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1、Cardiopulmonary cerebral resuscitation 心肺脑复苏,Rescuer?,Everyone can be a lifesaving rescuer for a cardiac arrestvictim.CPR skills and their application depend on therescuers training,experience,and confidence.,Introduction,1.The development of resuscitation 2.Basic life support,BLS(2010 AHA Guideline
2、)3.Advanced Life Support,ALS 4.Post-resuscitation treatment,PRT 5.General Management Principles,Are you confident to do something?,1.To perform CPR for a victim2.To guide others,1.The development of resuscitation,The primary concept of resuscitation is to restore a beating heart for a functioning ci
3、rculation and restore ventilationCPR,Cerebral hypoxia,The brain is more sensitive to hypoxia than any other organ.The cerebral cortex is damaged permanently by ischaemia of more than 4-5 min duration.,Therefore,when circulatory arrest has occurred,it is essential to start CPR as rapidly as possible.
4、CPR-CPCP-All management to treat or prevent cardiac arrest or other disorders.,Prevention is the best resuscitation,预防重于治疗，防患于未然-危重病人的管理原则,早期识别并恰当处理可以预防远期恶化早期发现危重病情可以用一些简单的方法解决早期识别就是给临床医生时间，给病人生命早期识别能给病人最早最佳的治疗健康科普惠及民众解放医生3P Medicine(Predictionpreventionpersonalization),The 2010 AHA Guidelines for C
5、PR,mark the 50th anniversary of modern CPR.Over the past 50 years,these modern-era basic life support fundamentals of early recognition and activation,early CPR,and early defibrillation have saved hundreds of thousands of lives around the world.,What is EBM?,Evidence-based medicine is the integratio
6、n of best research evidence with clinical expertise and patient values.,Why have so many clinicians and educators embraced Evidence-Based Medicine?,EBM is a new model for continually learning and practicing Medicine.EBM is:clinical decision-making process.EBM is also about translationthe translation
7、 of research findings into clinical practice.,Classification,Two types of evidence-based practice have been proposed:Evidence-based guidelinesEvidence-based individual decision making,2.Basic life support,BLS(2010 AHA Guideline),The Guidelines for CPR in 2000,Adult Basic Life SupportThe compression-
8、ventilation ratio for 1-and 2 rescuer CPR is 15 compressions to 2 ventilations.The ratio is 5:1 before 2000 for 1 rescuer.,The Guidelines for CPR in 2005,Adult Basic Life SupportA compression-ventilation ratio of 30:2 is recommended.Still:A-B-C,The Guidelines for CPR in 2010,Adult Basic Life Support
9、Use a compression to ventilation ratio of 30 chest compressions to 2 ventilations Beginning CPR with 30 compressions rather than 2 ventilations leads to a shorter delay to first compression.,How to perform CPR,Check safety very important When approaching a patient who appears to have suffered a card
10、iac arrest the rescuer should check that there are no hazards to himself before proceeding to treat the patient.Patients may suffer a cardiac arrest due to electric shocks or toxic substances.,Check safety Checking responsiveness,?Checking the pulse,Carotid 颈A Femoral股ANo more than 10s,Check for bre
11、athing Look Listen Feel,shout for helpTeam work,It is essential to telephone for help as soon as the assessment has been completed.This early call for help decreases the time to the first defibrillation（除颤）,shortens the time to the delivery of advanced life support,decreases the length of time of pe
12、rformance of basic life support and improves survival.,Adult Basic Life Support,External Chest Compressions胸外心脏按压,Get the patient on a firm surface at firstChest compressions are performed on the lower half of the sternum（胸骨）place the heel of the second hand on the sternum.,Location,the lower half o
13、f the sternum（胸骨）,How to perform chest compress,keep your elbows straight,pressure is directed through the sternum and not through the ribs,above the patient,Mechanisms of chest compressions,thoracic pump mechanism,cardiac pump mechanism,Mechanisms of chest compressions,Compressions create blood flo
14、w by increasing intrathoracic pressure and directly compressing the heart.This generates blood flow and oxygen delivery to the myocardium and brain.,high-quality CPR,providing chest compressions of adequate rate(at least 100/minute 120/minute)providing chest compressions of adequate depthadults:a co
15、mpression depth of at least 2 inches(5 cm),high-quality CPR,infants and children:a depth of least one third theanterior-posterior(AP)diameter of the chest or about(4 cm)in infants and about(5 cm)in children allowing complete chest recoil after each compression minimizing interruptions(5s)in compress
16、ions avoiding excessive ventilationIf multiple rescuers are available,they should rotate the task of compressions every 2 minutes.,high-quality CPR,Defibrillation,Complications:fractured ribs（肋骨骨折）lung contusion（挫伤）pneumothorax气胸 visceral disruption内脏破裂 Why?,Open-Chest CPR,Useof this technique gener
17、ates forward blood flow and coronaryperfusion pressure that typically exceed those generated byclosed chest compressions.,Airway and Ventilations,Opening the airway followed by rescue breaths can improve oxygenation and ventilation.,How to keep the airway open,tilting the head back（头后仰）and lifting t
18、he jaw forwards.,This displaces the most common cause of airway obstruction.In cases of suspected cervical spine injury,head tilt and neck extension must never be used in this situation.,suspected cervical spine injury,Mouth to mouth ventilation,Take a full breath and seal your lips over the patient
19、s mouth.Blow steadily into the patients mouth,watching the chest rise as if the patient was taking a deep breath.,To minimize high airway pressures，emphasis is placed on a slow inspiratory phase,Deliver two rescue breaths,If the victim is known to have a serious infectionappropriate precautions are
20、recommended.use a face shield or a facemask,Transmission of infection,Hands-Only CPR,Hands-Only(compression-only)bystander CPR substantially improves survival following adult out-of-hospital cardiac arrests compared with no bystander CPRThe simpler Hands-Only technique may help overcome panic and he
21、sitation,How can bystander CPR be effective without rescue breathing?,The oxygen level in the blood remains adequate for the first several minutes after cardiac arrest.In addition,many cardiac arrest victims exhibit gasping or agonal gasps,and gas exchange.If the airway is open,passive chest recoil
22、during the relaxation phase of chest compressions can also provide some air exchange.However,at some time during prolonged CPR,supplementary oxygen with assisted ventilation is necessary.,Time is life,Basic life support only provides 10-15%of normal cardiac output and should be regarded as buying ti
23、me until the start of advanced life support.,3.Advanced Life Support,Advanced Life Support refers to the use of specialised techniques.The most important components of the advanced life support techniques are direct current defibrillation and efficient BLS.,There are four underlying disorders associ
24、ated with cardiac arrest:,1.Ventricular fibrillation（心室颤动）2.Ventricular tachycardia（室性心动过速）3.Asystole(Ventricular standstill)心室停顿4.Electromechanical dissociation电机械分离.,心室纤维颤动ventricular fibrillation VF心脏不能进行强有力的收缩而出现心肌颤动，分为粗颤和细颤。临床上最多见。,DefibrillationAutomated external defibrillators(AEDs),The victi
25、ms chance of survival decreases with an increasing interval between the arrest and defibrillation.,Effects of time to defibrillation,For every minute that passes between collapse and defibrillation,survival rates from witnessed VF SCA decrease 7%to 10%if no CPR is provided.When bystander CPR is prov
26、ided,the decrease in survival rates is more gradual and averages 3%to 4%per minute from collapse to defibrillation.,Effects of time to defibrillation,If bystanders provide immediate CPR,many adults in VF can survive with intact neurologic function,especially if defibrillation is performed within 5 t
27、o 10 minutes after SCA.CPR prolongs VF,delays the onset of asystole,and extends the window of time during which defibrillation can occur.Basic CPR alone,however,is unlikely to terminate VF and restore a perfusing rhythm.,Intubation and Venous access,Resuscitation should continue with tracheal intuba
28、tion and lung ventilation with 100%oxygen.Another member of the ALS team should be cannulating a vein.,Adrenaline 1 mg is the next action.If intravenous access has not been established then 2-3 mg can be given via the tracheal route.This route is definitely second best.Adrenaline is used in resuscit
29、ation mainly for its a-adrenergic receptor stimulant effects:peripheral vasoconstriction,improved coronary perfusion.,Adrenaline,Resuscitation in the form of basic life support should not be interrupted for more than 10 s.Therefore in any 2 min cycle of resuscitation 1 defibrillation attempt,1 mg of
30、 intravenous adrenaline and 5 cycles of basic life support are applied to the patient.,Cycle of resuscitation,4.Post-resuscitation treatment,PRT,ICU IS THE SUITABLE PLACE,Cardiovascular system,Cardiac output may remain unsatisfactory as a result of cardiogenic shock from:1.Poor myocardial contractil
31、ity,e.g.MI 2.Hypovolaemia.3.Arrhythmias.,Respiratory system,Lung dysfunction is produced during resuscitation for reasons which may include inhalation of vomit,lung contusion（挫伤）,fractured ribs and pneumothorax.Pulmonary edema may occur in the presence of heart failure and after head injury,drowning
32、 or smoke inhalation.,Respiratory system,Oxygen therapy for 24 h should follow any episode of circulatory arrest.All Patients should have a chest X-ray and blood gas analysis after resuscitation.,Central nervous system,If efficient resuscitation was started immediately after circulatory arrest occur
33、red and was continued until restoration of an adequate spontaneous cardiac output,the patient should regain consciousness fairly quickly.,Monitoring CPR,Palpation of the carotid or femoral pulse and observation of pupillary size were the standard.Persistently contracted or initially dilated but subs
34、equently contracting pupils are associated with a greater likelihood of successful resuscitation and neurological recovery.,1.Low cardiac output.2.Brain damage,which may be present if resuscitation was delayed or if the circulatory arrest was caused by hypoxemia.,Patients may fail to recover conscio
35、usness for the following reasons:,Management of brain damage,The aim of treatment is to provide optimal conditions for recovery of cerebral cells and prevention of secondary neuronal damage.,General measures,1.Keep airway open:tracheal intubation.2.Arterial pressure maintained in the normal range.3.
36、Haematocrit the low normal range.4.Body temperature increases should be avoided.5.Depth of coma should be assessed regularly.,Specialized treatment,1.Hyperventilation.Mild passive hyperventilation to a PaCO2 of 4 kPa helps to minimize increases in intracranial pressure.,2.Osmotherapy（渗透疗法）Increasing
37、 the plasma osmolality decreases intracranial water content and thus ICP.Mannitol(0.5 g.kg-1 initially)is often used.Mannitol increases the circulating blood volume and may be dangerous in the presence of pulmonry edema or a high CVP.In this situation,frusemide（速尿）may be more appropriate.,Specialize
38、d treatment,Specialized treatment,3.Steroids.There is no evidence that steroids are beneficial after cardiac arrest.,4.Barbiturates and CNS depressants.Both these drugs must be used with care after circulatory arrest.,Specialized treatment,Specialized treatment,5.Use of Hypothermia 6.Glucose control
39、 7.Hyperbaric oxygen treatment,5.General Management Principles for Cardiac Arrest,1.Establish the safety.2.Confirm the diagnosis of an arrest 3.Send for help 4.Establish Basic Life Support 5.Aim for early defibrillation.,6.Chest compressions should not be interrupted for more than 10 seconds 7.Admin
40、ister drugs intravenously whenever 8.Consider and treat any underlying causes 9.Consider antiarrhythmic(抗心律失常)drugs and sodium bicarbonate(碳酸氢钠),5.General Management Principles for Cardiac Arrest,Key Principles in Resuscitation:Strengtheningthe Links in the Chain of Survival,The links include the fo
41、llowing:Immediate recognition of cardiac arrest and activation of the emergency response system Early CPR with an emphasis on chest compressions Rapid defibrillation Effective advanced life support Integrated post cardiac arrest care,CPR may vary,depending on the rescuer,the victim,and the available
42、 resources,Evidence-based guidelines in combinationwith clinical judgment,Clinicians should always apply these evidence-based guidelines in combination with clinical judgment.,Time for practice,Simulator training system,New Guideline for CPCR 2010 Circulation Vol 122 Nov 2 2010,integrates the best available evidence and clinical expertise to deliver the finest possible patient care.,
