心肺脑复苏文档资料

概述：心肺复苏CardiopulmonaryResuscitation,CPRCPR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CardiopulmonaryCerebralResuscitation,CPCR从心跳停止到细胞坏死的时间以脑神经细胞最短（4－6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。CardiacArrest心跳骤停无效的心输出量四种形式:(1).VentricularfibrillationVF(2).VentriculartachycardiaVT(3).Asystole(4).ElectromechanicaldissociationEMDpulselesselectricalactivityPEACPR的步骤初期复苏（BasicLifeSupport,BLS）后期复苏（AdvancedLifeSupport,ALS）复苏后处理（Post-resuscitationTreatment,PRT）决定因素时间（迅速）方法（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。判定要求简捷、迅速、果断1.Callforhelp2.StartResuscitationassoonaspossible120触摸颈动脉波动（两指沿喉向外滑入沟内）要求：10秒钟内完成复苏方法－CPRAirwayBreathingCirculationAirway－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800～1200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：80～100次/分深度：3.8～5.1cm（TwoInches）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.AdvancedlifesupportALS

后续生命支持特点:MedicalstaffwithprimaryequipmentSpotAmbulanceHospital任务:AcquiremoreefficientventilationandcirculationMaintainsufficientoxygendelivery/bloodperfusiontovitalorgansALS的CPR技术AirwayEndotrachealintubationBreathinganesthesiabagbag-valve-maskventilation(FiO2>0.4)CirculationChestcompressionECG:Defibrillation ivaccess:DrugsAirwaycontrol

气道管理Endotrachealintubation气管插管TheoptimaltechniqueforcontrollingtheairwayandventilatingthelungsduringCPREfficientventilationandprotecttheairwayfromaspiration.Alternative/temporarydevicesMaskPharyngealairwayEsophageal-trachealcombitube(ETC)Laryngealmaskairway(LMA)LMAIntubationBreathing-通气Anesthesiabag(self-inflating,onewayvalve)Bag-valve-maskventilationAutomatictransportventilators(ATVs).HighFiO2:0.4~1.0TidalVolume(Vt):400~600ml/adult确保气道通畅

有效的通气TrachealintubationandventilatorThebestLMAandanesthesiabagOKbag-valvemasksystemnotbadCirculation循环继续胸外按压ECG和除颤器开放静脉和药物治疗adrenaline(epinephrine)sodiumbicarbonateotheragents:atropine,lidocaine,calciumchloride,dopamineetc.RecoverspontaneouscirculationGaingoodbloodpressureandorganperfusion除颤方法EarlyECGmonitortodiscoverVFPrecordialthump心前区重击ThefirstsetofthreesequenceDCshocks:1.200Jminimalmyocardialdamage,adequatetoachievesuccessinmostrecoverablesituations;decreasesthethoracicimpedance,thusincreasingtheamountofenergyfromthesecondDCshock.2.200J3.360JIfallthreeinitialdefibrillationattempts(200J,200J,360J)areunsuccessful,theprospectsofrecoveryarepoor.肾上腺素的作用–adrenergicreceptorstimulanteffects.

causesperipheralvasoconstriction,raisesSVR,raisestheend-diastolicfillingpressureandthusimprovescoronaryperfusion.-adrenergicstimulantactivity

chronotropicandinotropicactivityofthemyocardium.Makethedefibrillationefficiency肾上腺素的给药途径1mg静脉注射如果静脉还没开通，2-3mg经气管注入Thisrouteisdefinitelysecondbestasthepharmacodynamicsofdrugsadministeredviathetrachealrouteareunpredictable.

肾上腺素的剂量标准剂量1.0mg(10mlofa1:10,000).Thisdoseshouldberepeatedevery3to5minutes,aslongascardiacarrestpersiststoassuresustainedbloodflowbenefit.另外的剂量疗法:中等剂量:2to5mg,q3-5min逐步增加剂量:1mg,3mg,5mgat3-minuteintervals高剂量:0.1mg/kg,q3-5minAlternativedosesareconsideredacceptableandpossiblyhelpfulifaninitialtrialwithstandarddosesisnoteffective.利多卡因Anti-fibrillatoryaction抗颤作用:Decreasesventricularautomaticity,suppressesreentrantcircuitsduetoboundarycurrentsinacuteischemia,abolishesreentrantexcitationbyinducingcompleteblockinreentrantpathways,andelevatestheVFthreshold.Alsoenhanceintraoperativeventriculardefibrillationincardiacsurgery,permittingdefibrillationwithfewershocksoflowerenergyandcurrent.initialdoseis1.5mg/kg,followedbya360-Jshock.repeatedinadoseof1.5mg/kgin3to5minutes,withatotalloadingdoseof3mg/kg.Lidocaine,likeepinephrineandatropine,canbeinjectedintothetracheobronchialtreeviaanendotrachealtube,Bretylium溴苄铵IfVFpersistsorrecursdespitelidocainetreatmentfollowedbydefibrillatoryshocksat360J,bretyliumcanbegiveninadoseof5mg/kg,followedbya360-Jshock.IfVFremains,aseconddoseof10mg/kgcanbegivenin5minutesfollowedbyanothershock.Ifnecessary,athirddoseof10mg/kgcanbegiven,followedbyanothershock.电解质紊乱Correction

ofhypokalemia,hyperkalemia,orhypomagnesemiamaypermitshockstorestoreasustainedconversion.Magnesiumplaysacriticalroleinmaintenanceofastablecardiacrhythm.HypomagnesemiashouldbesuspectedandtreatedwhenrefractoryVTorVFispresent.Magnesiumsulfate1to2gover1to2minutescanbeusedtotreatrefractoryVTorVF.Sodiumbicarbonate(NaHCO3)NaHCO3shouldnotbeusedroutinelyinthetreatmentofcardiacarrestJustforapre-existingmetabolicacidosisispresent,oraseveredocumentedmetabolicacidosisdevelopsduringthearrest.Aninitialdoseof1mmol/kgcanbegivenfollowedat10-minuteintervalsby0.5mmol/kg.Ofcourse,ifabasedeficitisdocumentedonbloodgasanalysisthedrugcanbegivenbaseduponthatmeasurement.Monitoringbotharterialandmixed-venousbloodgasesandpHwillleadtomorerationalantacidtherapy.

[Basedeficit/4bodyweight(kg)]inmmolofHCO3-solution1mlof5%NaHCO3=0.6mmolHCO3-1mmolHCO3=1.7mlof5%NaHCO3forexample:give1mmol/kgto60kgpatient,601.7ml100ml5%NaHCO3Thedosageofbicarbonatebaseduponbasedeficit

Sodiumbicarbonateshouldnotbeadministeredwithoutconsideringthat:Itdoesnotimproveabilitytodefibrillatetheheart.Itshiftstheoxyhaemoglobindissociationcurveandinhibitsthereleaseofoxygen.Itcauseshyperosmolalityandhypernatraemia.Itproducesparadoxicalcerebrospinalfluid

acidosis.Itexacerbatescentralvenousacidosis.III.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goodperfusionforvitalorgans治疗脑损伤

心血管系统Poormyocardialcontractility:Dopamine2-10g.kg-1.min-1byinfusionisthetreatmentofchoice.Hypovolaemia:TheoptimalpreloadforthefailingheartshouldbeensuredbythecautiousadministrationofcolloidasguidedbytheCVP.Arrhythmias:Allarrhythmiasarepotentiatedbydisturbancesinblood/gasorpotassiumhomeostasis.

呼吸系统Lungdysfunction:inhalationofvomit,lungcontusion,fracturedribsandpneumothorax.Pulmonaryoedema:heartfailureandafterheadinjury,drowningorsmokeinhalation.Oxygentherapyfor24hshouldfollowanyepisodeofcirculatoryarrest.Ifrespiratoryfailureoccurs,aperiodofartificialventilationisrequired.AllpatientsshouldhaveachestX-rayandbloodgasanalysisafterresuscitation.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Thetrachealtubeshouldbeleftinsituorinthelateralposition(Theunconsciouspatientwhosetracheaisnotintubated).Epileptiformfits(癫痫发作),whichincreaseCMRO2,maybetreatedsafelywithanticonvulsants.

BPinthenormalrangetoensureadequateCPPHctinthelownormalrangetooptimizeDO2TissuehydrationandbloodbiochemistryshouldbemaintainedasnormalAnincreaseinbodytemperatureincreasesCMRO2andshouldbeavoided.Depthof