－心肺复苏

nullCardiopulmonary ResuscitationCardiopulmonary Resuscitation Diagnosis of cardiac and respiratory arrestDiagnosis of cardiac and respiratory arrest Traditional methods : 1. Carotid pulse check by lay rescuers 2. Loss of consciousness 3. Pupil dilation 4. Respiratory arrest Guideline 2000 Guideline 2000Elimination of the pulse check for lay rescuers Evaluate for signs of circulation in 10 seconds breathing , coughing , movement in response to rescue breath Assess for a pulse Assess for a pulseTime is too longer Accurate rate 75 % Sensibitity 90% Specificity 60%Rate of false- positive(40%) Rate of false- positive(40%) Results Pulseless Pulse Mistakenly loss the saving opportunity Rate of false-negative (10 %)Rate of false-negative (10 %) Results Pulse Pulseless Unnecessarily do CPR Electrocardiogram changes of Cardiac arrest Electrocardiogram changes of Cardiac arrest Ventricular fibrillation A flat line or only atrial wave Pulseless Electrical Activity, PEA The chain of Survival The chain of Survival Early access Early CPR Early Defibrillation Early advanced life support * patient with Coma （ immediately do CPR ， not clear obstructed airways at first） Basic Life Support --- the first ABCDBasic Life Support --- the first ABCDAirway A Breathing B Circulation C Defibrillation D Airway AirwayTilt the head backwards Lift the jaw Open the mouth Clearing obstructed airways from choking Subdiaphragmatic abdominal thrust (Heimlich maneuver) Breathing BreathingMouth to mouth or mouth to nose Mouth to oropharyngeal tube Mouth to shield Mouth to mask(compressing the cricoid cartilage in order to decrease gastric distention and prevent gastric reflu) Bag-mask ventilation challenged endotracheal intubation – resuscitation’s “gold standard”Circulation —external chest compression Circulation —external chest compression High-frequency（100 compressions per min） aortic pressure ↑myocardial perfusion pressure↑ cardiac outputs ↑ rise survival rate Reduce interrupted compression ( compression – ventilation ratio simplified to 15:2) Compression-only CPR: unwilling or unable to perform mouth to mouth or cardiogenic cardiac arrestCirculation —Compression-only CPRCirculation —Compression-only CPRResearch suggests: ① Survival rate with compression-only CPR in first 6~12 minutes is 40.8% ② Survival rate with chest compression add artificial ventilation is 34.1% , because artificial ventilation may be result in respiratory alkalosis. Mechanism of external chest compression Mechanism of external chest compression Chest pump - sequential increased and decreased pressure in the thoracic cavity - valves maintaining forward direction of flow Cardiac pump -sequential filling and emptying of cardiac chambers -valves maintaining forward direction of flow Circulation CirculationThump version from 20-25 cm high to chest Cough Version in 10-15 second Intermittent abdominal compression-cardiopulmonary resuscitation（IAC-CPR) Activated compression-decompression（ACD-CPR) Phased－Chest and Abdominal ACD-CPR （Life-stick Resuscitation） increase mean pressure，coronary and cerebral perfusion pressure，left ventricular and cerebral blood flowAutomated external defibrillator --- AEDAutomated external defibrillator --- AED① Ventricular fibrillation : may be used by 200J*3 times) or 200J、200-300J、300J ② If polymorphic ventricular tachycardia can not be clearly distinguished from ventricular fibrillation (VF), treatment would refer to be as VF ③ Atrial fibrillation :100-200J synchronized ④ Atrial flutter or supraventricular tachycardia 50- 100J synchronized ⑤ Ventricular tachycardia 100J synchronized Biphasic waveform defibrillation Biphasic waveform defibrillation A compensated defibrillation for the second time in limited time Low-energy levels（150J correspond to 200-300J） Reduce the myocardial injury Advanced Life Support --- the second ABCD Advanced Life Support --- the second ABCDEndotracheal intubation (A) Mechanical ventilation and oxygen therapy (B) Intravenous injection (C) electrocardiogram and blood pressure monitoring, resuscitation drug , open chest cardiac compression (C) Differential diagnosis (D) Confirmation of Endotracheal tube placement Confirmation of Endotracheal tube placement Mark estimated depth Breath sounds by auscultation at 5 locus Thorax rise as inspiration increase of SaO2 Steam in canal of artificial ventilation device Use a specific technique or device to prevent tube dislodgment Mechanical ventilationMechanical ventilationLow tidal volume 6-7ml/kg（400-600ml） Hyper ventilation High airway pressure and endogenous PEEP Intracranial hypertension; High tidal volume Distension Too low tidal volume hypoxia and CO2 retention Epinephrine EN --(1) Epinephrine EN --(1)α-adrenergic receptor stimulating Peripheral arterial vasoconstriction(not cerebral and coronary arterioles) mean arterial pressure↑ myocardial and cerebral blood flow ↑Epinephrine EN --(2)Epinephrine EN --(2)Recommended dosage : 1.0mg(0.01-0.02mg/kg ) iv every 3-5 minutes, then 1mg + GS 250ml iv gtt, 1μg/min→3-4μg/min, or 1mg、3mg、5mg iv Compared high dosage: 0. 1-0.2mg/kg High dosage (>0.2mg/kg) may be harmful Endotracheal administration: NS 20ml + 2~2.5 time recommended dose Intracardiac injection: only in heart operation or chest trauma VasopressinVasopressinAct by direct stimulation of smooth muscle V1 receptors vasoconstriction No increased myocardial oxygen consumption Half-life is 10 ~20 minute, longer than EN Applicable to VF or prolonged cardiac arrest, and with PEA（pulseless electrical activity）or with asystole Effective in patients who remain in cardiac arrest after treatment with epinephrine Usage: 40IU iv Amiodarone(1) Amiodarone(1)Persistent VT or VF after defibrillation and epinephrine in cardiac arrest Hemodynamically stable VT polymorphic VT wide-complex tachycardia Ventricular rate control of rapid atrial arrhythmias with impaired LV function when digitalis ineffective Amiodarone(2) Amiodarone(2)Initially 300mg iv diluted in 20-30 ml in cardiac arrest Initial dose of 150mg iv（ over 10 min), followed by 1 mg/min infusion for 6 h, then 0.5mg/min Supplementary 150mg iv repeatedly for recurrent or resistant arrhythmias or hemodynamically unstable VT Maximum total dose: 2g／24h adverse effects：hypotension and bradycardia Magnesium sulfate Magnesium sulfateTorsades de pointes Arrhythmias caused by magnesium deficiency Loading dose :1～2g /50-100ml iv (over 5-60 minutes) Followed by an infusion of 0.5-1.0g/h Sodium Bicarbonate（1） Sodium Bicarbonate（1） Only after the confirmed interventions are ineffective Preexisting metabolic acidosis, hyperkalemia, tricyclic or phenobarbitone overdose Protracted arrest or long resuscitative effortsSodium Bicarbonate（2）Sodium Bicarbonate（2）Acid-base balance : chest compressions ROSC adequate alveolar ventilation and restoration of tissue perfusion CO2 more freely diffusible than HCO3 - into myocardial and cerebral cells intracellular acidosis Initial dosage： 5%NaHCO3 1mEq /kg iv gtt ( 1ml≌0.6mEq ) Etiological factors （5Hs，5Ts) Etiological factors （5Hs，5Ts) Hypovolemia Hypoxia Hydrogen ion (acidosis) Hyperkalemia or Hypokalemia Hyperthermia or HypothermiaTablets (drug) Tamponade Tension Pneumothorax Thrombosis coronary Thrombosis pulmonary Optimal response to resuscitation Optimal response to resuscitationAwake Responsive Breathing spontaneously restoration of spontaneous circulation (ROSC) Prolong Life Support Prolong Life SupportPostresuscitation care - Prevent and treatment SIRS and MODS organs function support Cerebral resuscitation Postresuscitation syndrome Postresuscitation syndromeReperfusion failure Reperfusion injury Cerebral intoxication from ischemic metabolites Coagulopathy Postresuscitation syndrome --- 4 phases Postresuscitation syndrome --- 4 phases Cardiovascular dysfunction in the hours after ROSC in 24 hours SIRS leads to MODS over 1 to 3 days Serious infection occurs and the patient declines rapidly Death Dopamine DopamineA potent adrenergic receptor agonist and a strong peripheral dopamine receptor agonist. Effects are dose-dependent: 5 ～ 20μg／min／kg Low-dose (2 ~ 4 μg／min／kg) is no longer used for acute oliguric renal failure, because occasionally diuresis no improve renal glomerular filtration rate. Middle dosage：5~10μg／min／kg, positive inotropic effect High dosage：10~20 μg／min／kg， vasoconstriction Sodium Bicarbonate Sodium Bicarbonateimmediately after ROSC Guided by the partial pressure of CO2 Cerebral resuscitation Cerebral resuscitation Maintain relative high blood pressure during CPR Hemodilution and mild hypothermia （32－34℃）for 12 h during CPR thrombolysis for ameliorate hypercoagulable state Antioxidant ，free radical scavenger Emergency hypothermia CPB Hyperbaric oxygen：suitable for persistent vegetative state Ethical and legal considerations of CPR Ethical and legal considerations of CPRWhen withdrawal or withhold of life support？ DNAR（do not attempt resuscitation) orders Transporting patient proceed CPR must be continue CPR Patient is in a persistent vegetative state or terminal condition certified by 2 physicians, including 1 with special expertise in evaluation cognitive function null