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1、Cardiopulmonary Resuscitation,Diagnosis 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,Elimination of the pulse check for lay rescuersEvaluate for signs of circulation in 10 seco
2、nds breathing,coughing,movement in response to rescue breath,Assess for a pulse,Time is too longerAccurate rate 75%Sensibitity 90%Specificity 60%,Rate of false-positive(40%),Results Pulseless Pulse Mistakenly loss the saving opportunity,Rate of false-negative(10%),Results Pulse Pulseless Unnecessari
3、ly do CPR,Electrocardiogram changes of Cardiac arrest,Ventricular fibrillationA flat line or only atrial wavePulseless Electrical Activity,PEA,The chain of Survival,Early access Early CPR Early Defibrillation Early advanced life support*patient with Coma（immediately do CPR，not clear obstructed airwa
4、ys at first）,Basic Life Support-the first ABCD,Airway ABreathing BCirculation CDefibrillation D,Airway,Tilt the head backwardsLift the jaw Open the mouthClearing obstructed airways from choking Subdiaphragmatic abdominal thrust(Heimlich maneuver),Breathing,Mouth to mouth or mouth to noseMouth to oro
5、pharyngeal tube Mouth to shieldMouth to mask(compressing the cricoid cartilage in order to decrease gastric distention and prevent gastric reflu)Bag-mask ventilation challenged endotracheal intubation resuscitations“gold standard”,Circulation external chest compression,High-frequency（100 compression
6、s 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 arrest,Circulation Compression-only CPR
7、,Research suggests:Survival rate with compression-only CPR in first 612 minutes is 40.8%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,Chest pump-sequential increa
8、sed and decreased pressure in the thoracic cavity-valves maintaining forward direction of flowCardiac pump-sequential filling and emptying of cardiac chambers-valves maintaining forward direction of flow,Circulation,Thump version from 20-25 cm high to chestCough Version in 10-15 secondIntermittent a
9、bdominal compression-cardiopulmonary resuscitation（IAC-CPR)Activated compression-decompression（ACD-CPR)PhasedChest and Abdominal ACD-CPR（Life-stick Resuscitation）increase mean pressure，coronary and cerebral perfusion pressure，left ventricular and cerebral blood flow,Automated external defibrillator-
10、AED,Ventricular fibrillation:may be used by 200J*3 times)or 200J、200-300J、300J If polymorphic ventricular tachycardia can not be clearly distinguished from ventricular fibrillation(VF),treatment would refer to be as VF Atrial fibrillation:100-200J synchronized Atrial flutter or supraventricular tach
11、ycardia 50-100J synchronized Ventricular tachycardia 100J synchronized,Biphasic waveform defibrillation,A compensated defibrillation for the second time in limited timeLow-energy levels（150J correspond to 200-300J）Reduce the myocardial injury,Advanced Life Support-the second ABCD,Endotracheal intuba
12、tion(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,Mark estimated depthBreath sounds by auscultation at 5
13、locus Thorax rise as inspirationincrease of SaO2Steam in canal of artificial ventilation deviceUse a specific technique or device to prevent tube dislodgment,Mechanical ventilation,Low tidal volume 6-7ml/kg（400-600ml）Hyper ventilation High airway pressure and endogenous PEEP Intracranial hypertensio
14、n;High tidal volume DistensionToo low tidal volume hypoxia and CO2 retention,Epinephrine EN-(1),-adrenergic receptor stimulating Peripheral arterial vasoconstriction(not cerebral and coronary arterioles)mean arterial pressure myocardial and cerebral blood flow,Epinephrine EN-(2),Recommended dosage:1
15、.0mg(0.01-0.02mg/kg)iv every 3-5 minutes,then 1mg+GS 250ml iv gtt,1g/min3-4g/min,or 1mg、3mg、5mg ivCompared high dosage:0.1-0.2mg/kgHigh dosage(0.2mg/kg)may be harmfulEndotracheal administration:NS 20ml+22.5 time recommended doseIntracardiac injection:only in heart operation or chest trauma,Vasopress
16、in,Act by direct stimulation of smooth muscle V1 receptors vasoconstrictionNo increased myocardial oxygen consumptionHalf-life is 10 20 minute,longer than ENApplicable to VF or prolonged cardiac arrest,and with PEA（pulseless electrical activity）or with asystoleEffective in patients who remain in car
17、diac arrest after treatment with epinephrineUsage:40IU iv,Amiodarone(1),Persistent VT or VF after defibrillation and epinephrine in cardiac arrestHemodynamically stable VTpolymorphic VT wide-complex tachycardiaVentricular rate control of rapid atrial arrhythmias with impaired LV function when digita
18、lis ineffective,Amiodarone(2),Initially 300mg iv diluted in 20-30 ml in cardiac arrestInitial dose of 150mg iv（over 10 min),followed by 1 mg/min infusion for 6 h,then 0.5mg/minSupplementary 150mg iv repeatedly for recurrent or resistant arrhythmias or hemodynamically unstable VT Maximum total dose:2
19、g24hadverse effects：hypotension and bradycardia,Magnesium sulfate,Torsades de pointes Arrhythmias caused by magnesium deficiencyLoading dose:12g/50-100ml iv(over 5-60 minutes)Followed by an infusion of 0.5-1.0g/h,Sodium Bicarbonate（1）,Only after the confirmed interventions are ineffectivePreexisting
20、 metabolic acidosis,hyperkalemia,tricyclic or phenobarbitone overdose Protracted arrest or long resuscitative efforts,Sodium Bicarbonate（2）,Acid-base balance:chest compressions ROSC adequate alveolar ventilation and restoration of tissue perfusionCO2 more freely diffusible than HCO3-into myocardial
21、and cerebral cells intracellular acidosisInitial dosage：5%NaHCO3 1mEq/kg iv gtt(1ml0.6mEq),Etiological factors（5Hs，5Ts),HypovolemiaHypoxiaHydrogen ion(acidosis)Hyperkalemia or HypokalemiaHyperthermia or Hypothermia,Tablets(drug)Tamponade Tension PneumothoraxThrombosis coronaryThrombosis pulmonary,Op
22、timal response to resuscitation,AwakeResponsiveBreathing spontaneouslyrestoration of spontaneous circulation(ROSC),Prolong Life Support,Postresuscitation care-Prevent and treatment SIRS and MODSorgans function supportCerebral resuscitation,Postresuscitation syndrome,Reperfusion failureReperfusion in
23、juryCerebral intoxication from ischemic metabolitesCoagulopathy,Postresuscitation syndrome-4 phases,Cardiovascular dysfunction in the hours after ROSC in 24 hoursSIRS leads to MODS over 1 to 3 daysSerious infection occurs and the patient declines rapidlyDeath,Dopamine,A potent adrenergic receptor ag
24、onist and a strong peripheral dopamine receptor agonist.Effects are dose-dependent:5 20gminkgLow-dose(2 4 gminkg)is no longer used for acute oliguric renal failure,because occasionally diuresis no improve renal glomerular filtration rate.Middle dosage：510gminkg,positive inotropic effectHigh dosage：1
25、020 gminkg，vasoconstriction,Sodium Bicarbonate,immediately after ROSCGuided by the partial pressure of CO2,Cerebral resuscitation,Maintain relative high blood pressure during CPRHemodilution and mild hypothermia（3234）for 12 h during CPRthrombolysis for ameliorate hypercoagulable state Antioxidant，fr
26、ee radical scavengerEmergency hypothermia CPBHyperbaric oxygen：suitable for persistent vegetative state,Ethical and legal considerations of CPR,When withdrawal or withhold of life support？DNAR（do not attempt resuscitation)ordersTransporting patient proceed CPR must be continue CPRPatient is in a persistent vegetative state or terminal condition certified by 2 physicians,including 1 with special expertise in evaluation cognitive function,Thanks,
