特殊情況下的cpr

1、CPR in Special Situations特殊情況下的CPR,福建醫(yī)科大學(xué)附屬協(xié)和醫(yī)院麻醉科 翁險(xiǎn)峰,ACLS in the Perioperative Period圍術(shù)期高級(jí)心臟生命支持,Causes of cardiac arrest +心跳驟停的原因1) intraoperative hemorrhage術(shù)中出血2) pre-existent cardiac pathology原有的心臟疾患3) hypox

2、ia, both at intubation or extubation插管或拔管時(shí)缺氧.,a different milieu of pathophysiology病理生理的不同之處,Hypovolemia, as a cause of myocardial ischemia, is far more common than transmural infarction from plaque rupture.術(shù)中低血容量導(dǎo)致的心肌

3、缺血遠(yuǎn)多于透壁心梗。The most common cardiac dysrrythmia during general and neuraxial anesthesia is bradycardia followed by asystole (45%).全麻和椎管內(nèi)麻醉中最常見的心律失常是心動(dòng)過緩之后的心跳停止。The other life threatening cardiac rhythms are severe tachyd

4、ysrrhythmias including ventricular tachycardia（VT), ventricular fibrillation (VF 14%), and pulseless electrical activity (PEA 7%).其它威脅生命的心律失常是嚴(yán)重的頻速型心律失常，包括室性心動(dòng)過速，室顫，和無脈性電活動(dòng)。,hyperventilation is almost invariablyassociat

5、ed with worsened survival過度通氣常與糟糕的生存預(yù)后相關(guān),in a low flow state the duration of increased intrathoracic pressure is proportional to the ventilation rate and inversely proportional to blood pressure, coronary and cerebral p

6、erfusion胸內(nèi)壓的增加與通氣頻率成正比，與血壓及冠脈、腦血管灌注成反比。Recent versions of the ACLS guidelines have recommended lower levels of ventilatory support.近期的高級(jí)生命支持指南推薦低水平的通氣支持。Ventilation at 20 breaths a minute is associated with significant

7、ly lower survival than ventilation at 12 breaths/minute. 每分鐘20次的通氣頻率與每分鐘12次通氣頻率相比，生存率低,Cardioversion心臟復(fù)律,Immediate cardioversion is indicated for a patient with serious signs & symptoms related to the tachycardia or

8、if ventricular rate is > 150 bpm伴有嚴(yán)重癥狀的心動(dòng)過速或心室率> 150次/分，是立即心臟復(fù)律的指征。 Always be prepared to externally pace patients who are being cardioverted, as some will convert into a very bradycardic rhythm.對(duì)心臟復(fù)律的患者應(yīng)準(zhǔn)備好體外起搏，這

9、是由于一些患者會(huì)出現(xiàn)嚴(yán)重的心動(dòng)過緩。,,Avoiding cardiac arrest requires successfully managing acute anemia, hypoxemia, and all contributing factors to cardiac output: preload, contractility, and afterload.要避免心跳驟停，應(yīng)處理好急性貧血、低氧血癥及與心輸出量有關(guān)的心臟前負(fù)

10、荷、心肌收縮力、心臟后負(fù)荷。,Common Causes of ACLS events in the perioperative setting Anesthetic 藥物原因,Intravenous anesthetic overdose靜脈麻醉藥過量Inhalation anesthetic overdose吸入麻醉藥過量Neuraxial block with high level sympathectomy

11、 椎管內(nèi)麻醉平面過高的交感神經(jīng)阻滯Local anesthetic systemic toxicity局麻藥毒性反應(yīng)Malignant hyperthermia惡性高熱Drug administration errors給藥錯(cuò)誤,Respiratory呼吸原因,Hypoxemia 低氧血癥Auto PEEP 內(nèi)源性呼氣末正壓Acute Bronchospasm 急性支氣管痙攣,Cardiovascular心血管原因,Va

12、sovagal reflex 血管迷走反射Hypovolemic and/or hemorrhagic shock低血容量 和/或 出血性休克Tension Pneumothorax 張力性氣胸Anaphylactic Reaction 過敏反應(yīng)Transfusion Reaction 輸血反應(yīng)Acute Electrolyte Imbalance (high K)急性電解質(zhì)失衡（高鉀）Severe Pulmonary Hy

13、pertension 嚴(yán)重肺動(dòng)脈高壓Increased intraabdominal pressure 腹內(nèi)壓增高Pacemaker failure 起搏器故障Prolonged Q-T syndrome 長Q-T綜合征Acute Coronary Syndrome 急性冠脈綜合征Pulmonary Embolism 肺栓塞Gas embolism 氣體栓塞Oculocardiac reflexes 眼心反射Electr

14、oconvulsive therapy 電休克治療,Recognizing cardiac arrest in the OR識(shí)別手術(shù)室內(nèi)的心跳驟停,EKG with pulseless rhythm (V-tach, V-fib)無脈心電活動(dòng)（室速、室顫）Loss of pulse X 10 seconds 無心跳10秒Loss of end-tidal CO2 無呼末二氧化碳Loss of plethysmograph （無動(dòng)

15、脈容積波形）,BLS/ACLS in the OR –Some key points to remember . . .,CPR for patients under general anesthesia need not be preceded by “Annie! Annie! Are you okay?”全麻下的CPR無需呼喚患者Instruct appropriate personnel to start effective

16、CPR.恰當(dāng)?shù)娜藛T開始有效的CPRDiscontinue the anesthetic and surgery停止麻醉藥和外科手術(shù)Call for help, defibrillator呼叫幫助，除顫Bag mask ventilation if ETT not in place followed by immediate endotracheal intubation if feasible FiO2 = 1.0未氣管插管者先面

17、罩通氣隨后立即氣管插管， FiO2 = 1.0,BLS/ACLS in the OR –Some key points to remember . . .,Don‘t stop CPR unnecessarily! Capnography is a more reliable indicator of ROSC than carotid or femoral arterial pulse palpation.不要無故停止CPR! 二氧化

18、碳波形圖在提示自主循環(huán)恢復(fù)方面比觸摸頸動(dòng)脈或股動(dòng)脈更可信。Capnograph to confirm advance airway positioning and effective CPR 二氧化碳波形圖可用來證實(shí)高級(jí)氣道位置及CPR的有效性。Hand ventilate rate 8 -10, VT to chest rise, TI one second with 100% oxygen – assess for obstru

19、ction, if none, institute mechanical ventilation. If obstruction, suction, fiberoptic bronchoscopy, consider exchanging the airway. Continue CPR.手動(dòng)呼吸8-10次/分，夠胸廓抬起的潮氣量，吸氣時(shí)間1秒，使用100%氧—處理氣道梗阻，建立機(jī)械通氣，如果有氣道梗阻，吸引，纖支鏡檢查，考慮更換氣管，

20、繼續(xù)CPROpen all IVs to wide open 開放粗大靜脈通路,,Anaphylaxis is a rare but important cause of circulatory collapse in the perioperative period. 過敏反應(yīng)雖然少見，但卻是圍術(shù)期循環(huán)衰竭的重要原因。While there is a wide range of minor allergic reactions,

21、hypotension, tachycardia and bronchospasm can be more easily followed by vasogenic shock when the offending agent is administered as a rapid intravenous bolus, the most common route of drug administration during anesthes

22、ia. 當(dāng)引起過敏的藥快速通過靜脈路給予時(shí)，可能出現(xiàn)低血壓、心動(dòng)過速和支氣管痙攣，隨后出現(xiàn)血管性休克。,,The preponderance of anaphylaxis in perioperative patients is caused by a small number of drugs. 多數(shù)的圍術(shù)期患者的過敏反應(yīng)是很少的一些藥物引起的Anaphylactic shock has been identified as a c

23、oexisting or major indeterminate factor for dysrhythmic cardiac arrest during anesthesia occurring in 2.2 to 22.4 per 10,000 anesthetics with 3% to 4% of them being life threatening.過敏性休克與麻醉中因嚴(yán)重心律失常心跳驟停有關(guān)，發(fā)生率2.2-22.4/100

24、00麻醉病例，其中3－4%威脅生命,Neuroaxial Anesthesia,Various hypotheses have been put forward over the years, invoking unrecognized respiratory depression, excessive sedation concurrent with high block, under appreciation of both the

25、 direct and indirect circulatory consequences of a high spinal anesthetic, and ‘failure to rescue’ with airway management and drugs.近年來出現(xiàn)各種假設(shè)，包括未及時(shí)發(fā)現(xiàn)的呼吸抑制，過多的鎮(zhèn)靜藥物伴高平面的阻滯，脊麻藥物用量過多導(dǎo)致的循環(huán)變化，未能正確的處理呼吸和循環(huán)。,Treatment of Cardiac

26、 Arrest Associated with Neuraxial Anesthesia椎管內(nèi)麻醉相關(guān)心跳驟停的處理,Discontinue anesthetic or sedation infusion停止麻醉藥或鎮(zhèn)靜藥的輸注Ventilate with 100% Oxygen, intubate trachea 100%濃度氧氣通氣，氣管插管Begin CPR if patient has significant bradyc

27、ardia or is pulseless >10sec 患者有嚴(yán)重的心動(dòng)過緩或無脈時(shí)間超過10秒即開始CPRTreat bradycardia with 1mg Atropine 阿托品1mg處理心動(dòng)過緩Treat with at least 1 mg epinephrine IV (up to)給予至少1mg腎上腺素靜注，最高可用到0.1mg/kgConsider concurrent treatment with 40

28、u vasopressin 可考慮同時(shí)給予40u血管加壓素,Differential Diagnosis for perioperative PEA or Asystole: 8H & 8T,Hypoxia 低氧Trauma創(chuàng)傷/hypovolemia低血容量Hypovolemia低血容量Tension Pneumothorax張力性氣胸Hyper-vagal 迷走反射 Thrombosis of Coronary 冠脈栓

29、塞Hydrogen Ion 酸中毒Tamponade 心臟壓塞Hyperkalemia 高鉀血癥Thrombus in Pulmonary Artery 肺動(dòng)脈栓塞Malignant Hyperthermia 惡性高熱Long QT syndrome 長QT綜合征Hypothermia低溫 Toxins (anaphylaxis)中毒（過敏反應(yīng)）Hypoglycemia 低血糖Pulmonary HTN 肺動(dòng)脈高壓,Cardi

30、ac Arrest Associated With Asthma與哮喘相關(guān)的心跳驟停,Since the effects of auto-PEEP in an asthmatic patient with cardiac arrest are likely quite severe, a ventilation strategy of low respiratory rate and tidal volume is reasonabl

31、e.哮喘心跳驟?；颊邇?nèi)源性PEEP可能很嚴(yán)重，因此低呼吸頻率和小潮氣量是合理的。During arrest a brief disconnection from the bag mask or ventilator may be considered, and compression of the chest wall to relieve air-trapping can be effective.可考慮將面罩或呼吸機(jī)短暫脫開，胸外

32、按壓可有效減輕空氣滯留。,,For all asthmatic patients with cardiac arrest, and especially for patients in whom ventilation is difficult, the possible diagnosis of a tension pneumothorax should be considered and treated. 哮喘心跳驟?；颊?，尤其通氣

33、困難者，應(yīng)考慮到可能存在張力性氣胸并給予處理。,Cardiac Arrest AssociatedWith Pregnancy,孕婦心跳驟停第一反應(yīng)啟動(dòng)孕婦心心跳驟停復(fù)蘇團(tuán)隊(duì)記錄心跳驟停發(fā)生時(shí)間將孕婦置于仰臥位開始心臟按壓，手的位置在胸骨上略高于通常位置,尋找并處理可能的原因B 出血/DICE 栓塞：冠脈/肺/羊水A 麻醉藥U 宮縮無力C 心臟疾病（心梗/缺血/主動(dòng)脈夾層/心肌?。〩 高血壓/先兆子癇/子癇O

34、其他：鑒別診斷P 胎盤早剝/前置胎盤S 膿毒血癥,,Airway氣道Bag-mask ventilation with 100% oxygen before intubation is especially important in pregnancy.在氣管插管前面罩呼吸囊100%氧氣特別重要Intubation with an endotracheal tube or supraglottic airway should b

35、e performed only by experienced providers if possible.如果可能應(yīng)由有經(jīng)驗(yàn)者進(jìn)行氣管插管或聲門上氣道,,Circulation循環(huán)Current recommended drug dosages for use in resuscitation of adults should also be used in resuscitation of the pregnant patient

36、.現(xiàn)有推薦用于成人復(fù)蘇的藥物同樣適用于孕婦的復(fù)蘇,,Defibrillation除顫Although there is a small risk of inducing fetal arrhythmias, cardioversion and defibrillation on the external chest are considered safe at all stages of pregnancy.盡管有較小的風(fēng)險(xiǎn)導(dǎo)致胎兒心

37、律失常，胸外的心臟復(fù)律和除顫被認(rèn)為在各孕期的孕婦是安全的。,Cardiac Arrest Associated With Life-Threatening Electrolyte Disturbances電解質(zhì)失衡相關(guān)的心跳驟停,Hyperkalemia高鉀血癥,Stabilize myocardial cell membrane:穩(wěn)定心肌細(xì)胞膜 Calcium chloride氯化鈣 (10%): 5 to 10 mL (500

38、 to 1000 mg) IV over 2 to 5 minutes or calcium gluconate葡萄糖酸鈣 (10%): 15 to 30 mL IV over 2 to 5 minutes,,Shift potassium into cells:促使鉀轉(zhuǎn)移至細(xì)胞內(nèi) Sodium bicarbonate碳酸氫鈉: 50 mEq IV over 5 minutes Glucose plus insulin葡萄糖加胰島

39、素: mix 25 g (50 mL of D50) glucose and 10 U regular insulin and give IV over 15 to 30 minutes Nebulized albuterol 霧化沙丁胺醇: 10 to 20 mg nebulized over 15 minutes,,Promote potassium excretion:促進(jìn)鉀的排出 Diuresis利尿: furosemid

40、e 速尿40 to 80 mg IV Kayexalate降鉀樹脂: 15 to 50 g plus sorbitol per oral or per rectum Dialysis 透析,,Hypokalemia can produce ECG changes such as U waves, T-wave flattening, and arrhythmias (especially if the patient is tak

41、ing digoxin), particularly ventricular arrhythmias, which, if left untreated, deteriorate to PEA or asystole.低鉀血癥ECG表現(xiàn)為U波、T波低平、心律失常（尤其正在使用地高辛的患者），尤其是室性心律失常，未處理可惡化為無脈性電活動(dòng) 或心跳靜止。Disturbances in sodium level are unlikely t

42、o be the primary cause of severe cardiovascular instability.血鈉的失衡不太可能是嚴(yán)重心血管循環(huán)不穩(wěn)定的初始原因。,Hypermagnesemia高鎂血癥,Hypermagnesemia is defined as a serum magnesium concentration 2.2 mEq/L (normal: 1.3 to 2.2 mEq/L). Neurological

43、symptoms of hypermagnesemia include muscular weakness, paralysis, ataxia, drowsiness, and confusion. Hypermagnesemia can produce vasodilation and hypotension. 高鎂血癥是指血清鎂濃度超過2.2 mEq/L（正常值為 1.3 to 2.2 mEq/L）。高鎂血癥的神經(jīng)癥狀包括：肌無力

44、、麻痹、共共濟(jì)失調(diào)、昏昏欲睡、神志恍惚。高鎂血癥可導(dǎo)致血管擴(kuò)張和低血壓。,Hypermagnesemia高鎂血癥,Extremely high serum magnesium levels may produce a depressed level of consciousness, bradycardia, cardiac arrhythmias, hypoventilation, and cardiorespiratory arr

45、est.極度的高鎂血癥可使神志消失、心動(dòng)過緩、心律失常、低通氣、心跳呼吸驟停。Administration of calcium (calcium chloride [10%] 5 to 10 mL or calcium gluconate [10%] 15 to 30 mL IV over 2 to 5 minutes) may be considered during cardiac arrest associated with

46、hypermagnesemia對(duì)于與高鎂血癥相關(guān)的心跳驟停，可給予鈣劑（10%氯化鈣5 to 10 mL 或10%葡萄糖酸鈣15 to 30 mL IV 2-5分鐘）,Hypomagnesemia低鎂血癥,Hypomagnesemia can be associated with polymorphic ventricular tachycardia, including torsades de pointes, a pulseless

47、 form (polymorphic) of ventricular tachycardia. 低鎂血癥與多形性室速有關(guān)，包括尖端扭轉(zhuǎn)、無脈室速。For cardiotoxicity and cardiac arrest, IV magnesium 1 to 2 g of MgSO4 bolus IV push is recommended.對(duì)心跳驟停者，靜注硫酸鎂1-2g，心要時(shí)靜脈追加。,Local Anesthetic Toxi

48、city局麻藥毒性,Consider 1.5 mL/kg of 20% long-chain fatty acid emulsion(長鏈脂肪乳） as an initial bolus, repeated every 5 minutes until cardiovascular stability is restored.考慮1.5ml/kg 20%長鏈脂肪乳作為首劑量，然后每5分鐘重復(fù)一次直到心血管功能穩(wěn)定,Cyanide氰化物

49、,Based on the best evidence available, a treatment regimen of 100% oxygen and hydroxocobalamin, with or without sodium thiosulfate, is recommended.使用純氧及靜注維生素B12，合用或不用硫代硫酸鈉。,Cardiac Arrest Associated With Trauma創(chuàng)傷相關(guān)的心跳驟

50、停,While CPR in the pulseless trauma patient has overall been considered futile, several reversible causes of cardiac arrest in the context of trauma are correctible and their prompt treatment could be life-saving. 對(duì)大多數(shù)無脈

51、性創(chuàng)傷患者CPR是無效的，但一些可逆因素導(dǎo)致的心跳驟停是可治療，立即處理是可以救命的。These include hypoxia, hypovolemia, diminished cardiac output secondary to pneumothorax or pericardial tamponade, and hypothermia.這些包括低氧、低血容量、繼發(fā)于張力性氣胸或心包壓塞的低心排血量、低溫。,,When multi

52、system trauma is present or trauma involves the head and neck, the cervical spine must be stabilized. A jaw thrust should be used instead of a head tilt– chin lift to establish a patent airway. 當(dāng)出現(xiàn)多器官系統(tǒng)創(chuàng)傷或創(chuàng)傷包括了頭頸，必須保持頸椎的

53、穩(wěn)定。在開放氣道時(shí)應(yīng)下推前頜取代頭部傾斜抬下頜。If breathing is inadequate and the patient’s face is bloody, ventilation should be provided with a barrier device, a pocket mask, or a bag-mask device while maintaining cervical spine stabilizati

54、on. 如果通氣不足且患者面部出血，在保持頸椎穩(wěn)定性的同時(shí)，應(yīng)提供面罩通氣。Stop any visible hemorrhage using direct compression and appropriate dressings. If the patient is completely unresponsive despite rescue breathing, provide standard CPR and defibril

55、lation as indicated.使用直接按壓或恰當(dāng)?shù)姆罅蟻碇寡?。如果患者?duì)呼吸救治無反應(yīng)，應(yīng)進(jìn)行常規(guī)的CPR和除顫。,,After initiation of BLS care, if bag-mask ventilation is inadequate, an advanced airway should be inserted while maintaining cervical spine stabilization. I

56、f insertion of an advanced airway is not possible and ventilation remains inadequate, experienced providers should consider a cricothyrotomy. 面罩通氣、高級(jí)氣道、環(huán)甲膜切開,,A unilateral decrease in breath sounds during positivepressur

57、e ventilation should prompt the rescuer to consider the possibility of pneumothorax, hemothorax, or rupture of the diaphragm.正壓通氣時(shí)單側(cè)呼吸音減弱，救治者應(yīng)想到氣胸、血胸、橫膈破裂的可能。When the airway, oxygenation, and ventilation are adequate, e

58、valuate and support circulation. Control ongoing bleeding where possible and replace lost volume if the losses appear to have significantly compromised circulating blood volume. Cardiac arrest resuscitation will likely b

59、e ineffective in the presence of uncorrected severe hypovolemia.當(dāng)氣道、供氧、通氣足夠時(shí)，評(píng)估支持循環(huán)?？刂瞥鲅⑤斠?，低血容量時(shí)心肺復(fù)蘇很可能是無效的。,Treatment of PEA requires identification and treatment of reversible causes, such as severe hypovolemia, hypot

60、hermia, cardiac tamponade, or tension pneumothorax.處理無脈性電活動(dòng)需要鑒別并處理可逆原因，如嚴(yán)重的低血容量、低溫、心臟壓塞或張力性氣胸。Development of bradyasystolic rhythms often indicates the presence of severe hypovolemia, severe hypoxemia, or cardiorespirat

61、ory failure.心動(dòng)過緩進(jìn)展到心跳停止常代表嚴(yán)重低血容量、嚴(yán)重低氧血癥或心肺衰竭。Ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) are treated with CPR and defibrillation. 室顫和室速常通過CPR和除顫來處理。Resuscitative thoracotomy may be indicate

62、d in selected patients.對(duì)一些病人可開胸復(fù)蘇。,Drowning溺水,The first and most important treatment of the drowning victim is the immediate provision of ventilation.立即通氣支持Management of the drowning victim’s airway and breathing is sim

63、ilar to that recommended for any victim of cardiopulmonary arrest.氣道與呼吸管理與其他心肺驟停相同,,Some victims aspirate no water because they develop laryngospasm or breath-holding.一些遇難者由于喉痙攣或屏氣并無吸入水。Even if water is aspirated, there

64、 is no need to clear the airway of aspirated water, because only a modest amount of water is aspirated by the majority of drowning victims, and aspirated water is rapidly absorbed into the central circulation.即使水被吸入，也無必要

65、清除氣道內(nèi)的水，因?yàn)榇蠖鄶?shù)的溺水者僅吸入不多的水，吸入的水可很快吸收入循環(huán)。Attempts to remove water from the breathing passages by any means other than suction (eg, abdominal thrusts or the Heimlich maneuver) are unnecessary and potentially dangerous.各種吸引之

66、外的企圖將水從呼吸道排出的方法（擠壓腹部或海姆利克操作法）都是沒有必要并且有潛在危險(xiǎn)的。,Cardiac Arrest During Percutaneous Coronary Intervention經(jīng)皮冠脈介入時(shí)的心跳驟停,Mechanical CPR During PCI 機(jī)械CPREmergency Cardiopulmonary Bypass 緊急體外循環(huán)Intracoronary Verapamil 冠脈內(nèi)維拉帕米Co

67、ugh CPR 咳嗽CPR Multiple case reports describe the use of cough CPR to temporarily maintain adequate blood pressure and level of consciousness in patients who develop ventricular arrhythmias during PCI while definitive th