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

1960------------2010

Kouwenhoven

2010 心肺复苏 50 周年

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

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

• 室颤 无脉性室速• VF/Pulseless VT

• chest compressions (CC)• early Defibrillation (DF)

Early recognition cardiac arrest

•及早识别心跳骤停

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

• 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

A Change From A-B-C to C-A-B

•“Adults” •Children•infants (excluding thenewly born)

复苏步骤

Few rescuers wants to do Few rescuers wants to do MouthMouth--toto--Mouth breathing!Mouth breathing!

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

C-A-B

• chest compressions

initiated sooner

及早按压

• 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

Standard CPR: 30:2Standard CPR: 30:2Continuous Chest CompressionsContinuous Chest Compressions

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

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

外行成人CPR

简化成人基本生命支持

:

CCC+DF

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

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.

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).

C A

B

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.

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

1 次除颤 vs 3 连续除颤 ?

• 2010 (No Change From 2005):

• 一次电击后

• 立即 CPR

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 )

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 )

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.

ADVANCED CARDIOVASCULAR LIFE SUPPORT

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

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..

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):

• 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)

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):

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.

• ACLS Cardiac Arrest Algorithm

•Post–Cardiac Arrest Care

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　

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 ) 　　 　 　

　 　 　

谢谢 !