2010年AHA心肺复苏指南

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2010国际心肺复苏与心血管急救指南

非专业人员不进行脉搏检查
3.革命性的修改:流程更换
更加强调了胸外按压的重要性！
2005年 A.保持气道通畅 B.人工呼吸 C.胸外按压 2010年 C.胸外按压 A.保持气道通畅 B.人工呼吸
成年人及儿科病人（包括儿童及婴幼儿，但不包括新生儿）
3.心肺复苏程序变化：C-A-B 代替 A-B-C

4.团队合作！
第八部分高级心血管生命支持ALS
高级心血管生命支持是在基础生命支持的基础上，应用辅助设备、特殊技术等建立更为有效的通气和血运循环主要内容:

1.气道管理、通气支持以及治疗缓慢型和快速型心律失常 2.治疗心脏骤停(药物治疗等) 3.改善心脏骤停后自主循环恢复的患者预后的措施(第九部分)

2. 弱化了脉搏的检查

医务人员在检查反应时应该快速检查是否没有呼吸或不能正常呼吸（即无呼吸或仅仅是喘息）。然后，该人员会启动急救系统并找到 AED（或由其他人员寻找）医务人员检查脉搏的时间不应超过10秒，如果10秒内没有明确触摸到脉搏，应开始心肺复苏并使用 AED（如果有的话）

声门上气道(喉罩、食管-气管联合导管和喉管)，由受过培训的人员实施CPR时声门上气道可以替代球囊-面罩通气和气管插管气管插管

8.1 气道管理辅助措施和通气

1.球囊-面罩通气:
当放置高级气道有延误或不成功时，球囊-面罩通气尤其有帮助；

抢救人员应确保用仰头-抬颏法充分开放气道，提起下巴紧贴面罩，手持面罩紧贴脸，使面罩与口密闭；
以上建议旨在支持尽早进行心肺复苏和早期除颤，特别是在发生心脏骤停时现场有AED或除颤器的情况下

成人BLS在ICU中的应用

2010心肺复苏指南

2010心肺复苏指南亮点 2010心肺复苏指南亮点
生存链的变化 CPR操作顺序的变化 CPR操作顺序的变化强调胸外按压的重要性取消“ 取消“一听二看三感觉胸外按压频率的变化胸外按压的深度的变化救援者应避免停止胸外按压和过度通气。救援者应避免停止胸外按压和过度通气。强烈建议普通施救者仅做胸外按压的CPR CPR，强烈建议普通施救者仅做胸外按压的CPR，弱化人工呼吸的作用。的作用。肾上腺素用法用量不变，不推荐对心脏停搏或PEA( PEA(无脉性肾上腺素用法用量不变，不推荐对心脏停搏或PEA(无脉性电活动）者常规使用阿托品。电活动）者常规使用阿托品。
早期识别成人心脏骤停是建立在评估患者的反应以及有没有正常的呼吸。及有没有正常的呼吸。心脏骤停患者一开始可能有叹气样呼吸或者甚至表现为癫痫样发作。现为癫痫样发作。这种非典型表现可能使施救者困导致呼救或开始CPR延迟。 CPR延迟惑，导致呼救或开始CPR延迟。培训的重点必须集中在使救援者警觉心脏骤停的特殊表现。殊表现。
CPR操作顺序的变化 CPR操作顺序的变化
A-B-C→→C-A-B C→→C2010（）：C ★2010（新）：C-A-B 胸外按压→ 开放气道→ 即：C胸外按压→A开放气道→B人工呼吸 2005（）：A ●2005（旧）：A-B-C 开放气道→ 人工呼吸→ 即：A开放气道→B人工呼吸→C胸外按压该顺序的改变适用于成人、儿童和婴幼儿，但该顺序的改变适用于成人、儿童和婴幼儿，不适用于新生儿。对于新生儿，不适用于新生儿。对于新生儿，心脏骤停的最可能的原因为呼吸因素导致的，复苏程序应当为A 能的原因为呼吸因素导致的，复苏程序应当为A顺序，除非已知是心脏原因导致的。 B-C顺序，除非已知是心脏原因导致的。

2010美国心脏协会AHA心肺复苏CPR及心血管急救ECC指南的学习

2.伦理学问题
与复苏有关的伦理学问题非常复杂，这些问题出现的环境不同（院内或院外）、涉及不同的操作者（非专业施救者或医务人员）并且涉及到开始或停止基础生命支持和/或高级生命支持。所有医务人员在为需要复苏的个人提供治疗时，都需要考虑伦理、法律和文化因素。虽然操作者在复苏过程中会参与决策，但他们应该综合科学、个人或其代理者的意愿以及当地的政策或法律规定。
D:\医学资料\心肺复苏讲稿\QQ截图20110712235818.jpg
7.CA后的治疗
“心脏骤停后治疗”是《2010 美国心脏协会心肺复苏及心血管急救指南》中的新增部分为提高在恢复自主循环后收入院的心脏骤停患者的存活率，应当通过统一的方式实施综合、结构化、完整、多学科的心脏骤停后治疗体系（方块图 3）。治疗应包括心肺复苏和神经系统支持。应根据指征提供低温治疗和经皮冠状动脉介入术 (PCI)。由于在心脏骤停后往往会发生癫痫症状，应进行脑电图检查以诊断癫痫并尽快给出解读，并在昏迷患者恢复自主循环后频繁或持续地进行监测。 D:\医学资料\心肺复苏讲稿\QQ截图20110713000441.jpg
6.ACLS
2010 版心血管病高级生命支持 (ACLS) 中的主要更改如下： • 建议进行二氧化碳波形图定量分析，以确认并监测气管插管位置和心肺复苏质量。 • 简化了传统心脏骤停流程，并提出了替代的概念性设计流程以强调高质量心肺复苏的重要性。 • 进一步强调了生理参数监测以优化心肺复苏质量并检测是否恢复自主循环。 • 不再建议在治疗无脉性心电活动 (PEA)/心搏停止时常规性地使用阿托品。
o-two呼吸机使用方法的演示： F:\心肺复苏讲稿\AVSEQ01.DAT
谢谢！
8.ACS患者病情稳定化治疗

2010AHA心肺复苏指南解读

①按压时除掌根部贴在胸骨外，手指也压在胸壁上，这容易引起肋骨或肋骨肋软骨交界处骨折。 ②按压定位不正确。向下错位易使剑突受压折断而致肝破裂。向两侧错位易致肋骨或肋骨肋软骨交界处骨折，导致气胸、血胸。 ③抢救者按压时肘部弯曲，因而用力不垂直，按压力量减弱，按压深度达不到5cm（图）。 ④冲击式按压、猛压，其效果差，且易导致骨折。 ⑤放松时抬手离开胸骨定位点，造成下次按压部位错误，引起骨折。 ⑥放松时未能使胸部充分松弛，胸部仍承受压力，使血液难以回到心脏。 ⑦按压速度不自主地加快或减慢，影响了按压效果。 ⑧两手掌不是重叠放臵，而呈交叉放臵。
1、吹气应有足够的气量，以使胸廓抬起，但一般不超过 1200mL。 2、吹气时间宜短，以占1次呼吸周期的1/3为宜；吹气频率，8-10次/分。 3、操作前先清除患者口腔及咽部的分泌物或堵塞物。 4、有义牙者应取下义牙。遇舌后坠的患者，应用舌钳将舌拉出口腔外，或用通气管吹气。 5、对婴幼儿，则对口鼻同时吹气更易施行 6、若患者尚有微弱呼吸，人工呼吸应与患者的自主呼吸同步进行。 7、注意防止交叉感染。 8、通气适当的指征是看到患者胸部起伏并于呼气时听到及感到有气体逸出。
中断按压时间不超过10s 确认气管导管位臵：临床评价：双侧胸廓有无对称起伏两侧腋中线听诊两肺呼吸音是否对称上腹部听诊：不应该有呼吸音呼吸CO2监测或者食管探测
潮气量：500～600ml，胸廓明显起伏送气时间大于1s 频率：8～10次/分避免过度通气
基础生命支持总结
1.能扪及大动脉搏动，收缩压>60mmHg 2.患者面色、口唇、甲床、皮肤等色泽转红 3.散大的瞳孔再度缩小 4.呼吸改善或出现自主呼吸 5.心电显示明显的RS波 6.昏迷变浅，出现各种反射，肢体出现无意识的挣扎动作.

2010版心肺复苏指南

2010版心肺复苏指南首先评估现场环境安全1、意识的判断：用双手轻拍病人双肩，问:“喂！你怎么了？”告知无反应。

2、检查呼吸：观察病人胸部起伏5-10秒（1001、1002、1003、1004、1005…）告知无呼吸3、呼救：来人啊！喊医生！推抢救车！除颤仪！4、判断是否有颈动脉搏动：用右手的中指和食指从气管正中环状软骨划向近侧颈动脉搏动处，告之无搏动（数1001，1002，1003，1004，1005…判断五秒以上10秒以下）。

5、松解衣领及裤带。

6、胸外心脏按压：两乳头连线中点（胸骨中下1/3处），用左手掌跟紧贴病人的胸部，两手重叠，左手五指翘起，双臂深直，用上身力量用力按压30次（按压频率至少100次∕分，按压深度至少5cm）7、打开气道：仰头抬颌法。

口腔无分泌物，无假牙。

8、人工呼吸：应用简易呼吸器，一手以“CE”手法固定，一手挤压简易呼吸器，每次送气400-600ml。

9、持续2分钟的高效率的CPR：以心脏按压：人工呼吸=30:2的比例进行，操作5个周期。

（心脏按压开始送气结束）10、判断复苏是否有效（听是否有呼吸音，同时触摸是否有颈动脉博动）。

11、整理病人，进一步生命支持。

提高抢救成功率的主要因素：1、将重点继续放在高质量的CPR上2、按压频率至少100次/分（区别于大约100次/分）3、胸骨下陷深度至少5 ㎝4、按压后保证胸骨完全回弹5、胸外按压时最大限度地减少中断6、避免过度通气心肺复苏 = (清理呼吸道) + 人工呼吸 + 胸外按压 + 后续的专业用药据美国近年统计，每年心血管病人死亡数达百万人，约占总死亡病因1/2。

而因心脏停搏突然死亡者60-70%发生在院前。

因此，美国成年人中约有85%的人有兴趣参加CPR初步训练，结果使40%心脏骤停者复苏成功，每年抢救了约20万人的生命。

心脏跳动停止者，如在4分钟内实施初步的CPR，在8分钟内由专业人员进一步心脏救生，死而复生的可能性最大，因此时间就是生命，速度是关键，初步的CPR按ABC进行。

美国心脏学会AHA心肺复苏

子通道阻滞剂过量、高镁血症或高钾血症阿托品：不推荐常规使用，可用于迷走张力增加
或胆碱能药物中毒导致的心动过缓碳酸氢钠：无明确指针不应给予
复苏时的监测
ETCO2 ：ETCO2和CO之间有很强的相关性，可以反映心脏按压的有效性。有研究显示成人高级心肺复苏1520分钟ETCO2处于低值（≤15mmHg）,强烈暗示恢复自主循环的可能性低。
谢谢
MAP≧65 mmHg、CVP 8 ～ 12 cmH2O、SVO2≧70%、 Hct＞30%、尿量＞1ml/（kg.h）、Lac接近正常
PCAC---体温
治疗性低温： ➢ 尽早将昏迷患者中心温度降至32 ～ 34℃持续
12 ～ 24h ➢ 早期头部冰帽降温 ➢ 快速输注冰水 30ml/kg，让中心温度降低1.5度 ➢ 防止发热
儿科BLS
简化流程，删除检查呼吸，不再强调脉搏检查无生命迹象+10秒内不能触及脉搏即应开始CPR HR＜60次/分伴低灌注征象即应开始CPR
儿科BLS
新的证据强调了通气在儿科CPR中的重要作用传统CPR（按压+通气）更具有优势
医务人员更应该为心跳骤停小儿提供传统CPR
儿科BLS
儿科患者复苏流程为CAB 按压深度：婴幼儿4cm，儿童5cm 按压通气比：
儿科ACLS---通道
骨内通道（IO）
快速、安全、有效血型、交叉配血、血气分析所有经静脉给予的药物起效时间、药物剂量与静脉相同输血、输液
儿科ACLS---通道
经气管导管
可经气管给予脂溶性药物，如：利多卡因、肾上腺素、阿托品、纳洛酮。禁止给予非脂溶性药物药物，如碳酸氢钠和钙剂
心尖-后部
ACLS---团队合作
小组合作与分工

2010美国心脏协会心肺复苏及心血管急救指

CPR2010指南
压心吹起比例儿童及婴儿
——气道未受保护 • 一位急救员的压心吹气比例是30:2，而两位急救员的压心吹气比例为15:2，原因是因为儿童及婴儿的心跳骤停的主因是气道阻塞及呼吸骤停，所以压心吹气的次数可以相应的减少至15:2。 ------气道已经受到保护 • 情况和成人一样，CPR不需要按比例，压心频率以每分钟 100次不停顿进行，而吹气者亦是每分钟做8-10次吹气（约6-8s做一次吹气），检查心电及脉搏是在2分钟后。 • 为避免急救者过度疲劳，专家建议应为每2分钟转换压心者一次，而转换的时间不应超过5s。
心房颤动(atrial fibrillation, AF)
无P波, 代之以“ f ” 波, 350～600 次/分； QRS-T波基本正常；心室律（R-R 间期）绝对不等；心室率 100-180次/分(未治疗者)。频率
窦性心动过速(sinus tachycardia)
• 逐渐加快和减慢、P波与窦律相同
高级生命支持技术（ACLS） 3急救药物
• ——抗心律失常药应该在第二或第三次除颤后施行，指南建议在处理VF时仍然首先采用胺碘酮，因为仍然有较多的研究证明胺碘酮比利多卡因更有效。 • ——抗心律迟缓方面的药，仍然采用阿托品，但剂量略有调整（0.5-1.0mg，1mg/kg 一般50mg）。 • ——室上速所采用的药物仍然是腺苷
高级生命支持技术（ACLS） 1除颤
1.指南建议，每次除颤后应立即施行2分钟 CPR才检查心电及脉搏。 2.除颤的程序为：（1）除颤一次（2）CPR2分钟（3）检查脉搏及心电（4）重复此循环 3.除颤成功：通常定义为放电后终止VF至少5 秒钟
高级生命支持技术（ACLS） 2高级人工气道

2010年美国心脏病学会心肺复苏指南(英文版)

ISSN: 1524-4539Copyright © 2010 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online72514Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TXDOI: 10.1161/CIRCULATIONAHA.110.9708892010;122;S640-S656Circulation HoekCallaway, Brett Cucchiara, Jeffrey D. Ferguson, Thomas D. Rea and Terry L. VandenMark S. Link, Laurie J. Morrison, Robert E. O'Connor, Michael Shuster, Clifton W. Marc D. Berg, John E. Billi, Brian Eigel, Robert W. Hickey, Monica E. Kleinman,Neumar, Mary Ann Peberdy, Jeffrey M. Perlman, Elizabeth Sinz, Andrew H. Travers, Farhan Bhanji, Diana M. Cave, Edward C. Jauch, Peter J. Kudenchuk, Robert W.Schexnayder, Robin Hemphill, Ricardo A. Samson, John Kattwinkel, Robert A. Berg, John M. Field, Mary Fran Hazinski, Michael R. Sayre, Leon Chameides, Stephen M. Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 1: Executive Summary: 2010 American Heart Association Guidelines for/cgi/content/full/122/18_suppl_3/S640located on the World Wide Web at:The online version of this article, along with updated information and services, is/reprints Reprints: Information about reprints can be found online atjournalpermissions@ 410-528-8550. E-mail:Fax:Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters/subscriptions/Subscriptions: Information about subscribing to Circulation is online atPart1:Executive Summary2010American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care John M.Field,Co-Chair*;Mary Fran Hazinski,Co-Chair*;Michael R.Sayre;Leon Chameides; Stephen M.Schexnayder;Robin Hemphill;Ricardo A.Samson;John Kattwinkel;Robert A.Berg;Farhan Bhanji;Diana M.Cave;Edward C.Jauch;Peter J.Kudenchuk;Robert W.Neumar;Mary Ann Peberdy;Jeffrey M.Perlman;Elizabeth Sinz;Andrew H.Travers;Marc D.Berg; John E.Billi;Brian Eigel;Robert W.Hickey;Monica E.Kleinman;Mark S.Link;Laurie J.Morrison; Robert E.O’Connor;Michael Shuster;Clifton W.Callaway;Brett Cucchiara;Jeffrey D.Ferguson;Thomas D.Rea;Terry L.Vanden HoekT he publication of the2010American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care marks the50th anniversary of modern CPR.In1960Kouwenhoven,Knickerbocker,and Jude documented14patients who survived cardiac arrest with the application of closed chest cardiac massage.1That same year,at the meeting of the Maryland Medical Society in Ocean City,MD,the combination of chest compressions and rescue breathing was introduced.2Two years later,in1962, direct-current,monophasic waveform defibrillation was de-scribed.3In1966the American Heart Association(AHA) developed the first cardiopulmonary resuscitation(CPR) guidelines,which have been followed by periodic updates.4 During the past50years the fundamentals of early recogni-tion and activation,early CPR,early defibrillation,and early access to emergency medical care have saved hundreds of thousands of lives around the world.These lives demonstrate the importance of resuscitation research and clinical transla-tion and are cause to celebrate this50th anniversary of CPR. Challenges remain if we are to fulfill the potential offered by the pioneer resuscitation scientists.We know that there is a striking disparity in survival outcomes from cardiac arrest across systems of care,with some systems reporting5-fold higher survival rates than others.5–9Although technology, such as that incorporated in automated external defibrillators (AEDs),has contributed to increased survival from cardiac arrest,no initial intervention can be delivered to the victim of cardiac arrest unless bystanders are ready,willing,and able to act.Moreover,to be successful,the actions of bystanders and other care providers must occur within a system that coordi-nates and integrates each facet of care into a comprehensive whole,focusing on survival to discharge from the hospital.This executive summary highlights the major changes and most provocative recommendations in the2010AHA Guide-lines for CPR and Emergency Cardiovascular Care(ECC). The scientists and healthcare providers participating in a comprehensive evidence evaluation process analyzed the sequence and priorities of the steps of CPR in light of current scientific advances to identify factors with the greatest potential impact on survival.On the basis of the strength of the available evidence,they developed recommendations to support the interventions that showed the most promise. There was unanimous support for continued emphasis on high-quality CPR,with compressions of adequate rate and depth,allowing complete chest recoil,minimizing inter-ruptions in chest compressions and avoiding excessive ventilation.High-quality CPR is the cornerstone of a system of care that can optimize outcomes beyond return of spontaneous circulation(ROSC).Return to a prior quality of life and functional state of health is the ultimate goal of a resuscitation system of care.The2010AHA Guidelines for CPR and ECC are based on the most current and comprehensive review of resuscitation litera-ture ever published,the2010ILCOR International Consensus on CPR and ECC Science With Treatment Recommendations.10 The2010evidence evaluation process included356resuscita-tion experts from29countries who reviewed,analyzed,evalu-ated,debated,and discussed research and hypotheses through in-person meetings,teleconferences,and online sessions(“web-inars”)during the36-month period before the2010Consensus Conference.The experts produced411scientific evidence re-views on277topics in resuscitation and emergency cardiovas-cular care.The process included structured evidence evaluation, analysis,and cataloging of the literature.It also included rigor-The American Heart Association requests that this document be cited as follows:Field JM,Hazinski MF,Sayre MR,Chameides L,Schexnayder SM, Hemphill R,Samson RA,Kattwinkel J,Berg RA,Bhanji F,Cave DM,Jauch EC,Kudenchuk PJ,Neumar RW,Peberdy MA,Perlman JM,Sinz E,Travers AH,Berg MD,Billi JE,Eigel B,Hickey RW,Kleinman ME,Link MS,Morrison LJ,O’Connor RE,Shuster M,Callaway CW,Cucchiara B,Ferguson JD,Rea TD,Vanden Hoek TL.Part1:executive summary:2010American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.Circulation.2010;122(suppl3):S640–S656.*Co-chairs and equal first co-authors.(Circulation.2010;122[suppl3]:S640–S656.)©2010American Heart Association,Inc.Circulation is available at DOI:10.1161/CIRCULATIONAHA.110.970889ous disclosure and management of potential conflicts of interest, which are detailed in Part2:“Evidence Evaluation and Man-agement of Potential and Perceived Conflicts of Interest.”The recommendations in the2010Guidelines confirm the safety and effectiveness of many approaches,acknowledge ineffectiveness of others,and introduce new treatments based on intensive evidence evaluation and consensus of experts. These new recommendations do not imply that care using past guidelines is either unsafe or ineffective.In addition,it is important to note that they will not apply to all rescuers and all victims in all situations.The leader of a resuscitation attempt may need to adapt application of these recommenda-tions to unique circumstances.New Developments in Resuscitation ScienceSince2005A universal compression-ventilation ratio of30:2performed by lone rescuers for victims of all ages was one of the most controversial topics discussed during the2005International Consensus Conference,and it was a major change in the2005 AHA Guidelines for CPR and ECC.11In2005rates of survival to hospital discharge from witnessed out-of-hospital sudden cardiac arrest due to ventricular fibrillation(VF)were low,averagingՅ6%worldwide with little improvement in the years immediately preceding the2005conference.5Two studies published just before the2005International Consen-sus Conference documented poor quality of CPR performed in both out-of-hospital and in-hospital resuscitations.12,13The changes in the compression-ventilation ratio and in the defibrillation sequence(from3stacked shocks to1shock followed by immediate CPR)were recommended to mini-mize interruptions in chest compressions.11–13There have been many developments in resuscitation science since2005,and these are highlighted below. Emergency Medical Services Systems andCPR QualityEmergency medical services(EMS)systems and healthcare providers should identify and strengthen“weak links”in the Chain of Survival.There is evidence of considerable regional variation in the reported incidence and outcome from cardiac arrest within the United States.5,14This evidence supports the importance of accurately identifying each instance of treated cardiac arrest and measuring outcomes and suggests additional opportunities for improving survival rates in many communities. Recent studies have demonstrated improved outcome from out-of-hospital cardiac arrest,particularly from shockable rhythms,and have reaffirmed the importance of a stronger emphasis on compressions of adequate rate and depth,allowing complete chest recoil after each compression,minimizing interrup-tions in compressions and avoiding excessive ventilation.15–22 Implementation of new resuscitation guidelines has been shown to improve outcomes.18,20–22A means of expediting guidelines implementation(a process that may take from18 months to4years23–26)is needed.Impediments to implemen-tation include delays in instruction(eg,time needed to produce new training materials and update instructors and providers),technology upgrades(eg,reprogramming AEDs), and decision making(eg,coordination with allied agencies and government regulators,medical direction,and participa-tion in research).Documenting the Effects of CPR Performance by Lay RescuersDuring the past5years there has been an effort to simplify CPR recommendations and emphasize the fundamental importance of high-quality rge observational studies from investiga-tors in member countries of the Resuscitation Council of Asia (the newest member of ILCOR)27,28–30and other studies31,32 have provided important information about the positive impact of bystander CPR on survival after out-of-hospital cardiac arrest. For most adults with out-of-hospital cardiac arrest,bystander CPR with chest compression only(Hands-Only CPR)appears to achieve outcomes similar to those of conventional CPR(com-pressions with rescue breathing).28–32However,for children, conventional CPR is superior.27CPR QualityMinimizing the interval between stopping chest compressions and delivering a shock(ie,minimizing the preshock pause) improves the chances of shock success33,34and patient sur-vival.33–35Data downloaded from CPR-sensing and feedback-enabled defibrillators provide valuable information to resus-citation teams,which can improve CPR quality.36These data are driving major changes in the training of in-hospital resuscitation teams and out-of-hospital healthcare providers. In-Hospital CPR RegistriesThe National Registry of CardioPulmonary Resuscitation (NRCPR)37and other large databases are providing new infor-mation about the epidemiology and outcomes of in-hospital resuscitation in adults and children.8,38–44Although observa-tional in nature,registries provide valuable descriptive informa-tion to better characterize cardiac arrest and resuscitation out-comes as well as identify areas for further research. Deemphasis on Devices and Advanced Cardiovascular Life Support Drugs During Cardiac ArrestAt the time of the2010International Consensus Conference there were still insufficient data to demonstrate that any drugs or mechanical CPR devices improve long-term outcome after cardiac arrest.45Clearly further studies,adequately powered to detect clinically important outcome differences with these interventions,are needed.Importance of Post–Cardiac Arrest Care Organized post–cardiac arrest care with an emphasis on multidisciplinary programs that focus on optimizing hemo-dynamic,neurologic,and metabolic function(including ther-apeutic hypothermia)may improve survival to hospital dis-charge among victims who achieve ROSC following cardiac arrest either in-or out-of-hospital.46–48Although it is not yet possible to determine the individual effect of many of these therapies,when bundled as an integrated system of care,their deployment may well improve outcomes.Therapeutic hypothermia is one intervention that has been shown to improve outcome for comatose adult victims of Field et al Part1:Executive Summary S641witnessed out-of-hospital cardiac arrest when the presenting rhythm was VF.49,50Since2005,two nonrandomized studies with concurrent controls as well as other studies using historic controls have indicated the possible benefit of hypo-thermia following in-and out-of-hospital cardiac arrest from all other initial rhythms in adults.46,51–56Hypothermia has also been shown to be effective in improving intact neurologic survival in neonates with hypoxic-ischemic encephalopa-thy,57–61and the results of a prospective multicenter pediatric study of therapeutic hypothermia after cardiac arrest are eagerly awaited.Many studies have attempted to identify comatose post–cardiac arrest patients who have no prospect for meaningful neurologic recovery,and decision rules for prognostication of poor outcome have been proposed.62Therapeutic hypother-mia changes the specificity of prognostication decision rules that were previously established from studies of post–cardiac arrest patients not treated with hypothermia.Recent reports have documented occasional good outcomes in post–cardiac arrest patients who were treated with therapeutic hypother-mia,despite neurologic exam or neuroelectrophysiologic studies that predicted poor outcome.63,64Education and ImplementationThe quality of rescuer education and frequency of retraining are critical factors in improving the effectiveness of resusci-tation.65–83Ideally retraining should not be limited to2-year intervals.More frequent renewal of skills is needed,with a commitment to maintenance of certification similar to that embraced by many healthcare-credentialing organizations. Resuscitation interventions are often performed simulta-neously,and rescuers must be able to work collaboratively to minimize interruptions in chest compressions.Teamwork and leadership skills continue to be important,particularly for advanced cardiovascular life support(ACLS)and pediatric advanced life support(PALS)providers.36,84–89 Community and hospital-based resuscitation programs should systematically monitor cardiac arrests,the level of resuscitation care provided,and outcome.The cycle of measurement,interpretation,feedback,and continuous qual-ity improvement provides fundamental information necessary to optimize resuscitation care and should help to narrow the knowledge and clinical gaps between ideal and actual resus-citation performance.Highlights of the2010GuidelinesThe Change From“A-B-C”to“C-A-B”The newest development in the2010AHA Guidelines for CPR and ECC is a change in the basic life support(BLS)sequence of steps from“A-B-C”(Airway,Breathing,Chest compressions)to “C-A-B”(Chest compressions,Airway,Breathing)for adults and pediatric patients(children and infants,excluding newly borns).Although the experts agreed that it is important to reduce time to first chest compressions,they were aware that a change in something as established as the A-B-C sequence would require re-education of everyone who has ever learned CPR.The 2010AHA Guidelines for CPR and ECC recommend this change for the following reasons:●The vast majority of cardiac arrests occur in adults,and the highest survival rates from cardiac arrest are reported among patients of all ages with witnessed arrest and a rhythm of VF or pulseless ventricular tachycardia(VT).In these patients the critical initial elements of CPR are chest compressions and early defibrillation.90●In the A-B-C sequence chest compressions are often delayed while the responder opens the airway to give mouth-to-mouth breaths or retrieves a barrier device or other ventilation equipment.By changing the sequence to C-A-B,chest compressions will be initiated sooner and ventilation only minimally delayed until completion of the first cycle of chest compressions(30compressions should be accomplished in approximately18seconds).●Fewer than50%of persons in cardiac arrest receive bystander CPR.There are probably many reasons for this,but one impediment may be the A-B-C sequence,which starts with the procedures that rescuers find most difficult:opening the airway and delivering rescue breaths.Starting with chest compressions might ensure that more victims receive CPR and that rescuers who are unable or unwilling to provide ventilations will at least perform chest compressions.●It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrest.For example,if a lone healthcare provider sees a victim suddenly collapse,the provider may assume that the victim has suffered a sudden VF cardiac arrest;once the provider has verified that the victim is unresponsive and not breathing or is only gasping,the provider should immediately activate the emergency response system,get and use an AED,and give CPR.But for a presumed victim of drowning or other likely asphyxial arrest the priority would be to provide about5cycles(about2minutes)of conventional CPR(including rescue breathing)before ac-tivating the emergency response system.Also,in newly born infants,arrest is more likely to be of a respiratory etiology,and resuscitation should be attempted with the A-B-C sequence unless there is a known cardiac etiology. Ethical IssuesThe ethical issues surrounding resuscitation are complex and vary across settings(in-or out-of-hospital),providers(basic or advanced),and whether to start or how to terminate CPR.Recent work suggests that acknowledgment of a verbal do-not-attempt-resuscitation order(DNAR)in addition to the current stan-dard—a written,signed,and dated DNAR document—may decrease the number of futile resuscitation attempts.91,92This is an important first step in expanding the clinical decision rule pertaining to when to start resuscitation in out-of-hospital car-diac arrest.However,there is insufficient evidence to support this approach without further validation.When only BLS-trained EMS personnel are available, termination of resuscitative efforts should be guided by a validated termination of resuscitation rule that reduces the transport rate of attempted resuscitations without compro-mising the care of potentially viable patients.93Advanced life support(ALS)EMS providers may use the same termination of resuscitation rule94–99or a derived nonvali-dated rule specific to ALS providers that when applied willS642Circulation November2,2010decrease the number of futile transports to the emergency department(ED).95,97–100Certain characteristics of a neonatal in-hospital cardiac arrest are associated with death,and these may be helpful in guiding physicians in the decision to start and stop a neonatal resuscitation attempt.101–104There is more variability in ter-minating resuscitation rates across systems and physicians when clinical decision rules are not followed,suggesting that these validated and generalized rules may promote uniformity in access to resuscitation attempts and full protocol care.105 Offering select family members the opportunity to be present during the resuscitation and designating staff within the team to respond to their questions and offer comfort may enhance the emotional support provided to the family during cardiac arrest and after termination of a resuscitation attempt. Identifying patients during the post–cardiac arrest period who do not have the potential for meaningful neurologic recovery is a major clinical challenge that requires further research.Caution is advised when considering limiting care or withdrawing life-sustaining therapy.Characteristics or test results that are predictive of poor outcome in post–cardiac arrest patients not treated with therapeutic hypothermia may not be as predictive of poor outcome after administration of therapeutic hypothermia. Because of the growing need for transplant tissue and organs,all provider teams who treat postarrest patients should also plan and implement a system of tissue and organ donation that is timely, effective,and supportive of family members for the subset of patients in whom brain death is confirmed or for organ donation after cardiac arrest.Resuscitation research is challenging.It must be scientifically rigorous while confronting ethical,regulatory,and public rela-tions concerns that arise from the need to conduct such research with exception to informed consent.Regulatory requirements, community notification,and consultation requirements often impose expensive and time-consuming demands that may not only delay important research but also render it cost-prohibitive, with little significant evidence that these measures effectively address the concerns about research.106–109Basic Life SupportBLS is the foundation for saving lives following cardiac arrest.Fundamental aspects of adult BLS include immediate recognition of sudden cardiac arrest and activation of the emergency response system,early performance of high-quality CPR,and rapid defibrillation when appropriate.The 2010AHA Guidelines for CPR and ECC contain several important changes but also have areas of continued emphasis based on evidence presented in prior years.Key Changes in the2010AHA Guidelines for CPRand ECC●The BLS algorithm has been simplified,and“Look,Listen and Feel”has been removed from the algorithm.Performance of these steps is inconsistent and time consuming.For this reason the2010AHA Guidelines for CPR and ECC stress immediate activation of the emergency response system and starting chest compressions for any unresponsive adult victim with no breathing or no normal breathing(ie,only gasps).●Encourage Hands-Only(compression only)CPR for the untrained lay rescuer.Hands-Only CPR is easier to perform by those with no training and can be more readily guided by dispatchers over the telephone.●Initiate chest compressions before giving rescue breaths(C-A-B rather than A-B-C).Chest compressions can be started immediately,whereas positioning the head,attaining a seal for mouth-to-mouth rescue breathing,or obtaining or assembling a bag-mask device for rescue breathing all take time.Begin-ning CPR with30compressions rather than2ventilations leads to a shorter delay to first compression.●There is an increased focus on methods to ensure that high-quality CPR is performed.Adequate chest compres-sions require that compressions be provided at the appro-priate depth and rate,allowing complete recoil of the chest after each compression and an emphasis on minimizing any pauses in compressions and avoiding excessive ventilation. Training should focus on ensuring that chest compressions are performed correctly.The recommended depth of com-pression for adult victims has increased from a depth of11⁄2 to2inches to a depth of at least2inches.●Many tasks performed by healthcare providers during resus-citation attempts,such as chest compressions,airway man-agement,rescue breathing,rhythm detection,shock delivery, and drug administration(if appropriate),can be performed concurrently by an integrated team of highly trained rescuers in appropriate settings.Some resuscitations start with a lone rescuer who calls for help,resulting in the arrival of additional team members.Healthcare provider training should focus on building the team as each member arrives or quickly delegat-ing roles if multiple rescuers are present.As additional personnel arrive,responsibilities for tasks that would ordi-narily be performed sequentially by fewer rescuers may now be delegated to a team of providers who should perform them simultaneously.Key Points of Continued Emphasis for the2010AHA Guidelines for CPR and ECC●Early recognition of sudden cardiac arrest in adults is based on assessing responsiveness and the absence of normal breathing.Victims of cardiac arrest may initially have gasping respirations or even appear to be having a seizure. These atypical presentations may confuse a rescuer,caus-ing a delay in calling for help or beginning CPR.Training should focus on alerting potential rescuers to the unusual presentations of sudden cardiac arrest.●Minimize interruptions in effective chest compressions until ROSC or termination of resuscitative efforts.Any unnecessary interruptions in chest compressions(including longer than necessary pauses for rescue breathing)de-creases CPR effectiveness.●Minimize the importance of pulse checks by healthcare providers.Detection of a pulse can be difficult,and even highly trained healthcare providers often incorrectly assess the presence or absence of a pulse when blood pressure is abnormally low or absent.Healthcare providers should take no more than10seconds to determine if a pulse is present. Chest compressions delivered to patients subsequently found not to be in cardiac arrest rarely lead to significant Field et al Part1:Executive Summary S643injury.110The lay rescuer should activate the emergency response system if he or she finds an unresponsive adult. The lay rescuer should not attempt to check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses,is unresponsive,and is not breathing or not breathing normally(ie,only gasping).CPR Techniques and DevicesAlternatives to conventional manual CPR have been devel-oped in an effort to enhance perfusion during resuscitation from cardiac arrest and to improve pared with conventional CPR,these techniques and devices typically require more personnel,training,and equipment,or apply to a specific setting.Some alternative CPR techniques and devices may improve hemodynamics or short-term survival when used by well-trained providers in selected patients. Several devices have been the focus of recent clinical trials. Use of the impedance threshold device(ITD)improved ROSC and short-term survival when used in adults with out-of-hospital cardiac arrest,but there was no significant improvement in either survival to hospital discharge or neurologically-intact survival to discharge.111One multicenter,prospective,randomized con-trolled trial112,112a comparing load-distributing band CPR(Auto-pulse)with manual CPR for out-of-hospital cardiac arrest demonstrated no improvement in4-hour survival and worse neurologic outcome when the device was used.More research is needed to determine if site-specific factors113or experience with deployment of the device114influence effectiveness of the load-distributing band CPR device.Case series employing me-chanical piston devices have reported variable degrees of success.115–119To prevent delays and maximize efficiency,initial training, ongoing monitoring,and retraining programs should be offered on a frequent basis to providers using CPR devices. To date,no adjunct has consistently been shown to be superior to standard conventional(manual)CPR for out-of-hospital BLS,and no device other than a defibrillator has consistently improved long-term survival from out-of-hospital cardiac arrest.Electrical TherapiesThe2010AHA Guidelines for CPR and ECC have been updated to reflect new data on the use of pacing in bradycar-dia,and on cardioversion and defibrillation for tachycardic rhythm disturbances.Integration of AEDs into a system of care is critical in the Chain of Survival in public places outside of hospitals.To give the victim the best chance of survival,3actions must occur within the first moments of a cardiac arrest120:activation of the EMS system,121provision of CPR,and operation of a defibrillator.122One area of continued interest is whether delivering a longer period of CPR before defibrillation improves out-comes in cardiac arrest.In early studies,survival was im-proved when1.5to3minutes of CPR preceded defibrillation for patients with cardiac arrest ofϾ4to5minutes duration prior to EMS arrival.123,124However,in2more recent randomized controlled trials,CPR performed before defibril-lation did not improve outcome.125,126IfՆ2rescuers are present CPR should be performed while a defibrillator is being obtained and readied for use.The1-shock protocol for VF has not been changed. Evidence has accumulated that even short interruptions in CPR are harmful.Thus,rescuers should minimize the interval between stopping compressions and delivering shocks and should resume CPR immediately after shock delivery. Over the last decade biphasic waveforms have been shown to be more effective than monophasic waveforms in cardio-version and defibrillation.127–135However,there are no clin-ical data comparing one specific biphasic waveform with another.Whether escalating or fixed subsequent doses of energy are superior has not been tested with different wave-forms.However,if higher energy levels are available in the device at hand,they may be considered if initial shocks are unsuccessful in terminating the arrhythmia.In the last5to10years a number of randomized trials have compared biphasic with monophasic cardioversion in atrial fibrillation.The efficacy of shock energies for cardioversion of atrial fibrillation is waveform-specific and can vary from120to 200J depending on the defibrillator manufacturer.Thus,the recommended initial biphasic energy dose for cardioversion of atrial fibrillation is120to200J using the manufacturer’s recommended setting.136–140If the initial shock fails,providers should increase the dose in a stepwise fashion.Cardiover-sion of adult atrial flutter and other supraventricular tachycardias generally requires less energy;an initial energy of50J to100J is often sufficient.140If the initial shock fails,providers should increase the dose in a stepwise fashion.141Adult cardioversion of atrial fibrilla-tion with monophasic waveforms should begin at200J and increase in a stepwise fashion if not successful. Transcutaneous pacing has also been the focus of several recent trials.Pacing is not generally recommended for pa-tients in asystolic cardiac arrest.Three randomized controlled trials142–144indicate no improvement in rate of admission to hospital or survival to hospital discharge when paramedics or physicians attempted pacing in patients with cardiac arrest due to asystole in the prehospital or hospital(ED)setting. However,it is reasonable for healthcare providers to be prepared to initiate pacing in patients with bradyarrhythmias in the event the heart rate does not respond to atropine or other chronotropic(rate-accelerating)drugs.145,146 Advanced Cardiovascular Life SupportACLS affects multiple links in the Chain of Survival,including interventions to prevent cardiac arrest,treat cardiac arrest,and improve outcomes of patients who achieve ROSC after cardiac arrest.The2010AHA Guidelines for CPR and ECC continue to emphasize that the foundation of successful ACLS is good BLS, beginning with prompt high-quality CPR with minimal interrup-tions,and for VF/pulseless VT,attempted defibrillation within minutes of collapse.The new fifth link in the Chain of Survival and Part9:“Post–Cardiac Arrest Care”(expanded from a subsection of the ACLS part of the2005AHA Guidelines for CPR and ECC)emphasize the importance of comprehensive multidisciplinary care that begins with recognition of cardiac arrest and continues after ROSC through hospital discharge and beyond.Key ACLS assessments and interventions provide anS644Circulation November2,2010。

2010(AHA)心肺复苏标准

2010 • 急诊 • 基地 • 培训
人工呼吸的注意事项
• 吹气应有足够的气量，以使胸廓抬起，但一般不超过1200mL。 • 吹气时间宜短，以占1次呼吸周期的1/3为宜；吹气频率，成人10-12 次/分，儿童15次/分，幼儿20/分。 • 操作前先清除患者口腔及咽部的分泌物或堵塞物。 • 有义牙者应取下义牙。遇舌后坠的患者，应用舌钳将舌拉出口腔外，或用通气管吹气。 • 对婴幼儿，则对口鼻同时吹气更易施行 • 若患者尚有微弱呼吸，人工呼吸应与患者的自主呼吸同步进行。 • 注意防止交叉感染。 • 通气适当的指征是看到患者胸部起伏并于呼气时听到及感到有气体逸出。
2010 • 急诊 • 基地 • 培训
时间就是生命
• • • • • • 心跳停止3秒钟 ----黑朦心跳停止5-10秒钟----晕厥心跳停止15秒钟 ----昏厥或抽搐心跳停止45秒钟 ----瞳孔散大心跳停止1-2分钟 ----瞳孔固定心跳停止4-5分钟 ----大脑细胞不可逆损害
2010 • 急诊 • 基地 • 培训
人工呼吸（人工呼吸（Breathing，B），） • • • • 口对鼻、气管造口人工呼吸面罩和简易呼吸囊人工呼吸气管内插管人工呼吸机
2010 • 急诊 • 基地 • 培训
口对口人工呼吸
• 方法:在保持呼吸道通畅和口部张开的位置下进行用按于前额一手的拇指与食指捏紧鼻翼下端、先缓慢吹气两口,以扩张萎缩的肺脏,并检验开放气道的效果.施救者深吸一口气后张开紧贴患者口部,用力向患者口内吹气,吹气要求快而深,直至患者胸部上抬,每次吹气应持续2秒以上. • 气量:每次吹入气量为700-1000mL 无氧或400每次吹入气量为700-1000mL(无氧 400无氧)或每次吹入气量为 600mL (有氧 ,一般不超过1200ml 有氧) 有氧 • 频率:成人10-12次/分，儿童15次/分，婴幼儿20次 /分。

心肺复苏

在恢复自主循环后，应该将吸氧浓度（FiO2）调整到需要的最低浓度，以实现动脉氧和血红蛋白饱和度≥94%，旨在避免组织内氧过多并确保输送足够的氧。虽然《2010年心肺复苏与心血管急救指南》的成人高级生命支持工作组并未发现足够证据来建议具体的撤离吸氧方案，但近期研究表明，恢复自主循环后组织内氧过多会产生有害影响。
维护其他器官功能循环功能呼吸功能肾功能胃肠功能水电解质酸碱平衡
谢谢！
常用药物肾上腺素：目前建议的剂量为肾上腺素 1mg静脉内推注，每3~5min一次；应用需愈早愈好。垂体后叶素：40u相当于1mg肾上腺素, 用于肾上腺素不敏感者。
胺碘酮：属广谱抗心律失常药物。2010
指南更加突出了胺碘酮作为治疗各种心律失常的主流地位，更适宜于严重心功能不全患者的治疗，用法：心脏骤停患者初始剂量为300mg溶入20~30ml生理盐水或葡萄糖内快速推注，3~5min 后再推注150mg，维持剂量1mg/min 持续6h。一般建议每日最大剂量不超过 2g。
心肺复苏终止指标

复苏成功：自主呼吸及心跳已恢复良好，转入下一阶段治疗。复苏失败：自主呼吸及心跳一直未恢复，脑干反射全部消失，心肺复苏操作已达30min 以上，心电图成直线，医生判断已临床死亡。特出情况：溺水、触电、新生儿抢救时间应延长1-2小时。
心脏骤停后治疗
“心脏骤停后治疗”是2010版指南中的新增部分，旨在提高恢复自主循环后收入院的心脏骤停患者的生存率，治疗应包括低温治疗，经皮冠状动脉介入术，脑电图检查等。
取消“一听二看三感觉”
CPR中不再有“一听二看三感觉”。 30次胸外按压后，单人抢救者开放被救者的气道，并给予2次通气。按照心肺复苏术中C-A-B的顺序，对于没有意识，呼吸或不能正常呼吸的成人，应首先给予胸外按压。因此，呼吸作为心脏骤停后简要检查的一部分，应放在胸外按压，开放气道，2次通气之后。

2010年AHA心肺复苏指南由ABC到CAB的意义

2010年AHA心肺复苏指南由ABC到CAB意义天津医科大学总医院万征边波1 心肺复苏（Cardiopulmonary Resuscitation, CPR）CPR是指病人呼吸心跳停止时采取的一切抢救措施，简称（CPR）。

复苏的最终目的是促使病人的神志清醒和脑功能恢复，因此，又可称为心肺脑复苏（CPCR）。

CPR对象多是心脏骤停（SCAs）病人，其是直接危及人们生命的一大杀手。

CPR 可分为基础生命支持（basic life support，BLS）和高级生命支持（advanced cardiac life support，ACLS）。

基础生命支持的核心技术是徒手进行人工循环（胸外按压）和人工呼吸，保证脑、心等重要脏器的血液和氧气供应，并及时进行电除颤恢复正常心脏节律。

高级生命支持是指由专业急救、医护人员应用急救器材和药品所实施的一系列复苏措施，主要包括人工气道的建立、机械通气、循环辅助设备、药物和液体的应用、电除颤、病情和疗效评估，复苏后脏器功能的维持等。

2 时间就是生命SCAs是公共卫生和临床医学领域中最危急的情况之一，如不能得到及时有效救治常致病人即刻死亡，即心脏性猝死（sudden cardiac death，SCD）。

在美国和加拿大，每年有35万人发生SCAs并接受复苏治疗，其中有一半发生在医院内。

我国十五攻关课题结果显示，我国SCD的发生率为每年41.84/10万(0.04％)，以13亿人口推算，我国每年SCD的发生率为54.4万。

随着工业化程度的提高、冠心病发生率的增加，我国SCD的发生率将有增加的趋势。

SCAs时心脏停止抽吸血液，随之呼吸停止，若不进行生命拯救措施，4~6分钟就将迅速开始发生严重脑损害直到死亡。

不进行CPR则每延迟1分钟死亡率增加7~10％，充分体现“时间就是生命”的急救理念。

但我们面对的事实是院外SCAs总体生存率仍然很低。

在美国尽管应急医疗服务系统（EMS）取得了重要进展，但在多数城市SCD生存率仍小于5％。

《2010美国心脏协会(AHA)心肺复苏(CPR)及心血管急救(ECC)指南》要点速递与释义

《2010美国心脏协会(AHA)心肺复苏(CPR)及心血管急救(ECC)指南》要点速递与释义心肺复苏（CPR）是抢救心脏呼吸停止患者的基本手段。

自1966年首个心肺复苏指南发布以来，已成功抢救了成千上万例患者。

2010年10月发布的《2010美国心脏协会（AHA）心肺复苏（CPR）及心血管急救（ECC）指南》包含了最新研究成果和循证医学证据，成为当前心肺复苏的最新标准。

本文就近年来心肺复苏研究与争议焦点及《2010美国心脏协会（AHA）心肺复苏（CPR）及心血管急救（ECC）指南》的要点作一介绍。

标签：心肺复苏；除颤器；心脏骤停；胸外心脏按压；人工呼吸自1956年彼得·萨法尔（Peter Safar）和詹姆斯·伊拉姆（James Elam）提出口对口人工呼吸和1960年Kowenhoven等[1]提出封闭式胸部心脏按压（closed chest cardiac massage），以及1966年美国心脏协会（AHA）发布首个心肺复苏指南[2]以来，基于早识别、早呼救、早心肺复苏（CPR）、早除颤和早期高级生命支持的心肺复苏在全球已经抢救了成千上万例患者。

如今，心肺复苏已经成为抢救心脏骤停和濒死患者的基本急救技术之一。

2010年10月发布的《2010美国心脏协会（AHA）心肺复苏（CPR）及心血管急救（ECC）指南》（简称《2010心肺复苏指南》）更是成为了全球心肺复苏的最新标准。

12010心肺复苏指南的修改背景自《2005美国心脏协会（AHA）心肺复苏（CPR）及心血管急救（ECC）指南》（简称《2005心肺复苏指南》）发布以来，仍存在较多悬而未决的问题[3]。

其后的相关研究表明，《2005心肺复苏指南》仍有较多需改进的地方，表现为：①实施《2005心肺复苏指南》以来，心肺复苏质量和存活率也有所提升，但胸外按压的质量还需提高；②各个急救系统（EMS）中的院外心脏骤停存活率差异较大[4-5]；③对于大多数院外心脏骤停患者，没有任何目击者进行过现场心肺复苏。

2010AHA心肺复苏指南

非专业简施化救流者程成人
BLS
专业施救者成人BLS流程
BLS步骤总结
快速除颤
• 先电击？先C-A-B ？先胸前捶击？ • 对于院内心脏骤停、有心电监护的患者，从VF到电击的时间应＜3 min，并且应在等待除颤器就绪时进行心肺复苏。 • 儿童（1～8岁）首选剂量衰减型AED • 婴儿（＜1岁）建议首选手动除颤器 • 电极位置：前-侧（或前-后、前-左肩胛以及前-右肩胛） • 装有植入式心律转复除颤器者：应避免将电极片或电极板直接放在植入装置上。
专业与非专业施救者BLS区别
• 非专业施救者成人心肺复苏
• 经过心肺复苏培训者： C-A-B • 未经过心肺复苏培训者，可进行HandsOnly™（单纯胸外按压）的心肺复苏或按照急救调度的指示操作
• 专业施救者
• 未触摸到脉搏（＜10 秒钟）：C-A-B并尽早使用 AED。 • 不建议常规性地采用环状软骨加压。 • 根据最有可能的骤停病因展开施救行动。 • 团体合作。
2010
美国心脏协会（AHA）心肺复苏及心血管急救
• • • • • 立即识别心脏骤停并启动急救系统尽早进行心肺复苏，着重于胸外按压快速除颤有效的高级生命支持综合的心脏骤停后治疗
立即识别心脏骤停并启动急救系统
发现患者突然倒地：
• 立即检查：
• 无反应 • 无呼吸或无正常呼吸（即仅有濒死喘息）
电复律与除颤能量
心律失常室上性心动过速室性心动过速
Af 双相波单相波 AF 稳定型单型性无脉性或多形性 Vf（成人） Vf（儿童）双相/单相波双相波
2005
未确定 100 - 200 J 未建议未建议非同步电击

2010AHA心肺复苏指南更新要点

同步电复律 —室上性快速心律失常
房颤首剂量电复律治疗的建议双相波能量首剂量是120至200J，房颤电复律治量首剂量是120至200J，房颤电复律治疗的单相波首剂量是200J。疗的单相波首剂量是200J。成人房扑和其他室上性心律的电复律治疗通常需要较低能量，一般采用50至疗通常需要较低能量，一般采用50至 100J的 100J的
作为他山之石，新指南无疑是急救医学界的重要财富，但也并非一个相当长时期内不可动摇的中国标准。我国医务人员尤其是实际参与现场心肺复苏、心血管急救从事专业院外急救的医护人员有很大的发言权，应经常总结、提高。
谢谢！谢谢！
2010版国际心肺复苏与心血管急救指南 2010版国际心肺复苏与心血管急救指南
识别问题快速进入复苏程序
2010版国际心肺复苏与心血管急救指南 2010版国际心肺复苏与心血管急救指南
单人（双人）复苏：单人（双人）复苏：“C-A-B” “D-C-A-B” D 临床发现：临床发现：心脏骤停最高存活率均为有目击者的。目击者的。基础生命支持的关键是胸外按压和早期除颤。压和早期除颤。
高级心血管生命支持
二氧化碳图的建议：目前，建议在围停搏期为插管患者持续使用二氧化碳波形图进行定量分析。目前的应用包括确认气管插管位置及根据呼气末二氧化碳值监护心肺复苏质量和检测是否恢复自主循环的建议（下图例）
新的用药方案
不再建议在治疗无脉性电活动和心搏停止是常规用阿托品并已将其从高级生命支持的心脏骤停流程中去掉有脉搏心动过速的流程简化。建议使用腺苷，但腺苷不得用于非规则宽QRS波腺苷，但腺苷不得用于非规则宽QRS波群心动过速，因为它会致室颤
Circulation
基本生命支持（BLS）基本生命支持（BLS）的主要改变

AHA心肺复苏指南更新

2.尽早进行心肺复苏，着重于胸外按压
• 强调胸外按压
• 2005（旧）：《2005 AHA心肺复苏及心血管急救指南》中没有针对经过培训和未经培训的施救者给出不同建议，而且未强调为非专业施救者与医务人员给予不同指导，但已建议调度员为未经培训的旁观者提供单纯胸外按压心肺复苏指导。另外，在《2005 AHA心肺复苏及心血管急救指南》中已注明，如果施救者不愿或无法提供通气，则施救者应进行单纯胸外按压。请注意，AHA已经在 2008 年发表了“单纯胸外按压心肺复苏”这一说法。
2.尽早进行心肺复苏，着重于胸外按压
• 取消“看、听和感觉呼吸” • 理由：通过采用“首先进行胸外按压”的新程序，会在成人患者无反应且不呼吸或无正常呼吸时实施心肺复苏（即，无呼吸或仅仅是喘息）并开始按压（C-A-B 程序）。所以，检查是否发生心脏骤停时会同时快速检查呼吸。进行第一轮胸外按压后，气道已开放，施救者会进行 2 次人工呼吸。
1.立即识别心脏骤停并启动急救系统 • 调度员确认濒死喘息
• 2010（新）：为帮助旁观者识别心脏骤停，调度员应向其询问成人患者的反应，确定患者是否有呼吸以及呼吸是否正常，以尝试区分濒死喘息的患者（即需要心肺复苏的患者）以及可正常呼吸且不需要心肺复苏的患者。应指导医务人员在患者没有呼吸或不能正常呼吸（即仅仅是喘息）的情况下开始心肺复苏。所以，医务人员检查是否发生心脏骤停时应该快速检查呼吸，然后启动急救系统并找到 AED（或由其他人员寻找），再（快速）检查脉搏并开始进行心肺复苏和使用 AED。
1.立即识别心脏骤停并启动急救系统
• 调度员确认濒死喘息 • 2005（旧）：调度员给出的心肺复苏指令应包括相关问题，帮助旁观者确认偶尔喘息的患者是否为心脏骤停患者，以提高旁观者为这类患者实施心肺复苏的可能性。

2010年AHA心肺复苏指南 - 由ABC到CAB意义和启示社区医生版-文档资料

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根据2005年指南如何进行CPR？
• A（airway):开放气道 • B（breathing):人工呼吸 • C（circulation):人工循环，即胸外按压
我们熟悉的A-B-C顺序在2010年指南中已作出重大调整！！！
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2010年CPR指南：C-A-B
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为什么“C frist”
• 胸外按压几乎可以立即开始，而摆好头部位置并尽可能密封以进行口对口或气囊面罩人工呼吸的过程则需要一定时间
• 如果有两名施救者在场，可以减少开始按压的延误：第一名施救者开始胸外按压，第二名施救者开放气道并准备好在第一名施救者完成第一轮 30 次胸外按压后立即进行人工呼吸
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生命救治流程
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小结
• 新指南强调首先尽快开始“C”：胸外按压 • 新指南强调快速用力有效的“C”:胸外按压 • 新指南简化流程，易于操作，鼓励非专业人员参与仅
有“C”:胸外按压的CPR(专业人员和医务人员仍应该在C-A-B顺序下尽快开始人工呼吸） • 新指南强调综合的心脏骤停后治疗 • 新指南弱化对于脉搏的评估
19
实践高质量的CPR
• 按压方法按压时上半身前倾，腕、肘、肩关节伸直，以髋关节为轴，垂直向下用力，借助上半身的体重和肩臂部肌肉的力量进行按压
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实践高质量的CPR
• 弱化检查脉搏 • 研究显示非专业和医务人员检查脉搏都会化去较长时间 • 非专业人员发现成人突然意识不清、对呼叫无反应可以假
• 在大多数研究中，给予更多按压可提高存活率，而减少按压则会降低存活率。进行足够胸外按压不仅强调足够的按压速率，还强调尽可能减少中断这一关键步骤的次数

2010国际心肺复苏指南

2010国际心肺复苏指南
2010 International Cardiopulmonary Resuscitation guidelines
伊春市中心医院ICU
孟楠
概述
伊春市中心医院ICU 孟楠
2010年1月31日—2月6日国际复苏联合会（ILCOR）和美国心脏协会（AHA）共同在美国达拉斯洲酒店举行的2010心肺复苏指南（CPR）暨心血管急救（ECC）国际科学共识推荐会既要。 2010年10月18日-美国心脏协会（AHA）公布最新心肺复苏（CPR）指南
开放气道
伊春市中心医院ICU 孟楠
开放气道手法
伊春市中心医院ICU 孟楠
仰面抬颌法要领：用一只手按压伤病者的前额，使头部后仰，同时用另一只手的食指及中指将下颏托起
复苏步骤第三步（B）人工呼吸
伊春市中心医院ICU 孟楠
B：即人工呼吸
人工呼吸是心肺复苏基本技术之一开放气道后应立即进行人工呼吸。最常见、最方便的人工呼吸方法是采取口对口人工呼吸和口对鼻人工呼吸。方法：口对口人工呼吸时要用一手将病人的鼻孔捏紧（防止吹气气体从鼻孔排出而不能由口腔进入到肺内），深吸一口气，屏气，用口唇严密地包住昏迷者的口唇（不留空隙），注意不要漏气，在保持气道畅通的操作下，将气体吹入人的口腔到肺部。吹气后，口唇离开，并松开捏鼻的手指，使气体呼出。观察人的胸部有无起伏，如果吹气时胸部抬起，说明气道畅通，口对口吹气的操作是正确的。
伊春市中心医院ICU 孟楠
心肺复苏—BLS(CAB)
伊春市中心医院ICU 孟楠
按压方法：按压时上半身前倾，腕、肘、肩关节伸直，以髋关节为支点，垂直向下用力孟楠
心肺复苏—BLS(CAB)