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1、教学大纲要求,掌握心跳骤停的诊断；掌握基础生命支持的内容和方法；掌握进一步生命支持的主要内容和方法；熟悉导致心跳骤停的常见原因；熟悉心脑后期生命支持的治疗原则；,Vital Organ Function,Oxygen Supply,Sufficient Oxygenated Blood,Sufficient Oxygen,Blood,Good circulation,Insufficient or cease of Oxygen supply,Vital organ ischemia or death,Hypoxia,Low CBV or Desaturation,Circulation pr
2、oblem,Ventilation,Airway,Hemorrhage or Hb abnormal,Cardiac Pump,hemodynamics,microcirculation,Definition of Cardiac Arrest-Clinical Death,Medical emergency with absent or inadequate contraction of the left ventricle of the heart that immediately causes bodywide circulatory failure.The signs and symp
3、toms include loss of consciousness;rapid shallow breathing progressing to apnea(absence of breathing);profoundly low blood pressure(hypotension)with no pulses that can be felt over major arteries;and no heart sounds.Cardiac arrest is one of the greatest of all medical emergencies.Within several minu
4、tes,there is lack of oxygen(tissue hypoxia),leading to multiple organ injury.Unless cardiac arrest is quickly corrected,it is fatal.,Ventilation,Airway,Hemorrhage or Hb abnormal,Cardiac Pump,Hemodynamics,microcirculation,Cardiac Arrest,Tissue Hypoxia,Breathing,Brain ischemia,Ventilation,Airway,Hemor
5、rhage or Hb abnormal,Hemodynamics,microcirculation,Cardiac Arrest,Heart,MI,arrhythmia,Heart failure,reflex,Summery of Mechanisms of CA,Reduction of Coronary Blood FlowCritical Cardiac ArrhythmiaAbsent of inadequate Contraction of the Left VentricleSevere Reduction of Cardiac Return Volume,Cardiac Ar
6、rest,Brain ischemia,Signs of Cardiac Arrest,Unconscious,Dilated Pupils,No pulse,BP o/o,Cyanosis,No Breathing,No bleeding,No SPO2,无脉性室速,Pulseless,VT,室颤,VT,无脉性电活动,Pulseless,Electrical,Activity,心室停搏,Asystole,Pulseless,VT,VF,Pulseless,Electrical,Activity,Asystole,ECG Patterns of Cardiac Arrest,Cardio-Pu
7、lmonary Resusitation,An emergency procedure in which the heart and lungs are made to work by manually compressing the chest overlying the heart and forcing air into the lungs.CPR is used to maintain circulation when the heart stops pumping,usually because of disease,drugs,or trauma.An emergency proc
8、edure consisting of external cardiac massage and artificial respiration;the first treatment for a person who has collapsed and has no pulse and has stopped breathing;attempts to restore circulation of the blood and prevent death or brain damage due to lack of oxygen,The factors most related to poor
9、outcome from cardiac arrest,long arrest time before CPR prolonged ventricular fibrillation without definitive therapy inadequate coronary and cerebral perfusion during cardiac massage.rapid application of closed chestcompression and early defibrillation,Early AccessEarly CPREarly DefibrillationEarly
10、 Advanced Care,Chain of Survival for Adults,Chain of Survival for Children,Prevention of ArrestEarly and Effective Bystander CPRRapid Activation of the EMSEarly Advanced Life Support,Basic Life Support(RABC),Objectives:to deliver oxygenated blood to vital organsResponse(consciousness)Airway Control
11、Ventilation(Breathing)Chest Compression,Help!Help!Help!,Initial steps of CPR,Unresponsive?,Open airway,Check breathing(10s),Breathing,Check Pulse(10s),Circulation present?,EAR,yes,Chest compression,no,Shake and shout,Head tilt/chin lift,Look,listen and feel,Two effective breaths,Signs of circulation
12、,Check signs of circulation every 2min,Call for help and AED,Adult BLS Healthcare Provider Algorithm:.Boxes bordered with dotted lines indicate actions or steps performed by the healthcare provider but not the lay rescuer.,BLS,BLS,Open Airway,Why open airway is important?CA may be caused by airway b
13、lockageUnconscious patients tend to have airway obstructed by posterior displacement of the tongue or epiglottis due to the decrease of muscle tone decreased tone of the genioglossus muscle(颏舌肌）in particularIt is essential to provide adequate respiration for victims(functional respiration),Normal ai
14、rway vs Obstructed airway,How to Open Airway?,Tilt the head back-head tilt(dont do this if cervical spine injury is suspected)Lift the jaw-chin liftJaw thrust(First Choice if cervical spine injury is suspected)Clear the airway(very important for infant),Open Airway,Jaw Thrust,Head Tilt-Chin Lift,Oro
15、pharyngeal Airways OPA,Nasopharyngeal Airways NPA,Breathing,Signs and symptoms of respiratory emergencies?,Breathing is:,Too fast or too slowIrregularToo shallow or too deepNoisy or rasping,Person is:,Struggling or gasping for airBecoming tired from trying to breatheSemi-consciousDizzy or anxietyLip
16、s,ears and fingernails bluishAbnormal chest movementAir cannot be felt moving out of mouth or nose,In out-of-hospital or hospital ward settings,initial airway control and ventilation usually are accomplished by mouth-to-mouth or mouth-to-mask techniques.10-12/min with pulse 8-10/min without pulseVt=
17、400-500ml in an adult(amount to produce visible chest lifting)A deliberate pause is incorporated after every 30th chest compression,Expired air resuscitation,EAR,Mouth to mask ventilation,BAG-Mask ventilation,Signs of circulation Assessment,Look for any movement,including swallowing or breathingObse
18、rve colour of skin on faceCheck if carotid pulse present or brachial for children.,Take no more than 10s to do this,Effective CPR is based on the artificial delivery of oxygenated blood to systemic circulatory beds at rates that are sufficient to preserve vital organ function and at the same time pr
19、oviding the physiologic substrate for the rapid return of spontaneous circulation,Chest Compression,Crucial for oxygenated blood delivery,Mechanisms of Cardiac Compression,Cardiac pump,Thoracic pump,Chest Compression Skills,Find the right place:Center of the Chestlower half of the sternumRate:100/mi
20、ncompression/release=1:1 4-5cm deep for adultsPressure be firm,controlled and applied verticallyCC/EAR=30:2,Push hard and fastAllow the chest fully recoilMinimal interruptionsRotate every 2 mins,Cardiac output is severely decreased during CPR,ranging from 10 to 33 percent of pre-arrest values in exp
21、erimental animals.Total blood flow also tends to decrease with time during closed chest compression although changes in technique and the use of epinephrine may help sustain cardiac output.Nearly all of the cardiac output is directed to organs above the diaphragm.Brain blood flow is 50 to 90%of norm
22、al and myocardial blood flow 20 to 50%of normallower extremity and abdominal visceral flow is reduced to less than 5%of normal.,Efficiency of CPR,Assessing the Adequacy of Circulation During CPR,myocardial blood flows of 15 to 30 ml/min/100gaortic diastolic pressure exceeds 40 mm Hg and myocardial p
23、erfusion pressure(aortic diastolic minus right atrial diastolic pressure)exceeds 20-25 mm Hg.end-tidal CO2 is an excellent noninvasive guide(end-tidal CO2 does correlate well with cardiac output during CPR)usually to 20 mm Hg during successful CPR)Earliest sign is a sudden increase in end-tidal CO2
24、to greater than 40 mm Hg,when spontaneous circulation resumes.no patient with an end-tidal CO2 10 mm Hg could be successfully resuscitated.not be useful for three to five minutes following bicarbonate administration.,Defibrillation,Ventricular fibrillation is common in adults non-traumatic cardiac a
25、rrestEarlier defibrillation is important for survivalThe chances for survival decline 7-10%every minute lapseBe defibrillated at the earliest possible moment In hospital CA,defibrillation should be delivered in 3 minOut hospital CA,defibrillation better down in 5 min,Management of VT,Rapid defibrill
26、ation is key,Minutes:collapse to 1st shock,In Hospital Defibrillation,A new study using data collected by NRCPR:6789 VF/VT patients in 369 hospitals Enrolled in NRCPR between Jan.1,2000,and July 31,2005.Defibrillation in 2 min：Survival rate to hospital discharge:39%Defibrillation more than 2 min:dec
27、reased to 22%.And Less likely to have no major neurological disability,Mechanisms of Defibrillation,External current depolarize entire myocardium simultaneouslyEntire myocardium is in refractory phaseEctopic discharges of myocardium is not able to induce abnormal electro-activitiesSinus rhythm take
28、control,Energy for Defibrillation,Too low will not provide successful cardiovertToo high may cause myocardium injuryUse unsynchronized defibrillation360J for monophasic damped sine(MDS)defibrillatorsStart with120-150J for biphasic,defibrillatorsGive 200 J for unknown defibrillators,Position of elect
29、ropad,Automated external Defibrillator(AED),Commonly used by non-health workersCapable of electrocardiographic analysisRecognition of cardiac rhythm and VFDeliver biphasic shockDisadvantage for health worker is too slow to deliver a shock,Tips for Defibrillation,Must put wet gauges(soaked with salin
30、e)or gels under the electropadsMust clear the people surrounded before giving the shockPerform CPR if defibrillator is not ready and continue CPR if shock is not successful,Summery of BLS,A Airway:open the airwayB Breathing:positive-pressure ventilationC Circulation:Chest compressionD defibrillation
31、:shock for VF/pulseless VT,Advanced Cardiac Life Support,A Airway:place airway deviceB Breathing:comfirmation airway deviceB Breathing:secure airway deviceB Breathing:effective oxygenationC Circulation:establish IV accessC Circulation:identify rhythmC Circulation:administer drugs for rhythm D differ
32、ential diagnosis:identify reversible causes,ENDOTRACHEAL INTUBATION,LARYNGEAL MASK AIRWAY(controversial in CPR),THE COMBITUBE,Ventilation,Intubate the patients for airway protection and better oxygenationCardiac compression should not stop during intubation processVentilate manually or by ventilator
33、Cardiac compression is not required to discontinue during lung inflation,ECG Monitoring,Connect ECG monitors as soon as CPR startedFour common cardiac rhythms in CAPulseless VTVentricular fibrillationAsystolePulseless Electrical Activity,Pharmacologic Agents for CPR,1.Epinephrine Initial Dose:1mg IV
34、(0.01 mg/kg,IV/IO for children)tracheal route:2-3times of IV dose diluted in 10ml salineSubsequent Doses(every 3-5 minutes)Repeat initial doseSubsequent Doses(every 3-5 minutes)May consider high-dose protocol;0.1 mg/kg,IV,The efficacy of epinephrine lies entirely in its-adrenergic propertiesepinephr
35、ine helps develop the critical coronary perfusion pressureHigh dose epinephrine has no improvement in survival to hospital discharge or neurological outcome,high dose epinephrine was used as rescue therapy.,Epinephrine,2.Vasopressin,as an alternative to the first dose of epinephrine during ventricul
36、ar fibrillation cardiac arrestdose:40 units IV,single dose,1 time onlyis a potent non-adrenergic vasoconstrictor,acting by stimulation of smooth muscle V1 receptors.half-life in the intact circulation is 10 to 20 minutes,3.Amiodarone(胺碘酮）,Block sodium,potassium,calcium,alpha-channels and beta-adrene
37、rgic receptorsIndication:should be considered in CA due to VF or pulseless VT after third shock(refractory ventricular fibrillation).Dose:300mg IV Push,maintanace1mg/min for 6h,then 0.5mg/min,maximum daily dose of 2 gramsCause hypotension and bradycardia when infused too rapidly,4.Lidocaine,Lidocain
38、e:tends to reverse the reduction in VT threshold.as second-line treatment for VF/VT after 3 unsuccessful shocks.A starting dose of 1-1.5mg/kg.Repeat dose 0.5-0.75%within 5 to 10 min.Total dose should be lower than 300mg(200-300mg in an hour).followed by a maintenance dose of 2mg/min.,5 Bicarbonate b
39、est administered on the basis of blood-gas analysis.It is recommended in the presence of severe acidosis(arterial pH7.1,base excess-10).Dose:1moml/kg(1moml=0.6ml 5%NaHCO2),6.Magnesium,Indications:(1)Hypomagnesemia(2)Torsades de pointes even with normal serum levels of magnesiumDose:1-2g in 50-100ml
40、5%GS over 5-10min,followed by infusion 0.5-1g/hNot recommended in Cardiac arrest except when arrhythmia suspected,Cardiac arrest,Basic life support,Attach defib/monitor,Assess rhythm,Pulse present?,no,PEA/Asystle,CPR for 3 min,Adrenaline 1mg,During CPRCorrect any reversible causesConnect ECGSet up I
41、V accessAdvanced airway control Give adrenaline every 3 minConsider alternative medications,no,VF/VT,Defibrillate X1,CPR for 2min,Adult protocol,Rescuers and health care providers must assume that all un-monitored adult cardiac arrests are due to VF/VT.,Ventricular FibrillationandPulseless Ventricul
42、ar Tachycardia,The monitor shows:,Probability of Survival Is Related to 2 Intervals:(1)Collapse to Defibrillation and(2)Collapse to CPR,Collapse to start of CPR:1,5,10,15(min),Collapse to defibrillation interval(min),Probability of survival to hospital discharge,Background:Defibrillation and Time,Ap
43、proximately 50%survival after 5 minutesSurvival reduced by 7%to 10%per minute(if no CPR)Rapid defibrillation is keyCPR prolongs VF,slows deterioration,Minutes:collapse to 1st shock,VF-Pulseless VT Algorithm,Pulseless Electrical Activity(PEA)&Asystole,The monitor shows:,Sinus Tachycardia With No Puls
44、e,Pulseless Electrical Activity,Pulseless Electrical Activity?,Pulseless Electrical Activity?,PEA?Asystole?,PEA&Asystole,Reversible Causes of PEA/Asystole,Bradycardia,Identify and treat possible causes:the 6 Hs and 5 TsAtropine dose for bradycardia is 0.5 mg with the maximum total dose at 3 mgPacing
45、 is used when the patient fails to respond to atropine or has a high-degree blockDosages for epinephrine:2-10g/min and dopamine 2-10 g/kg/min.,Emergency Pacemaker Therapy-Transcutaneous cardiac pacing(TCP),Indications:to treat atropine-resistant symptomatic bradyarrhythmias Features:defibrillator mo
46、del;disposable pacing electrodes positioned anterior-posterior manner.(negative on V2 electrocardiograph position,positive on the left posterior chest beneath the scapula and lateral to the spine Application:Current output is slowly increased until the pacing stimuli obtain electrical and mechanical
47、 captureTips:Patients may be sedated due to discomfort of skeletal muscle contractionTCP is a temporary measure,transvenous pacing or other definitive treatment should be initiated.,Bradycardia,Bradycardia,Tachycardia,Supraventricular Tachyarrhythmia,include atrial flutter,atrial fibrillation,AV jun
48、ctional tachycardia,multifocal atrial tachycardia,paroxysmal reentrant tachycardias,250/min,180/min,Ventricular Tachyarrhythmia,280/min,potentially life-threatening need of urgent intervention Find out the causes is very important(Hypoxia,hypercarbia,hypokalemia and/or hypomagnesemia,digitalis toxic
49、ity,and acid-base derangements,Tachycardia,Post-resuscitation therapy,3/10 in hospital resuscitation survive the initial resuscitation procedures1.5/10 to be discharged1/10 survived for more than a yearMajority of them died of myocardial or central nervous system failureThis indicates the importance
50、 of post-resuscitation careFollowing resuscitation,all patients should be cared for on a special unit,POST-RESUSCITATION MYOCARDIAL DYSFUNCTION,myocardial dysfunction happens immediately after successful resuscitation the most common causes of death Post-resuscitationIncluding myocardial failure and
