guidelines writing group chairs michael r. sayre, md
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Guidelines Writing Group Chairs Michael R. Sayre, MD. 2010 年 AHA 心肺复苏指南介绍. 贵阳医学院附院麻醉科 曾庆繁. 2010 心肺复苏 50 周年. 1960------------ 2010 Kouwenhoven. 2010 International Consensus Conference. 356 位专家 来自 29 个国家 历时 36 个月讨论. Robert A. Berg - PowerPoint PPT PresentationTRANSCRIPT
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Guidelines Writing Group Chairs
Michael R. Sayre, MD
贵阳医学院附院麻醉科 曾庆繁
2010 年 AHA 心肺复苏指南介绍
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1960------------2010
Kouwenhoven
2010 心肺复苏 50 周年
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356 位专家来自 29 个国家 历时 36 个月讨论
2010 International Consensus Conference
Robert A. Berg University of PennsylvaniaProfessor of Anesthesiology and Critical Care Medicine, DivisionChief, Pediatric Critical Care
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Cardiac arrest can be caused by
• 室颤 VF
• 室速 ( 无脉 )VT
• 无脉性电活动 PEA
• 心博停止 asystole. 无脉性心动过缓 Pulseless bradycardia
4 rhythms
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• 室颤 无脉性室速• VF/Pulseless VT
• chest compressions (CC)• early Defibrillation (DF)
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Early recognition cardiac arrest
•及早识别心跳骤停
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外行急救lay rescuer 1. 突然晕倒 suddenly collapse 2. 意识消失 Unresponsive 3. 无呼吸或无正常呼吸 not breathing 4.Seizure (not normally,gasping).
• cardiac arrest• 降低脉搏检查的重要性• Minimize the importance of pulse checks
不检查脉搏 Not check for a pulse
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• 2005 (Old): • “Look, listen, and feel”
•2010 (New): NO: “Look, Listen, Feel for Breathing”* 30 compressions 2 breaths
•NO: “Look, Listen, Feel for Breathing”* 不看 不听 不觉
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A Change From A-B-C to C-A-B
•“Adults” •Children•infants (excluding thenewly born)
复苏步骤
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Few rescuers wants to do Few rescuers wants to do MouthMouth--toto--Mouth breathing!Mouth breathing!
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What about Oxygen?What about Oxygen?
• VF-CAVF-CA: :
中心血液中富含氧 中心血液中富含氧
– Experimental work has shown Arterial Sats reExperimental work has shown Arterial Sats remain acceptable for main acceptable for up to 10 min of CCCup to 10 min of CCC
• 呼吸停呼吸停 - - 通气通气 !!
• Respiratory Arrest-DifferentRespiratory Arrest-Different ! !– Ventilation crucial to replace OxygenVentilation crucial to replace Oxygen
关键 :CCC心 脑
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C-A-B
• chest compressions
initiated sooner
及早按压
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• Forget CPR, Give CCR Instead
心脑复苏新概念心脑复苏新概念Cardiocerebral ResuscitationCardiocerebral Resuscitation
忘了 CPR 代之 CCR
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Standard CPR: 30:2Standard CPR: 30:2Continuous Chest CompressionsContinuous Chest Compressions
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心脑复苏概念心脑复苏概念Cardiocerebral ResuscitationCardiocerebral Resuscitation
200 chestcompressions
200 chestcompressions
Single shockwithout pulse Check or rhythm analysis
BVM or PassiveInsuflation 100% FIO2
Begin IV
Ana
lysi
s
200 chestcompressions
Single shock if Indicated without pulse check orrhythm analysis
Ana
lysi
s
Single shock if Indicated without pulse check orrhythm analysis
Resume Standard ACLSConsider Endotracheal
Intubation
200 chestcompressions
CC
Only•
EMSarrival
Administer 1 mg IV Epinephrine
Ana
lysi
s
• If adequate bystander chest compressions are provided, EMS providers perform immediate rhythm analysis
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Three-Phase Model of Resuscitation
Three-Phase Model of Resuscitation
0 2 4 6 8 10 12 14 16 18 20
Arrest Time (min)
CirculatoryPhase
ElectricalPhase
MetabolicPhase
0
100%Myocardial ATP
Weisfeldt ML, Becker LB. JAMA 2002: 288:3035-8
rapid defibrillation
good chest compressions
little we can do
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外行成人CPR
简化成人基本生命支持
:
CCC+DF
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Chest Compressions*
• 2010 (New):
• Hands-Only™
• “push hard and fast”
• on the center of the chest
• 动手不动口• 30 compressions to 2 breaths
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Chest Compression Rate: At Least 100 per Minute*
• 2010 (New): • chest compressions at a rate of• at least 100/min.( 快 ! 不间断 )• 2005 (Old): • Compress at a rate of about 100/min.
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Chest Compression Depth*
• 2010 (New): hard !• The adult sternum should be depressed • at least 2 inches (5 cm).• 2005 (Old): • approximately 1,1/2 to 2 inches • (approximately 4 to 5 cm).
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C A
B
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电击治疗 ELECTRICAL THERAPIES
• AED Use in Children Now Includes Infants
• 2010 (New):• <1 year of age.
• 2005 (Old):• Not use of AEDs for infants <1 year of age.
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先除颤 VS 先 CPR ?
• CPR
• <3min• Defibrillation• However, in monitored patients, the time from
VF to shock delivery should be under 3 minutes
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1 次除颤 vs 3 连续除颤 ?
• 2010 (No Change From 2005):
• 一次电击后
• 立即 CPR
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200 chestcompressions
200 chestcompressions
Single shockwithout pulse Check or rhythm analysis
BVM or PassiveInsuflation 100% FIO2
Begin IV
Ana
lysi
s
200 chestcompressions
Single shock if Indicated without pulse check orrhythm analysis
Ana
lysi
s
Single shock if Indicated without pulse check orrhythm analysis
Resume Standard ACLSConsider Endotracheal
Intubation
200 chestcompressions
CC
Only•
EMSarrival
Administer 1 mg IV Epinephrine
Ana
lysi
s
• If adequate bystander chest compressions are provided, EMS providers perform immediate rhythm analysis
CC200 -shockcc200( 不检查脉搏 / 心律分析 )
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电极放置 Electrode Placement
• 2010 (Modification of Previous Recommendation):
AED electrode pads positions :
lateral
posterior
Anterior left infra scapular
right infrascapular
胸骨旁 ( 锁骨下 )
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2005 (Old):
• conventional sternal-apical (anteriorlateral) position.
• Right pad left pad • Sternal apical• 胸骨旁 ( 锁骨下 ) 心尖
• right or left upper back.
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ADVANCED CARDIOVASCULAR LIFE SUPPORT
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监测 PETCO2 :
1. 确定气管导管位置 confirming tracheal tube placement
2. 监测 CPR 有效性 monitoring CPR quality
3. 检查心跳恢复 detecting ROSC
CPR 质量
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药物 New Medication Protocols• 2010 (New):
• 阿托品不常规• 用于 PEA/asystole• Atropine • not routine use • for PEA/asystole
2005 (Old):
阿托品用于高级心血管生命支持 Atropine included in the ACLS 心搏停止 asystole or slow PEA 可用阿托品Atropincould be considered..
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心动过速 tachycardia
• 规律的 Regular• 单型 monomorphic• 宽 QRS 心动过速• wide-complex tachycardia
• 腺苷 Adenosine
• (rhythm is regular)
2010 (New)
adenosine只用于规则的窄 QRS 的折返性室上速only for suspected regular narrow-complexreentry supraventricular tachycardia
2005 (Old):
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• 不规律的宽 QRS 心动过速
• irregular wide-complex tachycardias
• 不用腺苷• Adenosine shoul
d not be used• (may cause dege
neration of the rhythm to VF)
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心动过缓 Bradycardia
• 症状性不稳定心动过缓
• symptomatic unstable Bradycardia
• 变时性药物输注• chronotropic drug i
nfusions (an alternative to p
acing)
atropine while awaiting a pacer or if pacing was ineffective.
chronotropic drug infusions
2010 (New) 2005 (Old):
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避免过度通气 Avoiding Hyperventilation
• 10 -12 breaths per minute
• PETCO2 of 35 - 40 mm Hg
• PaCO2 of 40 -45 mm Hg.
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• ACLS Cardiac Arrest Algorithm
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•Post–Cardiac Arrest Care
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Table 1. Multiple System Approach to Post–Cardiac Arrest CareVentilation Hemodynamics Cardiovascular Neurological Metabolic
●CO2 监测 直接动脉 : 心脏监测 : 神经学检查 : 乳酸监测
确定气管插管MAP> 65 mm
Hg 心律失常再发及治疗 昏迷 脑损伤 保证灌注
昏迷 : 插管 SBP≥ 90 mm Hg不预防性抗心律失常
药 判断预后 K > 3.5 mEq/L
调节通气 : 治疗低血压 去除心律失常原因 对语言 刺激反应避免低钾 ( 心律失
常 )
PETCO2: Fluid bolus 12-lead ECG/ 瞳孔光反射 尿量 , 血清肌酐
35–40 mm HgDopamine 5–
10mcg ACS STEMI QT 角膜反射 发现 ARF
Paco2: Norepinephrine 治疗急性冠脉综合征 自主眼球活动 等容 euvolemia
40–45 mm Hg Epinephrine Aspirin/heparin 动嘴 呛咳 自主呼吸 肾替代治疗
脉搏氧 血气0.1–0.5mcg/
kg.mi PCI or 脑电图 : replacement 降低 FIO2 fibrinolysis 惊厥 血糖监测SpO2 ≥94% 抗惊厥治疗 治疗低血糖 <80mg
PaO2-100 mm Hg 昏迷者中心温度监测 : 高血糖 : 控制在
Pao2/FIO2 300 降低脑损伤 改善预后 144–180 mg/dL
机械通气 : 预防高热 :>37.7°CLocal insulin
protocols
VT 6-8mL/kg
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VentilationHemodyna
mic Cardiovascular Neurological Metabolic
Chest X-ray: 心脏超声 : 治疗性低温 :
确定气道 检查室壁运动Cold IV fluid bolus 30 mL/kg
AvoidHypotonicFluis
检查 CA原因并发症 心肌病
Surface or endovascular
increase edema
pneumonitis 心肌顿抑cooling for 32°C–
34°C(cerebral
edema)
pulmonary edema
Treat Myocardial Stunning: 24 hours
Fluids to optimize
volume After 24 hours
Dobutamine 5–10 m
cg/kgslow rewarming 0.25
°C/hr
动脉气囊反博 (IABP) CT
镇静肌松
控制寒战 机控呼吸 (非同步 )
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谢谢 !