自主循环 在 ICU, CCU，监测多项生命体征 维持循环和呼吸在稳定状态 good perfusion for vital organs 治疗脑损伤 心肺脑复苏课件心血管系统心血管系统 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

30、 cautious administration of colloid as guided by the CVP. Arrhythmias: All arrhythmias are potentiated by disturbances in blood/gas or potassium homeostasis. 心肺脑复苏课件呼吸系统呼吸系统 Lung dysfunction: inhalation of vomit, lung contusion, fractured ribs and pneumothorax. Pulmonary oedema: heart failure and af

31、ter head injury, drowning or smoke inhalation. Oxygen therapy for 24 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.心肺脑复苏课件中枢神经系统中枢神经系统

32、 有效的有效的 CPR 可以防止脑损伤可以防止脑损伤, 但不能防止对脑但不能防止对脑功能的抑制。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（当的自主循环（CO），病人的意识应当很快），病人的意识应当很快地恢复清醒。地恢复清醒。 病人尚未恢复意识的原因病人尚未恢复意识的原因: 低心输出量低心输出量 脑损伤脑损伤 复苏延迟了复苏延迟了 低氧血症导致的心跳骤停低氧血症导致的心跳骤停.心肺脑复苏课件脑损伤的一般治疗脑损伤的一般治疗 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 adequate CPP Hct in the low normal range