2010年心肺复苏指南

2010年心肺复苏指南 40多年过去了，心肺复苏(CPR)的预后仍令人失望，无论院内还是院外心跳骤停的预后改善均不尽人意。目前，《心肺复苏指南》的制订主要以同行共识为基础，2005年的《心肺复苏指南》中，仍存在较多悬而未决的问题。美国心脏协会正着手制订2010年国际心肺复苏指南，于2010年10月正式出台。与2005年指南比较，新指南的主要变动包括心肺复苏的优先次序、低温治疗，以及复苏后管理等三个方面。 心肺复苏优先次序的选择 专家达成的共识 目前专家已对在心跳骤停后及早除颤的重要性达成共识，现有指南建议当院外心跳骤停事件被目击或者发生院内心跳骤停事件时，假如在现场可以立刻获得AED或者人工除颤器的话，急救人员应当立刻进行CPR(胸外按压和人工呼吸)和尽早使用除颤器;当院外心跳骤停事件发生时未被目击，尤其是快速反应时间超过5分钟者，推荐先给予CPR然后再给予电击除颤。 优先除颤还是做CPR 在临床工作中，如何界定心跳骤停的早期和晚期比较困难，而且统一用某个时间点来界定优先除颤还是CPR的先后次序难以反映个体的差异性。 近年来对心室颤动(VF)波形的研究进展给选择除颤的时机提供了新的思路。研究表明，ECG波形与心肌的血流具有明显的相关性，这样就可以根据心室颤动(VF)波形决定先行胸外按压还是先行电击除颤。如果电击除颤很有可能终止当前的VF，那么就应立即除颤;相反，如果当前电击除颤终止VF的可能性低，那么立刻进行CPR，改善冠脉灌注，准备电击除颤，这是提高复苏成功率的最优先考虑措施。 Weil心脏医学研究院近年对于VF波形的分析研究取得突破性进展，开发出了组合心电波形幅度与频率数值的幅度谱面积(AMSA)技术，根据VF波形分析决定优先除颤、还是先行CPR后再除颤。因此，除颤不再是仅依据心跳骤停事件发生时间或者急救人员的个体经验简单估计。整合AMSA技术的新一代智能商品化自动体外除颤器现已进入临床试验阶段，当AMSA分析表明当前的VF波形已达到除颤阈值，将提示医务人员给予除颤，否则的话不考虑除颤，而是继续给予CPR。AMSA技术用于除颤治疗有望能在2010年的心肺复苏指南中得以推荐。 亚低温治疗 历史沿革早在1959年，研究人员已经发现复苏后若采用低温治疗，有可能明显改善预 rAt present, we have formed a "three-three" Park. …… Industrial Park, according to ... ... The instructions of comrade, focus on development needs in the next decade, based on the original, and then extended the 6 square kilometers. Of the Park, to further improve the roads, power supply, communications, water supply and drainage and sewage pipe network and other infrastructure, to achieve full coverage of infrastructure and interconnection with the facilities and raise capacity. Each park to determine 1 leading industries, in particular stone Materials, cans, gloves, through guided, force and other measures to promote the "road company" Park, industrial agglomeration. Currently, to focus on building better ... ... Industrial Park, ... ... Wood Park as the starting area of the industrial park, planners need to take out plan, start construction as soon as possible, undertake in a timely manner ... ... Transfer of the wood industry. This opportunity slip by, so the timing must be tight. Second is to optimize government service. Low efficiency of government services, departments do not coordinate the views of businesses large, poor business environment, it is ... ... Short Board, decide to change. We will continue to deepen reform of the administrative examination and approval system, good digestion, implement the Government canceled, adjustment and devolution of administrative examination and approval matters, strengthen the existing supervision in matters of administrative power, has made it clear to cancel, are not allowed to keep or disguised approval. To do list list of administrative powers and responsibilities 后。但令人遗憾的是，当时人们并没有敏感地发现低温治疗措施的益处，低温治疗并没有得到更多的关注。 2002年《新英格兰医学杂志》同期发表分别在奥地利和欧洲进行的院外心跳骤停患者低温治疗的两项临床研究，证明:复苏后低温治疗能明显改善复苏后神经功能，低温治疗再次引起了广泛的重视。美国心脏协会在2005年《心肺复苏指南》中明确推荐对复苏后患者实施亚低温治疗，低温治疗再次成为心肺复苏领域的新热点，并将在2010年指南中得到进一步的认可。 低温治疗存在的问题 目前低温治疗仍存在着相当多悬而未决的问题，如是全身性降温好还是局部低温(如选择性头部降温)好,目前研究基本集中在全身性降温治疗，然而心跳骤停和心肺复苏过程中脑是最容易受损且明显影响预后的重要器官，从这个角度出发，应首先考虑头部低温。 其次是早期还是晚期低温治疗好,目前在欧洲通常是采用复苏成功半小时后全身低温治疗。然而由于脑神经细胞对缺氧的耐受性极为有限，低温治疗宜尽快实施，甚至在心跳骤停和复苏的伊始开始实施。第三，低温治疗的持续时间多长为宜,欧洲的临床研究采用12~24小时的低温治疗，是否为低温治疗的最佳时间,目前尚没有明确的临床证据。 最后，低温治疗的最佳温度控制在多少,现有的临床研究虽采用32~34?，但仍值得商榷，最佳的低温温度目前尚未有明确的定论。在2010年指南最终公布前，美国心脏协会的专家们正遵从循证医学的原则对上述问题进行讨论，期望给人们较合适的指引。 当前专家们已达成共识:复苏中和复苏后进行亚低温治疗能改善心跳骤停患者的预后和神经功能，越早越好～ 复苏后管理 包括2005年指南在内，众多心肺复苏指南的建议并不关注复苏后治疗流程。当前国际上专家已经意识到缺少复苏后治疗部分是现有指南缺失的环节，2010年的指南将会强调复苏后管理的重要性并做出明确的建议。 绝大多数心跳骤停的患者有冠状动脉疾病，但如何处理尚缺乏明确的建议。既往对于复苏后的患者，我们一直采用消极的治疗手段:给予开放静脉通路，应用血管活性药物，以及对症处理。目前欧洲正在进行一项临床治疗研究中，对发生心跳骤停的患者，无论是否复苏成功，还是正在进行复苏，均首先送入心导管室进行PCI治疗。研究结果表明血管再通治疗显著改善心跳骤停患者的预后，证实积极主动的治疗较传统消极治疗能显著改善患者 ative examination and approval matters, strengthen the existing supervision in matters of administrative power, has made it cinistrstrative examination and approval system, good digestion, implement the Government canceled, adjustment and devolution of admarge, poor business environment, it is ... ... Short Board, decide to change. We will continue to deepen reform of the adminisses ld is to optimize government service. Low efficiency of government services, departments do not coordinate the views of busineertake in a timely manner ... ... Transfer of the wood industry. This opportunity slip by, so the timing must be tight. Secon, undWood Park as the starting area of the industrial park, planners need to take out plan, start construction as soon as possible te the "road company" Park, industrial agglomeration. Currently, to focus on building better ... ... Industrial Park, ... ...promo k to determine 1 leading industries, in particular stone Materials, cans, gloves, through guided, force and other measures tofrastructure, to achieve full coverage of infrastructure and interconnection with the facilities and raise capacity. Each parher inhe Park, to further improve the roads, power supply, communications, water supply and drainage and sewage pipe network and otomrade, focus on development needs in the next decade, based on the original, and then extended the 6 square kilometers. Of tthree" Park. …… Industrial Park, according to ... ... The instructions of c-rAt present, we have formed a "threelear to cancel, are not allowed to keep or disguised approval. To do list list of administrative powers and responsibilities2 预后。 当前新指南制订研讨会中，专家们意识到在既往的治疗中，人们仅关注包括动脉压、心脏指数等在内的血流动力学，然而现在人们发现:血流动力学状况并不能反映重要器官的微循环灌注情况。复苏后的管理应该着重解决组织氧供和氧耗的平衡问题，应该在微血管水平上改善组织的灌注。2010年指南对于复苏后综合治疗管理将会做出说明。 当前我们充分的认识到，对于心跳骤停和心肺复苏的机制我们还只是一知半解，现有的临床实践在很大程度上是建立在经验基础之上的，其原因之一是由于科学研究少之又少。因此，探索之路任重道远。 经过五年的应用实施，有相应的调整 生存链的变化 ?2010(新): 胸外按压先于通气 ?2005(旧): 成人心肺复苏，首先开放气道，检查是否有正常呼吸，2次通气后再做30次胸外按压，如此循环 原因: 1、胸外按压能够向心脏和脑提供重要的血流量，研究表明，心脏骤停时，患者经过抢救的生存率要比那些未作CPR的高。 2、动物数据表明，延误胸外按压会减少生存率，所以被延误的情况应最小化。 3、胸外按压不受体位的影响，可以即时进行，而定位头部和进行嘴对嘴呼吸都需要花费时间。 4、在双人抢救时，C-A-B的优势更突出，在第一个抢救者进行胸外按压的同时，第二个抢救者施行开放气道。在开始做人工呼吸时，第一个30次胸外按压也就结束了。 5、不管是单人还是多人抢救，以胸外按压开始CPR不会推迟进行人工呼吸这点应该明确。 强调胸外按压的重要性 ?2010(新): 明确:如果旁观者没有经过心肺复苏术，可以提供只有胸外按压的CPR。 , are not allowed to keep or disguised approval. To do list list of administrative powers and responsibilitiescancelamination and approval matters, strengthen the existing supervision in matters of administrative power, has made it clear to nation and approval system, good digestion, implement the Government canceled, adjustment and devolution of administrative exexami or business environment, it is ... ... Short Board, decide to change. We will continue to deepen reform of the administrativeze government service. Low efficiency of government services, departments do not coordinate the views of businesses large, pooptimin a timely manner ... ... Transfer of the wood industry. This opportunity slip by, so the timing must be tight. Second is to the starting area of the industrial park, planners need to take out plan, start construction as soon as possible, undertake ik as oad company" Park, industrial agglomeration. Currently, to focus on building better ... ... Industrial Park, ... ... Wood Par1 leading industries, in particular stone Materials, cans, gloves, through guided, force and other measures to promote the "r ermineture, to achieve full coverage of infrastructure and interconnection with the facilities and raise capacity. Each park to detrther improve the roads, power supply, communications, water supply and drainage and sewage pipe network and other infrastrucade, based on the original, and then extended the 6 square kilometers. Of the Park, to futhree" Park. …… Industrial Park, according to ... ... The instructions of comrade, focus on development needs in the next dec-rAt present, we have formed a "three3 即“用力按，快速按”，在胸部中心按压，直至受害者被专业抢救者接管。 训练有素的救援人员，应该至少为被救者提供胸外按压。 另外，如果能够执行人工呼吸，按压和呼吸比例按照30:2进行。 在到达抢救室前，抢救者应持续实施CPR ?2005(旧): 没有区别抢救者是否受过培训。 仅建议旁观者可以在指导下行胸外按压。 原因: 对于未受过培训的抢救者来说，通过电话，就可实行仅有胸外按压的CPR。 然而，经过训练的救援人员，还是应该胸外按压和通气同时进行。 取消“一听二看三感觉” ?2010(新): CPR中不再有“一听二看三感觉”。 30次胸外按压后，单人抢救者开放被救者的气道，并给予2次通气。 ?2005(旧): 开放气道实施时CPR的前提。 气道开放后，通过“一听二看三感觉”来评估呼吸。 评估没有呼吸心跳后，在进行胸外按压～ 原因: 按照心肺复苏术中C-A-B的顺序，对于没有意识，呼吸或不能正常呼吸的成人，应首先给 予胸外按压。 因此，呼吸作为心脏骤停后简要检查的一部分，应放在胸外按压，开放气道，2次通气之 后 胸外按压频率:至少100次/分 ?2010(新): 以每分钟至少100次的频率，进行胸外按压。 ?100次/分 ?2005(旧): 以每分钟100次的频率，进行胸外按压 =100次/分 原因: sses ld is to optimize government service. Low efficiency of government services, departments do not coordinate the views of busineertake in a timely manner ... ... Transfer of the wood industry. This opportunity slip by, so the timing must be tight. Secon, undWood Park as the starting area of the industrial park, planners need to take out plan, start construction as soon as possible te the "road company" Park, industrial agglomeration. Currently, to focus on building better ... ... Industrial Park, ... ...promo k to determine 1 leading industries, in particular stone Materials, cans, gloves, through guided, force and other measures tofrastructure, to achieve full coverage of infrastructure and interconnection with the facilities and raise capacity. Each parher inhe Park, to further improve the roads, power supply, communications, water supply and drainage and sewage pipe network and otomrade, focus on development needs in the next decade, based on the original, and then extended the 6 square kilometers. Of tthree" Park. …… Industrial Park, according to ... ... The instructions of c-rAt present, we have formed a "threelear to cancel, are not allowed to keep or disguised approval. To do list list of administrative powers and responsibilitiesative examination and approval matters, strengthen the existing supervision in matters of administrative power, has made it cinistrstrative examination and approval system, good digestion, implement the Government canceled, adjustment and devolution of admarge, poor business environment, it is ... ... Short Board, decide to change. We will continue to deepen reform of the admini4 按压次数，中断时间，决定了胸外按压的频率。 这也是影响正常循环和神经功能的重要因素。 在大多数研究中，胸外按压次数与存活率成正比。 作为CPR组成的重要部分，胸外按压不仅要把重点放在按压频率上，也要尽量缩短中断时 间。 按压不足或频繁中断将会使每分钟的按压次数减少。 胸外按压的深度:至少5 ? ?5cm ?2010(新): 成人胸骨下陷的深度至少 5? ?5cm ?2005(旧): 成人胸骨下陷的深度 4?-5 ? 4-5cm 原因: 胸外按压通过挤压心脏增加的血流量，可以为脑和心脏提供氧和能量。 尽管建议按压时要用力按，快速按，从几年来的实际操作情况看，多数抢救者按压深度还 是不够。 此外，现有科学表明，按压深度至少5 ?时比4 ?更有效。 介于这个原因，2010AHA规定了CPR和ECC胸外按压时的最小深度。 , are not allowed to keep or disguised approval. To do list list of administrative powers and responsibilitiescancelamination and approval matters, strengthen the existing supervision in matters of administrative power, has made it clear to nation and approval system, good digestion, implement the Government canceled, adjustment and devolution of administrative exexami or business environment, it is ... ... Short Board, decide to change. We will continue to deepen reform of the administrativeze government service. Low efficiency of government services, departments do not coordinate the views of businesses large, pooptimin a timely manner ... ... Transfer of the wood industry. This opportunity slip by, so the timing must be tight. Second is to the starting area of the industrial park, planners need to take out plan, start construction as soon as possible, undertake ik as oad company" Park, industrial agglomeration. Currently, to focus on building better ... ... Industrial Park, ... ... Wood Par1 leading industries, in particular stone Materials, cans, gloves, through guided, force and other measures to promote the "r ermineture, to achieve full coverage of infrastructure and interconnection with the facilities and raise capacity. Each park to detrther improve the roads, power supply, communications, water supply and drainage and sewage pipe network and other infrastrucade, based on the original, and then extended the 6 square kilometers. Of the Park, to futhree" Park. …… Industrial Park, according to ... ... The instructions of comrade, focus on development needs in the next dec-rAt present, we have formed a "three5