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1、1,Special Resuscitation Situations特殊情況下的復甦術,長庚醫院 急診醫學科邱德發,Advanced Challenges in Resuscitation,2,Advanced Challenges in Resuscitation,1.致命的電解質異常2.毒藥物造成之心血管急症3.緊急心臟照護的特殊挑戰低體溫 溺水瀕死性氣喘過敏性反應 外傷併心臟停止懷孕併心臟停止電擊及雷擊,3,Advanced Challenges in Resuscitation,致命的電解質異常血鉀、血鈉、血鎂及血鈣的太高或太低毒藥物造成之心血管急症以藥物引起症狀及急救流程為導向緊急心
2、臟照護的特殊挑戰瀕死性氣喘(Near-Fatal Asthma)過敏性反應(Anaphylaxis),4,致命的電解質異常,造成心臟停止或降低急救成效在檢驗數值出來前即採取急救措施以高血鉀最易致命,5,高血鉀,血鉀 5.0 mEq/LpH 0.1 U serum K+0.3 mEq/L,6,高血鉀原因,Drugs(K+-sparing diuretics,ACEI,NSAIDs,K supplements)ESRDMuscle breakdown(rhabdomyolysis)Metabolic acidosisPseudohyperkalemiaHemolysisTumor lysis sy
3、ndromeDiet(rarely sole cause)Hypoaldosteronism(Addison disease,hyporeninemia)Type 4 renal tubular acidosisOther:hyperkalemic periodic paralysis,7,高血鉀,症狀:全身無力(由下肢往上漸進式發生)，呼吸衰竭心電圖變化T波變高P波變平PR延長QRS波變寬,S波變深idioventricular rhythmsine wavesVF、心跳停止,8,處置,輕症(5-6)以利尿劑、離子交換樹脂或血液透析來移除鉀中症(6-7)加上NaHCO3、Glucose+in
4、sulin、Albuterol噴霧治療重症(7)再加上CaCl2,9,低血鉀,血鉀 3.5 mEq/L原因攝取減少流失過多(腸胃道及腎臟為主)由細胞外移至細胞內,10,低血鉀,症狀:無力、疲累、麻痺呼吸困難便秘、麻痺性腸阻塞小腿痙攣肌肉崩解,11,低血鉀,心電圖變化U波T波變平ST改變心律不整(服用digoxin者尤甚)PEA or Asystole,12,處置,減少流失及補充鉀心律不整或 K+2.5 IV K+最大量10-20 mEq/h+ECG 心跳停止(VF/VT):2 mEq/min 10 mEq/5-10 min血鉀1mEq須補充150-400 mEq,13,高血鈉,血鈉 145 m
5、Eq/L症狀:口渴、意識不清、無力、躁動、局部神經症狀、抽搐、昏迷,14,處置,減少水份流失、補水低血容:補生理食鹽水缺水量=體重 x 0.5 x(血鈉-140)/140 體重 x 0.4 x(血鈉-140)/140 70公斤男性，血鈉160，缺水量?L血鈉 0.5-1.0 mEq/h(12/24 hrs),15,低血鈉,血鈉 135 mEq/L症狀:急性或 120 才有症狀噁心、嘔吐、頭痛、躁動、疲累、抽搐、昏迷或死亡,16,處置,補鈉排水SIADH:限水(50-66%)Na+deficit=(desired Na+-current Na+)x 0.6*x body wt(kg)(*0.6
6、for men,0.5 for women.)3%saline=513 mEq Na+/L Na+0.5-1/hr(max.10-15/24h)補充太快 pontine myelinolysis,17,鎂,Na,K,Ca之移動所必需低血鎂細胞內鉀無法補齊穩定細胞膜作用:可治療心律不整,18,高血鎂,血鎂 2.2 mEq/L最常見原因:腎衰竭其它原因:攝取過多內臟破裂仍持續進食,19,高血鎂,神經症狀:肌無力、麻痺、運動失調、嗜睡、意識混亂腸胃症狀:噁心、嘔吐心血管症狀:血管擴張、緩脈、換氣不足、心肺停止,20,高血鎂,心電圖變化PR、QT 延長QRS 變寬P波電位變小T波變高Complete
7、AV block、Asystole,21,處置,補鈣離子CaCl2(5 to 10 mEq IV)可避免致命性心律不整移除血鎂血液透析腎及心血管功能正常IV N/S+furosemide 減少攝取,22,低血鎂,血鎂 1.3 mEq/L 比高血鎂症常見吸收減少、流失增加所致PTH或某些藥物(eg,pentamidine,diuretics,alcohol)補乳婦女:高危險,23,低血鎂-原因,GI loss:bowel resection,pancreatitis,diarrhea Renal disease Starvation Drugs:diuretics,pentamidine,gen
8、tamicin,digoxin Alcohol Hypothermia Hypercalcemia Diabetic ketoacidosis Hyperthyroidism/hypothyroidism Phosphate deficiency Burns Sepsis Lactation,24,低血鎂-症狀,肌肉震顫、束顫或強直眼球震顫意識改變、運動失調、眩暈、抽搐、吞嚥困難低血鈣、低血鉀,25,低血鎂-心電圖變化,QT、PR 延長ST 下降T波倒置胸前導程 P 波變平或倒置QRS 變寬Torsades de pointes VF 惡化 digitalis 中毒,26,處置,Severe
9、or symptomatic hypoMg1 to 2 g IV MgSO4 over 15 Torsades de pointes 2 g of MgSO4 over 1-2Seizures 2 g IV MgSO4 over 10Calcium gluconate(1 g)大部分有 hypoCa 腎功能不全者小心補,27,鈣,1/2 Ca in the ECF:bound to albAlkalosis:Ca-alb binding Ca2+Acidosis Ca2+serum alb 1 g/dL total serum Ca 0.8 mg/dL(but Ca2+)In hypoalb.
10、,Ca2+may be normalCa antagonizes K and Mg at the cell mem.Ca regulated by PTH and vit.D,28,高血鈣,serum Ca 10.5 mEq/L or Ca2+4.8 mg/dLPrimary hyperparathyroidism and malignancy account for 90%cases.,29,高血鈣-症狀,Total serum Ca 12 to 15 mg/dLNeuro.S/S:depression,weakness,fatigue,confusion(at lower levels)h
11、allucination,disorientation,hypotonicity,coma(at higher levels)Renal concentration of urine,30,高血鈣-症狀,CV S/S:variable 15 to 20:myocardial depression Automaticity and ventricular systole is shortened Arrhythmias(refractory period)Digitalis toxicity is worsenedHypertension Many patients with hyperCa d
12、evelop hypoK,31,高血鈣-症狀,GI S/S:dysphagiaconstipationpeptic ulcerspancreatitisRenal S/S:ability to concentrate urine dehydration diuresis(loss of Na,K,Mg,and P vicious circle of Ca reabsorption),32,高血鈣-心電圖變化,QT變短PR and QRS 延長QRS voltage 變大T-wave變平、變寬Notching of QRS AV block,33,處置,Symptomatic or 15 mg/
13、dLNS at 300 to 500 mL/h-維持尿量200 to 300 mL/hAfter adequate rehydration:NS at 100 to 200 mL/h Closely monitor K&MgHeart F.or Renal I.:hemodialysis Extreme conditions:chelating agents PO4 50 mmol/8-12 h orEDTA 10 to 50 mg/kg/4 h,34,處置(II),Lasix(1 mg/kg IV)controversialheart failure:required reuptake of
14、 Ca from boneReduce bone resorption calcitoninglucocorticoids,35,低血鈣,serum Ca 8.5 mEq/L or Ca2+4.2 mg/dLCauses:toxic shock syndromeabnormalities in Mgtumor lysis syndromerapid cell turnover hyperK,hyperP,and hypoCa,36,低血鈣-症狀,Occur when Ca2+2.5 mg/dLParaesthesiaMuscle cramps,carpopedal spasmStridorTe
15、tanySeizuresHyperreflexiaChvostek and Trousseau signsCardiac contractility,heart failure,37,低血鎂-心電圖變化,QT延長末段T波倒置 Heart blocks VF,38,處置,急性，有症狀 10%Ca gluconate IV 10 IV drip 0.5 to 2.0 mg/kg/hr in D5W檢測血鈣 Q4-6H 維持血鈣 7-9 mg/dL矯正 Mg,K,and pH,39,毒藥物造成之心血管急症,以藥物引起症狀及急救流程為導向I-223 有意義之緩脈有意義之頻脈有意義之高血壓急性冠心症VT
16、 及 VF傳導障礙（QRS 變寬）休克心臟停止,40,呼吸道及呼吸的處理：,中毒病人需時常評估呼吸道及呼吸 BZD中毒使用 flumazenil 是危險的，不推薦常規使用,41,鴉片劑中毒 Heroin,Fentanyl,Methadone,急性呼吸衰竭先使用呼吸器，再給 naloxone(Class IIa)I-89呼吸不充分插管前使用NaloxoneNaloxone 0.4-0.8mg IV or 0.8mg IM or SC目標:恢復呼吸道反射及通氣，非完全清醒,42,藥物引起有意義的緩脈,Atropine 少有幫助但可接受例外:急性有機磷及 carbamate中毒Isoproteren
17、ol避免使用，可能引起低血壓及心室心率不整大量-blocker中毒，高劑量isoproterenol有效Digoxin-specific Fab 對毛地黃或cardiac glycosides引起之緩脈非常有效心臟節律器：經皮及經靜脈,43,藥物引起有意義的頻脈,避免使用adenosine 及同步電擊:頻脈可能再度發生或是難以治療血壓偏低:diltiazem 及verapamil是相對禁忌症Benzodiazepines：有效Physostigmine:anticholinergic 中毒-blocker,44,藥物引起有意義的高血壓,短期的，不需要積極治療Benzodiazepines：第一
18、線藥物Nitroprusside:第二線藥物Labetalol:第三線藥物Propranolol:禁忌症,45,藥物引起的急性冠心症,與藥物引起有意義的高血壓的治療類似Benzodiazepines及nitroglycin：第一線藥物Phentolamine:第二線藥物（-blocker）Propranolol:禁忌症Labetalol:爭論Intracoronary thrombolytics or coronary vasodilators：無效的病例考慮使用,46,藥物引起的VT 及VF,不穩定情況下，考慮使用電擊Procainamide:不可使用在TCA或其他抗心律不整藥物中毒Lido
19、caine:大部分使用、對cocaine中毒安全有效Phenytoin 及 bretylium 不建議使用Torsades de pointes:Mg、lidocaine(Class Indeterminate)、overdrive pacing(electrical or isoproterenol)、K,47,藥物引起的傳導障礙（QRS 變寬）,易引起單形性VT高張性鹽水及系統性鹼化、終止因鈉離子通道阻斷劑所引起的VTSodium bicarbonate呼吸性鹼化,48,藥物引起的休克,藥物引起的低血容休克補充水份Dopamine藥物引起的分布性休克Norepinephrine or ph
20、enylephrine不可使用dobutamine、isoproterenol藥物引起的心因性休克Ca,amrinone,glucagon,insulin,isoproterenol,dobutamine,49,藥物引起的心臟停止,去顫術較久的CPR 及急救循環輔助設備,50,瀕死性氣喘Near-Fatal Asthma,氣喘引起心臟停止之因嚴重氣管緊縮及黏液哽塞缺氧或藥物引起之心律不整Auto-PEEP 血流，血壓 張力性氣胸(常兩側)大部分死亡在院外,Asthma,51,預防心跳停止的措施-I,O2:維持 PaO2 92 mm HgHigh-flow mask PRN氣管插管莫遲疑意識模糊
21、大量盜汗 肌張力差(hypercarbia)嚴重躁動，混亂，不願戴面罩(hypoxemia),Asthma,52,預防心跳停止的措施-II,Nebulized 2-AgonistsAlbuterol(salbutamol)2.5 to 5.0 mg Q15-20 up to 3 times epinephrine or terbutaline SCCorticosteroids IVBegin in the first 30Methylprednisolone 40-250 mg IV(or equivalent hydrocortisone),Asthma,53,預防心跳停止的措施-III,
22、Nebulized Anticholinergicsipratropium 0.5 mgdelayed onset(20)Aminophylline IV2nd line1/3 as potent as 2-agonistsloading dose of 5 mg/kg over 30-45followed by 0.5 to 0.7 mg/kg/hr,Asthma,54,預防心跳停止的措施-IV,MgSO4 IV有些報告有效2 to 3 g IV(1 g/min)Epinephrine or Terbutaline SC減少呼吸器之使用Epinephrine 1:1000,(total 0.
23、01 mg/kg)/3 Q20Terbutaline 0.25 mg SC Q30 up to 3 doses,Asthma,55,預防心跳停止的措施-V,Ketamine支氣管擴張氣管分泌物增加幻覺0.1 to 0.2 mg/kg 0.5 mg/kg/hrIntubation:bolus of 0.5 to 1.5 mg/kg,repeated 20 later,or 1 to 5 mg/kg/hradd atropine(0.01 mg/kg,min.0.1 mg)BZD,Asthma,56,預防心跳停止的措施-VI,Helioxhelium+oxygen(70:30)可減少intubat
24、ionBilevel Positive Airway Pressure(BiPAP)delay or abort the need for intubationcounteracts the auto-PEEPBegin with IPAP 8-10 cmH2O,EPAP 3-5 cmH2O,Asthma,57,氣管插管,適度鎮靜 ketamine,BZD,or barbiturate麻痺病患succinylcholine or vecuronium.考慮 permissive hypercarbia麻醉藥吸入(powerful bronchial relaxants)halothane,is
25、oflurane,enflurane,and ether vasodilators and myocardial depressants(except for ether),Asthma,58,氣管插管,Extracorporeal membrane oxygenation(ECMO)頑固性氣喘Ketamine IVFfor status asthmaticusmild bronchodilator effectnot cause vasodilatation,circulatory collapse,or myocardial depression.,Asthma,59,氣管插管後,確定位置
26、Primary:Visualize vocal cord5-point auscultationwatch chest risecondensation in tubeSecondary:end-tidal CO2esophageal detector devicepulse oximetry capnometers or capnographsAlbuterol 2.5-5.0 mg 經氣管插管,Asthma,60,呼吸器,Permissive hypercapnia Adequate sedation and paralysis 100%O2Rate:8-10/min,to avoid a
27、uto-PEEPTidal volume:5 to 7 mL/kg Peak flow:60 L/min with a decelerating pattern,Asthma,61,呼吸器,大量Auto-PEEP 的產生造成氣管插管後嚴重低血壓短暫中止呼吸器(1 min)注意氧合狀況,Asthma,62,過敏性反應 Anaphylaxis,原因:Insect stingsDrugs,and toxins,vaccinesContrast mediaSome foods(milk,eggs,fish,shellfish,peanut and tree nut.)Latex-associated
28、anaphylaxis Exercise-induced anaphylaxis Idiopathic,Anaphylaxis,63,過敏性反應-症狀,上呼吸道-咽喉水腫下呼吸道-氣喘低血容性+分布性休克蕁麻疹，鼻炎，結膜炎，腹痛，嘔吐，腹瀉皮膚潮紅或蒼白,Anaphylaxis,64,預防心跳停止的措施-I,姿勢：自覺舒適；低血壓下肢抬高O2:高流量聲啞，舌水腫或咽水腫時及早氣管插管不使用麻痺劑Epinephrine:IM 0.3 to 0.5 mg(1:1000)Q5-10 IV(1:10 000;10 mL)1-5 mL over 5 minutes(嚴重有生命危險者)IVF 1-4 g
29、/minSC 休克病患吸收差,Anaphylaxis,65,預防心跳停止的措施-II,Antihistamines:diphenhydramine 25 mg IV or IMH2 blockers:cimetidine 300 mg PO,IM,or IV等張溶液:NS 1-2 L甚至4Lalbuterol ipratropium inhalationCorticosteroids:高劑量 IV or IMGlucagon:使用-blockers者,1-2 mg IM or IVQ5 min 密切觀察24小時,Anaphylaxis,66,心跳停止時的措施-I,無法暢通呼吸道者Fiberoptic tracheal intubation Needle cricothyrotomy+transtracheal ventilation快速大量輸液 2-4LEpinephrine高劑量 IV1-3 mg 3-5 mg 4 to 10 g/minAntihistamines IV:可能有害,Anaphylaxis,67,心跳停止時的措施-II,Steroid:對急救後有益較久的CPR 及 病患大多為年輕健康者,Anaphylaxis,68,
