2015版AHA心肺复苏(完整通俗版)

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2015年心肺复苏指南课件

3、先按还是先电？
尽快除颤一直是CPR中保证患者存活率的关键一环。在2010年的指南中，在自动体外除颤仪（AED）或除颤器准备就绪时，先进行1.5-3分钟的CPR，然后再除颤。今年的指南则表示，一旦除颤器准备就绪，就直接除颤。当然，在AED和除颤器的获取和准备过程中，还是需要CPR的。
除颤必须及早进行的原因
极少（5-8%）常为终末期心脏病，心泵衰竭心脏应激性极差，复苏十分困难。注：心室停顿和电机械分离是非可电击心律
2015年10月，新版《美国心脏学会 CPR和ECC指南》隆重登场。今年的指南到底有啥变动？是否如同5年前那样几乎彻底颠覆？下面我们就梳理一下该指南中标准CPR流程的主要变更点。
呼吁
美国每年有 20 万例院内心脏骤停发生。 CPR 培训是基础必会的课程。然而，研究显示，这一技能会在接受培训后数月内逐渐生疏。所以应进行反复、高频的培训来保证院内持续掌握，并熟悉如何将患者转运到最高质量的心血管急救部门。
《美国急诊临床365问》之心肺，急救人员应该多久给一次通气？在气管插管后，管理呼吸道人员要在不影响胸外按压前提下，每 6～8 秒钟给一次通气，即每分钟 8 ～10 次
心肺复苏CPR
是一系列提高心脏骤停后生存机会的救命措施，
主要包括： 1、基础生命支持(basic life support，BLS)
心肺复苏（Cardio-Pulmonary Resuscitation CPR ）
2、高级心血管生命支持(advanced cardiovascular life support，ACLS)
5、按压间隙不倚靠患者胸部
2010年的指南中强调按压间隙需要保证胸廓充分回弹。但是在绝大多数实际临床过程中，每次按压间隙时我们的重心还是偏向患者。现指南要求按压间隙不能“倚靠”在患者胸部。这就意味着按压间隙，不能有任何力量施加在患者胸部，这对施救者的重心调整提出了更高的要求：手可以放在患者胸上，但是不能有任何力量。

心肺复苏2015年国际新标准操作流程CPR

心肺复苏2015年国际新标准操作流程CPR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，频率10-12次/分。

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。

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。

先判断患者有无意识。

拍摇患者并大声询问，手指甲掐压人中穴约五秒，如无反应表示意识丧失。

这时应使患者水平仰卧，解开颈部钮扣，注意清除口腔异物，使患者仰头抬颏，用耳贴近口鼻，如未感到有气流或胸部无起伏，则表示已无呼吸。

2015 AHA心肺复苏指南

IntroductionPublication of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) marks 49 years since the first CPR guidelines were published in 1966 by an Ad Hoc Committee on Cardiopulmonary Resuscitation estab-lished by the National Academy of Sciences of the National Research Council.1 Since that time, periodic revisions to the Guidelines have been published by the AHA in 1974,2 1980,3 1986,4 1992,5 2000,6 2005,7 2010,8 and now 2015. The 2010 AHA Guidelines for CPR and ECC provided a comprehensive review of evidence-based recommendations for resuscitation, ECC, and first aid. The 2015 AHA Guidelines Update for CPR and ECC focuses on topics with significant new science or ongoing controversy, and so serves as an update to the 2010 AHA Guidelines for CPR and ECC rather than a complete revision of the Guidelines.The purpose of this Executive Summary is to provide an overview of the new or revised recommendations contained in the 2015 Guidelines Update. This document does not contain extensive reference citations; the reader is referred to Parts 3 through 9 for more detailed review of the scientific evidence and the recommendations on which they are based.There have been several changes to the organization of the 2015 Guidelines Update compared with 2010. “Part 4: Systems of Care and Continuous Quality I mprovement” is an important new Part that focuses on the integrated struc-tures and processes that are necessary to create systems of care for both in-hospital and out-of-hospital resuscitation capable of measuring and improving quality and patient out-comes. This Part replaces the “CPR Overview” Part of the 2010 Guidelines.Another new Part of the 2015 Guidelines Update is “Part 14: Education,” which focuses on evidence-based recommen-dations to facilitate widespread, consistent, efficient and effec-tive implementation of the AHA Guidelines for CPR and ECC into practice. These recommendations will target resuscitationeducation of both lay rescuers and healthcare providers. This Part replaces the 2010 Part titled “Education, Implementation, and Teams.” The 2015 Guidelines Update does not include a separate Part on adult stroke because the content would rep-licate that already offered in the most recent AHA/American Stroke Association guidelines for the management of acute stroke.9,10Finally, the 2015 Guidelines Update marks the begin-ning of a new era for the AHA Guidelines for CPR and ECC, because the Guidelines will transition from a 5-year cycle of periodic revisions and updates to a Web-based format that is continuously updated. The first release of the Web-based inte-grated Guidelines, now available online at is based on the comprehensive 2010 Guidelines plus the 2015 Guidelines Update. Moving forward, these Guidelines will be updated by using a continuous evidence evaluation process to facilitate more rapid translation of new scientific discoveries into daily patient care.Creation of practice guidelines is only 1 link in the chain of knowledge translation that starts with laboratory and clini-cal science and culminates in improved patient outcomes. The AHA ECC Committee has set an impact goal of doubling bystander CPR rates and doubling cardiac arrest survival by 2020. Much work will be needed across the entire spectrum of knowledge translation to reach this important goal.Evidence Review and GuidelinesDevelopment ProcessThe process used to generate the 2015 AHA Guidelines Update for CPR and ECC was significantly different from the process used in prior releases of the Guidelines, and marks the planned transition from a 5-year cycle of evidence review to a continuous evidence evaluation process. The AHA con-tinues to partner with the I nternational Liaison Committee on Resuscitation (I LCOR) in the evidence review process. However, for 2015, ILCOR prioritized topics for systematic review based on clinical significance and availability of new© 2015 American Heart Association, Inc.Circulation is available at DOI: 10.1161/CIR.0000000000000252The American Heart Association requests that this document be cited as follows: Neumar RW, Shuster M, Callaway CW, Gent LM, Atkins DL, Bhanji F, Brooks SC, de Caen AR, Donnino MW, Ferrer JME, Kleinman ME, Kronick SL, Lavonas EJ, Link MS, Mancini ME, Morrison LJ, O’Connor RE, Sampson RA, Schexnayder SM, Singletary EM, Sinz EH, Travers AH, Wyckoff MH, Hazinski MF. Part 1: executive summary: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation . 2015;132(suppl 2):S315–S367.(Circulation. 2015;132[suppl 2]:S315–S367. DOI: 10.1161/CIR.0000000000000252.)Part 1: Executive Summary2015 American Heart Association Guidelines Update for CardiopulmonaryResuscitation and Emergency Cardiovascular CareRobert W. Neumar, Chair; Michael Shuster; Clifton W. Callaway; Lana M. Gent; Dianne L. Atkins; Farhan Bhanji; Steven C. Brooks; Allan R. de Caen; Michael W. Donnino; Jose Maria E. Ferrer; Monica E. Kleinman; Steven L. Kronick; Eric J. Lavonas; Mark S. Link; Mary E. Mancini; Laurie J. Morrison; Robert E. O’Connor; Ricardo A. Samson; Steven M. Schexnayder;Eunice M. Singletary; Elizabeth H. Sinz; Andrew H. Travers; Myra H. Wyckoff; Mary Fran HazinskiS316 Circulation November 3, 2015evidence. Each priority topic was defined as a question in PICO (population, intervention, comparator, outcome) format. Many of the topics reviewed in 2010 did not have new pub-lished evidence or controversial aspects, so they were not rere-viewed in 2015. In 2015, 165 PICO questions were addressed by systematic reviews, whereas in 2010, 274 PICO questions were addressed by evidence evaluation. In addition, ILCOR adopted the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process for evidence evaluation and expanded the opportunity for public comment. The output of the GRADE process was used to generate the 2015 International Consensus on CPR and ECC Science With Treatment Recommendations (CoSTR).11,12The recommendations of the I LCOR 2015 CoSTR were used to inform the recommendations in the 2015 AHA Guidelines Update for CPR and ECC. The wording of these recommendations is based on the AHA classification system for evidentiary review (see “Part 2: Evidence Evaluation and Management of Conflicts of Interest”).The 2015 AHA Guidelines Update for CPR and ECC con-tains 315 classified recommendations. There are 78 Class I rec-ommendations (25%), 217 Class II recommendations (68%), and 20 Class III recommendations (7%). Overall, 3 (1%) are based on Level of Evidence (LOE) A, 50 (15%) are based on LOE B-R (randomized studies), 46 (15%) are based on LOE B-NR (non-randomized studies), 145 (46%) are based on LOE C-LD (lim-ited data), and 73 (23%) are based on LOE C-EO (consensus of expert opinion). These results highlight the persistent knowledge gap in resuscitation science that needs to be addressed through expanded research initiatives and funding opportunities.As noted above, the transition from a 5-year cycle to a continuous evidence evaluation and Guidelines update process will be initiated by the 2015 online publication of the AHA I ntegrated Guidelines for CPR and ECC at ECCguidelines. . The initial content will be a compilation of the 2010 Guidelines and the 2015 Guidelines Update. In the future, the Scientific Evidence Evaluation and Review System (SEERS) Web-based resource will also be periodically updated with results of the ILCOR continuous evidence evaluation process at /seers.Part 3: Ethical IssuesAs resuscitation practice evolves, ethical considerations must also evolve. Managing the multiple decisions associated with resuscitation is challenging from many perspectives, espe-cially when healthcare providers are dealing with the ethics surrounding decisions to provide or withhold emergency car-diovascular interventions.Ethical issues surrounding resuscitation are complex and vary across settings (in or out of hospital), providers (basic or advanced), patient population (neonatal, pediatric, or adult), and whether to start or when to terminate CPR. Although the ethical principles involved have not changed dramatically since the 2010 Guidelines were published, the data that inform many ethical discussions have been updated through the evi-dence review process. The 2015 ILCOR evidence review pro-cess and resultant 2015 Guidelines Update include several recommendations that have implications for ethical decision making in these challenging areas.Significant New and Updated Recommendations That May Inform Ethical Decisions• The use of extracorporeal CPR (ECPR) for cardiac arrest • Intra-arrest prognostic factors for infants, children, and adults• Prognostication for newborns, infants, children, and adults after cardiac arrest• Function of transplanted organs recovered after cardiac arrestNew resuscitation strategies, such as ECPR, have made the decision to discontinue cardiac arrest measures more complicated (see “Part 6: Alternative Techniques and Ancillary Devices for Cardiopulmonary Resuscitation” and “Part 7: Adult Advanced Cardiovascular Life Support”). Understanding the appropriate use, implications, and likely benefits related to such new treat-ments will have an impact on decision making. There is new information regarding prognostication for newborns, infants, children, and adults with cardiac arrest and/or after cardiac arrest (see “Part 13: Neonatal Resuscitation,” “Part 12: Pediatric Advanced Life Support,” and “Part 8: Post–Cardiac Arrest Care”). The increased use of targeted temperature management has led to new challenges for predicting neurologic outcomes in comatose post–cardiac arrest patients, and the latest data about the accuracy of particular tests and studies should be used to guide decisions about goals of care and limiting interventions.With new information about the success rate for trans-planted organs obtained from victims of cardiac arrest, there is ongoing discussion about the ethical implications around organ donation in an emergency setting. Some of the different view-points on important ethical concerns are summarized in “Part 3: Ethical I ssues.” There is also an enhanced awareness that although children and adolescents cannot make legally bind-ing decisions, information should be shared with them to the extent possible, using appropriate language and information for their level of development. Finally, the phrase “limitations of care” has been changed to “limitations of interventions,” and there is increasing availability of the Physician Orders for Life-Sustaining Treatment (POLST) form, a new method of legally identifying people who wish to have specific limits on interven-tions at the end of life, both in and out of healthcare facilities.Part 4: Systems of Care andContinuous Quality ImprovementAlmost all aspects of resuscitation, from recognition of cardio-pulmonary compromise, through cardiac arrest and resuscita-tion and post–cardiac arrest care, to the return to productive life, can be discussed in terms of a system or systems of care. Systems of care consist of multiple working parts that are interdependent, each having an effect on every other aspect of the care within that system. To bring about any improvement, providers must recognize the interdependency of the various parts of the system. There is also increasing recognition that out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) systems of care must function differently. “Part 4: Systems of Care and Continuous Quality I mprovement” in this 2015 Guidelines Update makes a clear distinction between the two systems, noting that OHCA frequently is the result of an unexpected event with a reactive element, whereasNeumar et al Part 1: Executive Summary S317the focus on IHCA is shifting from reactive resuscitation to prevention. New Chains of Survival are suggested for in-hospital and out-of-hospital systems of care, with relatively recent in-hospital focus on prevention of arrests. Additional emphasis should be on continuous quality improvement by identifying the problem that is limiting survival, and then by setting goals, measuring progress toward those goals, creating accountability, and having a method to effect change in order to improve outcomes.This new Part of the AHA Guidelines for CPR and ECC summarizes the evidence reviewed in 2015 with a focus on the systems of care for both I HCA and OHCA, and it lays the framework for future efforts to improve these systems of care. A universal taxonomy of systems of care is proposed for stakeholders. There are evidence-based recommendations on how to improve these systems.Significant New and Updated RecommendationsI n a randomized trial, social media was used by dispatch-ers to notify nearby potential rescuers of a possible cardiac arrest. Although few patients ultimately received CPR from volunteers dispatched by the notification system, there was a higher rate of bystander-initiated CPR (62% versus 48% in the control group).13 Given the low risk of harm and the poten-tial benefit of such notifications, municipalities could consider incorporating these technologies into their OHCA system of care. I t may be reasonable for communities to incorporate, where available, social media technologies that summon res-cuers who are willing and able to perform CPR and are in close proximity to a suspected victim of OHCA (Class I I b, LOE B-R).Specialized cardiac arrest centers can provide comprehen-sive care to patients after resuscitation from cardiac arrest. These specialized centers have been proposed, and new evi-dence suggests that a regionalized approach to OHCA resus-citation may be considered that includes the use of cardiac resuscitation centers.A variety of early warning scores are available to help identify adult and pediatric patients at risk for deterioration. Medical emergency teams or rapid response teams have been developed to help respond to patients who are deteriorating. Use of scoring systems to identify these patients and creation of teams to respond to those scores or other indicators of deterioration may be considered, particularly on general care wards for adults and for children with high-risk illnesses, and may help reduce the incidence of cardiac arrest.Evidence regarding the use of public access defibrillation was reviewed, and the use of automated external defibril-lators (AEDs) by laypersons continues to improve survival from OHCA. We continue to recommend implementation of public access defibrillation programs for treatment of patients with OHCA in communities who have persons at risk for cardiac arrest.Knowledge Gaps• What is the optimal model for rapid response teams in the prevention of IHCA, and is there evidence that rapid response teams improve outcomes?• What are the most effective methods for increasing bystander CPR for OHCA?• What is the best composition for a team that responds to IHCA, and what is the most appropriate training for that team?Part 5: Adult Basic Life Support andCardiopulmonary Resuscitation Quality New Developments in Basic Life Support Science Since 2010The 2010 Guidelines were most notable for the reorientation of the universal sequence from A-B-C (Airway, Breathing, Compressions) to C-A-B (Compressions, Airway, Breathing) to minimize time to initiation of chest compressions. Since 2010, the importance of high-quality chest compressions has been reemphasized, and targets for compression rate and depth have been further refined by relevant evidence. For the untrained lay rescuer, dispatchers play a key role in the recognition of abnor-mal breathing or agonal gasps as signs of cardiac arrest, with recommendations for chest compression–only CPR.This section presents the updated recommendations for the 2015 adult basic life support (BLS) guidelines for lay res-cuers and healthcare providers. Key changes and continued points of emphasis in this 2015 Guidelines Update include the following: The crucial links in the adult Chain of Survival for OHCA are unchanged from 2010; however, there is increased emphasis on the rapid identification of potential cardiac arrest by dispatchers, with immediate provision of CPR instructions to the caller. These Guidelines take into consideration the ubiq-uitous presence of mobile phones that can allow the rescuer to activate the emergency response system without leaving the victim’s side. For healthcare providers, these recommenda-tions allow flexibility for activation of the emergency response to better match the provider’s clinical setting. More data are available indicating that high-quality CPR improves survival from cardiac arrest. Components of high-quality CPR include • Ensuring chest compressions of adequate rate• Ensuring chest compressions of adequate depth• Allowing full chest recoil between compressions• Minimizing interruptions in chest compressions• Avoiding excessive ventilationRecommendations are made for a simultaneous, choreo-graphed approach to performance of chest compressions, airway management, rescue breathing, rhythm detection, and shock delivery (if indicated) by an integrated team of highly trained rescuers in applicable settings.Significant New and Updated Recommendations Many studies have documented that the most common errors of resuscitation are inadequate compression rate and depth; both errors may reduce survival. New to this 2015 Guidelines Update are upper limits of recommended compression rate based on pre-liminary data suggesting that excessive rate may be associated with lower rate of return of spontaneous circulation (ROSC). In addition, an upper limit of compression depth is introducedS318 Circulation November 3, 2015based on a report associating increased non–life-threatening injuries with excessive compression depth.• I n adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min (Class IIa, LOE C-LD). The addition of an upper limit of compression rate is the result of 1 large registry study associating extremely rapid compression rates with inadequate compression depth.• During manual CPR, rescuers should perform chest compressions at a depth of at least 2 inches or 5 cm for an average adult, while avoiding excessive chest com-pression depths (greater than 2.4 inches [6 cm]) (Class I, LOE C-LD). The addition of an upper limit of com-pression depth followed review of 1 publication suggest-ing potential harm from excessive chest compression depth (greater than 6 cm, or 2.4 inches). Compression depth may be difficult to judge without use of feedback devices, and identification of upper limits of compres-sion depth may be challenging.• I n adult cardiac arrest, total preshock and postshock pauses in chest compressions should be as short as pos-sible (Class I, LOE C-LD) because shorter pauses can be associated with greater shock success, ROSC, and, in some studies, higher survival to hospital discharge. The need to reduce such pauses has received greater empha-sis in this 2015 Guidelines Update.• In adult cardiac arrest with an unprotected airway, it may be reasonable to perform CPR with the goal of a chest compression fraction as high as possible, with a target of at least 60% (Class IIb, LOE C-LD). The addition of this target compression fraction to the 2015 Guidelines Update is intended to limit interruptions in compressions and to maximize coronary perfusion and blood flow during CPR.• For patients with known or suspected opioid addic-tion who have a definite pulse but no normal breathing or only gasping (ie, a respiratory arrest), in addition to providing standard BLS care, it is reasonable for appro-priately trained BLS providers to administer intramus-cular or intranasal naloxone (Class IIa, LOE C-LD). It is reasonable to provide opioid overdose response educa-tion with or without naloxone distribution to persons at risk for opioid overdose in any setting (Class IIa, LOE C-LD). For more information, see “Part 10: Special Circumstances of Resuscitation.”• For witnessed OHCA with a shockable rhythm, it may be reasonable for emergency medical service (EMS) systems with priority-based, multi-tiered response to delay positive-pressure ventilation by using a strategy of up to 3 cycles of 200 continuous compressions with passive oxygen insufflation and airway adjuncts (Class IIb, LOE C-LD).• We do not recommend the routine use of passive ven-tilation techniques during conventional CPR for adults, because the usefulness/effectiveness of these techniques is unknown (Class IIb, LOE C-EO). However, in EMS systems that use bundles of care involving continuous chest compressions, the use of passive ventilation tech-niques may be considered as part of that bundle (Class IIb, LOE C-LD).• I t is recommended that emergency dispatchers deter-mine if a patient is unconscious with abnormal breathingafter acquiring the requisite information to determine the location of the event (Class I, LOE C-LD).• I f the patient is unconscious with abnormal or absent breathing, it is reasonable for the emergency dispatcher to assume that the patient is in cardiac arrest (Class IIa, LOE C-LD).• Dispatchers should be educated to identify unconscious-ness with abnormal and agonal gasps across a range of clin-ical presentations and descriptions (Class I, LOE C-LD).• We recommend that dispatchers should provide chest compression–only CPR instructions to callers for adults with suspected OHCA (Class I, LOE C-LD).• It is reasonable for healthcare providers to provide chest compressions and ventilation for all adult patients in cardiacarrest, from either a cardiac or a noncardiac cause (Class IIb, LOE C-LD). When the victim has an advanced airway in place during CPR, rescuers no longer deliver cycles of30 compressions and 2 breaths (ie, they no longer interruptcompressions to deliver 2 breaths). Instead, it may be rea-sonable for the provider to deliver 1 breath every 6 seconds(10 breaths per minute) while continuous chest compres-sions are being performed (Class IIb, LOE C-LD). When the victim has an advanced airway in place during CPR, it may be reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths per minute) while continuous chest compressions are being performed (Class IIb, LOE C-LD). This simple rate, rather than a range of breaths per minute, should be easier to learn, remember, and perform.• There is insufficient evidence to recommend the use of artifact-filtering algorithms for analysis of electrocardio-graphic (ECG) rhythm during CPR. Their use may be con-sidered as part of a research program or if an EMS system has already incorporated ECG artifact-filtering algorithms in its resuscitation protocols (Class IIb, LOE C-EO).• It may be reasonable to use audiovisual feedback devices during CPR for real-time optimization of CPR perfor-mance (Class IIb, LOE B-R).• For victims with suspected spinal injury, rescuers should initially use manual spinal motion restriction (eg, plac-ing 1 hand on either side of the patient’s head to hold it still) rather than immobilization devices, because use of immobilization devices by lay rescuers may be harmful (Class III: Harm, LOE C-LD).Knowledge Gaps• The optimal method for ensuring adequate depth of chest compressions during manual CPR• The duration of chest compressions after which venti-lation should be incorporated when using Hands-Only CPR• The optimal chest compression fraction• Optimal use of CPR feedback devices to increase patient survivalPart 6: Alternative Techniques and Ancillary Devices for Cardiopulmonary Resuscitation High-quality conventional CPR (manual chest compressions with rescue breaths) generates about 25% to 33% of normal cardiac output and oxygen delivery. A variety of alternativesNeumar et al Part 1: Executive Summary S319and adjuncts to conventional CPR have been developed with the aim of enhancing coronary and cerebral perfusion during resuscitation from cardiac arrest. Since the 2010 Guidelines were published, a number of clinical trials have provided new data regarding the effectiveness of these alternatives. Compared with conventional CPR, many of these techniques and devices require specialized equipment and training. Some have been tested in only highly selected subgroups of cardiac arrest patients; this selection must be noted when rescuers or healthcare systems consider implementation of the devices. Significant New and Updated Recommendations• The Resuscitation Outcomes Consortium (ROC) Prehospital Resuscitation mpedance V alve and EarlyV ersus Delayed Analysis (PRI MED) study (n=8718)14failed to demonstrate improved outcomes with the use ofan impedance threshold device (ITD) as an adjunct to con-ventional CPR when compared with use of a sham device.This negative high-quality study prompted a Class III: NoBenefit recommendation regarding routine use of the ITD.• One large randomized controlled trial evaluated the use ofactive compression-decompression CPR plus an ITD.15 Thewriting group found interpretation of the true clinical effectof active compression-decompression CPR plus an I TDchallenging because of wide confidence intervals aroundthe effect estimate and also because of methodological con-cerns. The finding of improved neurologically intact sur-vival in the study, however, supported a recommendationthat this combination may be a reasonable alternative withavailable equipment and properly trained providers.• Three randomized clinical trials comparing the use ofmechanical chest compression devices with conventionalCPR have been published since the 2010 Guidelines.None of these studies demonstrated superiority ofmechanical chest compressions over conventional CPR.Manual chest compressions remain the standard of carefor the treatment of cardiac arrest, but mechanical chestcompression devices may be a reasonable alternativefor use by properly trained personnel. The use of themechanical chest compression devices may be consid-ered in specific settings where the delivery of high-qualitymanual compressions may be challenging or dangerousfor the provider (eg, prolonged CPR during hypothermiccardiac arrest, CPR in a moving ambulance, CPR in theangiography suite, CPR during preparation for ECPR),provided that rescuers strictly limit interruptions in CPRduring deployment and removal of the device (Class IIb,LOE C-EO).• Although several observational studies have been pub-lished documenting the use of ECPR, no randomizedcontrolled trials have evaluated the effect of this therapyon survival.Knowledge Gaps• Are mechanical chest compression devices superior tomanual chest compressions in special situations suchas a moving ambulance, prolonged CPR, or proceduressuch as coronary angiography?• What is the impact of implementing ECPR as part of thesystem of care for OHCA?Part 7: Adult AdvancedCardiovascular Life SupportThe major changes in the 2015 advanced cardiovascular life support (ACLS) guidelines include recommendations regard-ing prognostication during CPR based on end-tidal carbon dioxide measurements, use of vasopressin during resuscita-tion, timing of epinephrine administration stratified by shock-able or nonshockable rhythms, and the possibility of bundling steroids, vasopressin, and epinephrine administration for treatment of IHCA. In addition, vasopressin has been removed from the pulseless arrest algorithm. Recommendations regard-ing physiologic monitoring of CPR were reviewed, although there is little new evidence.Significant New and Updated Recommendations • Based on new data, the recommendation for use of the maximal feasible inspired oxygen during CPR was strengthened. This recommendation applies only while CPR is ongoing and does not apply to care afterROSC.• The new 2015 Guidelines Update continues to state that physiologic monitoring during CPR may be use-ful, but there has yet to be a clinical trial demonstrating that goal-directed CPR based on physiologic parametersimproves outcomes.• Recommendations for ultrasound use during cardiac arrest are largely unchanged, except for the explicit pro-viso that the use of ultrasound should not interfere with provision of high-quality CPR and conventional ACLS therapy.• Continuous waveform capnography remained a Class I recommendation for confirming placement of an endo-tracheal tube. Ultrasound was added as an additional method for confirmation of endotracheal tube placement.• The defibrillation strategies addressed by the 2015 ILCOR review resulted in minimal changes in defibrilla-tion recommendations.• The Class of Recommendation for use of standard dose epinephrine (1 mg every 3 to 5 minutes) was unchangedbut reinforced by a single new prospective randomized clinical trial demonstrating improved ROSC and survivalto hospital admission that was inadequately powered to measure impact on long-term outcomes.• Vasopressin was removed from the ACLS Cardiac ArrestAlgorithm as a vasopressor therapy in recognition of equivalence of effect with other available interventions (eg, epinephrine). This modification valued the simplic-ity of approach toward cardiac arrest when 2 therapies were found to be equivalent.• The recommendations for timing of epinephrine admin-istration were updated and stratified based on the initial presenting rhythm, recognizing the potential difference inpathophysiologic disease. For those with a nonshockablerhythm, it may be reasonable to administer epinephrine as soon as feasible. For those with a shockable rhythm, there is insufficient evidence to make a recommendation。

2015年心肺复苏指南(1)

6、设定固定的高级气道通气频率
对于实施了高级气道措施（气管插管、
喉罩等）的患者，2010年指南要求通气频
率为每分钟80次，这次为了更方便学习和
实施，将通气频率设定为每6秒1次（即10
次/分）
8. 瘾君子的福音
纳洛酮
新版指南指出，对于已知或疑似阿片类药物成瘾的患者，如果无反应且呼吸正常，但有脉搏，救治同时可以给予患者肌内注射或鼻内给予纳洛酮。同时给出了纳洛酮的用法，即纳洛酮 2 mg 滴鼻或 0.4 mg 肌注。并可根据患者反应情况，在 4 分钟后重复给药。
3秒--黑朦
5-10秒—意识丧失，突然倒地，晕厥 15-30秒—全身抽搐 45秒—瞳孔散大 60秒—自主呼吸逐渐停止 4分钟—开始出现脑水肿 6分钟—开始出现脑细胞死亡

10分钟—脑细胞出现不可逆转的损害，进入“脑死亡”“植物状态”
“4-6分钟”黄金救命时间
时间就是生命
心肺复苏存活率
CPR开始的时间 CPR成功率＞90%
前言
2015年10月，新版《美国心脏学会 CPR和ECC指南》隆重登场。今年的指南到底有啥变动？是否如同5年前那样几乎彻底颠覆？下面我们就梳理一下该指南中标准CPR流程的主要变更点。
1、生命链一分为二
AHA成人生存链分为两链：一链为院内急救体系，另一链为院外急救体系
Hale Waihona Puke 院外心脏骤停（OHCA）生存链
婴幼儿胸外心脏按压方法
定位：双乳连线与胸骨垂直交叉点下方1横指。幼儿：一手手掌下压。婴儿：环抱法，双拇指重叠下压；或一手食指、中指并拢下压。下压深度：（婴儿）胸部前后径的三分之一，（4 厘米）。儿童（5 厘米）。按压频率：100--120次。

2015年版心肺复苏术

20
单人使用气囊面罩
操作者取患者头侧位置，提起下颌保持气道开放，使用一只手的拇指和食指形成“C”形，其他手指提起下颌角（形成“E”形）使患者开放气道，将面罩缘压到患者脸上。
21
双人使用气囊面罩
一施救者仰起患者的头部，并将每只手的拇指和食指形成“C”形，他3个手指（形成“E”形）提起下颌，将面罩密封到患者脸部。另一名施救者缓慢挤压气囊（持续1秒钟）直到胸廓抬起。
非心脏性疾病，如气道梗阻、烟雾吸入、溺水、感染，中毒等。
操作流程
仍建议成人、儿童和婴儿（不包括新生儿）的基础生命支持程序为 C-A-B（胸外按压、开放气道、人工呼吸）
心脏按压速率和幅度
高质量的心肺复苏应该有足够的速率和按压幅度：按压速率为100 -120次/分钟幅度至少是5厘米，不超过6厘米
22
操作要点
人工呼吸（Breathing）
在有条件下不主张口对口人工呼吸，主张用简易呼吸气囊人工呼吸（E-C手法）
儿童及婴儿：12-20次/分钟（约每3-5秒吹气1次）
成人：10-12次/分（约每5-6秒吹气1次）
23
操作要点心肺复苏有效指标判断
在CPR开始后每2分钟或5个循环周期后进行（1）面色（2）颈动脉（3）意识（4）自主呼吸
24
操作要点
复苏可出现以下四种情况 • 1.有呼吸、有大动脉搏动，准备后送。 • 2.无呼吸、有大动脉搏动，予人工呼吸。 • 3.有呼吸、无大动脉搏动，予心脏按压。 • 4.效果不佳者，应持续CPR直到救护增援人
员、AED到达或患者恢复呼吸和意识为止。
25
CPR终止指标
院前：
1.环境安全危及到施救者 2.恢复有效自主循环及通气 3.病人转移到其他医护人员或医院 4.判定死亡无救（致死性伤害、疾病终末期、

心肺复苏-2015版

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。
哪几种情况可以不予CPR
1、实施CPR会对实施者本人产生严重的损伤或致死性的风险。 2、明显的不可逆的死亡征象如：尸僵、尸斑、断头、横断尸或腐尸等。 3、具备有效签名和日期不希望复苏声明的。
2015版国际心肺复苏指南
宜昌市妇幼保健院丁茜
基本概念
1、心肺复苏（ Cardio-Pulmonary Resuscitaion=CPR ）：针对
呼吸和循环骤停所采取的抢救措施，以人工呼吸替代病人的自主呼吸，
以心脏按压形成暂时的人工循环并诱发心脏的自主搏动。
2、心搏停止：心脏射血功能的突然停止，大动脉搏动与心音消失，
5、纳洛酮：呼吸兴奋剂，拮抗该药引起的呼吸抑制，促使病人苏醒。
使用安全、可靠。静脉通路建立后，应尽早静注纳洛酮 2.0mg ，以后每半小时注射2.0mg，儿童酌减。
五、恢复自主循环后，在 ICU 的心脏骤停后治疗，并对其神
经系统和生理状态进行评估（包括使用低温治疗）。
临床采用的降温方法包括：
低温疗法
——静脉持续冷液体（3-4℃ 0.9%NS）30ml/kg,

降温速度为≤ 4.0℃／h ,
——使体表或血管内温度达：32-34℃ ≥24h ， —— 24h后，以0.25 ℃/h 的速度，缓慢复温。 ——防止体温 ≥ 37.7℃。
心肺复苏的有效指标
自主呼吸及心跳恢复
1、物理：冰袋、冰毯、冰帽； 2、灌注：一侧颈动脉体外冷却血液灌注；冰水鼻腔灌洗等； 3、液体：输入冷液体。

2015版AHA心肺复苏(步骤)

全民CPR，尤其是医务人员
以下疾病表现预示猝死可能发生（尤其要在院内重点监测和预防这些疾病！）

1.胸痛：多见ACS、肺栓塞、夹层、气胸等 2.呼吸困难：急性心衰、重症哮喘、气胸等 3.心慌：室上速、室速、重度传导阻滞 4.剧烈头痛：急性脑血管病 5.肢体瘫痪：急性脑血管病或神经系统的其他严重疾病 6.昏迷：心脏骤停、急性脑血管病、脑损伤、低血糖、各种急性中毒等急危重症 7.抽搐：可见于心脏骤停瞬间，癫痫等 8.急性腹痛:ACS、危重急腹症、夹层等 9.窒息：气道阻塞、喉头水肿、累及气道的外伤

开放气道
开放气道之前清理口腔
（将病人头偏向一侧）
开放气道方法：

仰头举颏法——
下颌角与耳垂连线与地面垂直
看胸是否起伏！
捏鼻子
人工呼吸球囊—活瓣-面罩装置人工呼吸
用一指手将面罩置于患者的脸部，用鼻梁来做正确位置的依据。将中指、无名指、小指放在下颌部，用同一只手的拇指和食指按在面罩上，保持头部后仰、下颌抬高以保持气道通畅，以及面罩密闭，用另一只手挤压气囊，并观察胸部以确定由适当的通气。以2秒钟给予呼吸。气管插管后呼吸频率10次/分。
高质量人工通气需注意

应：给予患者足够的通气（ 30次按压后 2次人工呼吸，每次呼吸超过 1 秒，潮气量以能够使胸廓扩张为准，不需要作深呼吸）不应：给予过量通气，（即呼吸次数太多，或呼吸用力过度）以免出现胃胀、反流、误吸在气管插管等高级气道后，每 6秒钟给一次通气，即每分钟 10 次，同时进行持续胸外按压
共勉！！
Thanks for your patience！
感谢
大家关注

2015年AHA心肺复苏指南

儿童基础生命支持和心肺复苏质量
• BLS的程序为C-A-B。心肺复苏应从30次/分按压（单人）或15次/分按压（由两名医护人员为婴儿和儿童进行复苏）开始，而不是从2次通气开始。（目前仍存在知识差距，需要具体研究来检验儿童心肺复苏的最佳程序）。 • 按压深度：婴儿约4厘米左右，儿童5厘米左右。 • 按压速率：100-120次/分。
用于复苏的血管加压药：肾上腺素
• 因不可电击心律引发心脏骤停后，应尽早给予肾上腺素。研究发现，及早给予肾上腺素可以增加ROSC、存活出院率和神经功能完好存活率。
ETCO2预测复苏失败
• 经20分钟心肺复苏后，二氧化碳波形图检测的ETCO2 仍不能达到10毫米汞柱，则恢复自主循环和存活的机率极低。但不建议单纯依靠ETCO2来决定终止复苏的时间。
用于复苏的血管加压药
• 肾上腺素在心脏骤停过程中可以给予。在建议级别中略有下调。可以提高自主循环恢复率和24小时存活率，但不能提高出院率。
新生儿复苏
• 新生儿的心脏骤停绝大部分是窒息性的，因此开始通气仍然是最初心肺复苏的重点。 • 胎粪污染的羊水中出生的婴儿，肌张力差，呼吸不足，应在辐射台下开展心肺复苏的初始步骤后如没有呼吸或心率低于100次/分，则开始PPV，不建议常规插管用于气管内吸引。 • 小于35周的早产儿复苏应该在低氧（21-30%）下开始，调整氧浓度使氧饱和度达到健康足月儿达到的范围。 • 胸部按压和按压通气比（3：1）。在提供胸部按压时全部使用100%氧气，心率一旦恢复，应立即降低氧浓度。 • 药物的使用没有变化。
2015年AHA心肺复苏及心血管急救指南更新
米易县人民医院麻醉科张劲涛
成人基础生命支持和心肺复苏质量
• 非专业施救者心肺复苏 • 医护人员BLS

2015年版心肺复苏

4.立即呼救，看抢救时间，推抢救车，拉窗帘，移开床旁桌。
5.摆放体位：去枕平卧，施救者在患者右侧。
6.判断颈动脉搏动：术者示指和中指触及患者气管正中部（相当于喉结的部位，）旁开两指，至胸锁乳突肌前缘凹陷处，判断时间为5-10秒。
）放按压板，搬脚垫，行胸外按压；
3
3
2
2
操作
质量
10%
1.仪表端庄，认真严肃。
2.关心患者，观察病情细致。
3.动作敏捷，迅速准确。
3
3
4
2
2
10
2
5
2
2
注意
事项
10%
1.按压应确保足够的速度与深度，尽量减少中断，如需安插人工气道或除颤时，中断不应超过10s。
2.成人使用1-2L的简易呼吸器，1L简易呼吸器挤压1/2-2/3，2L简易呼吸器挤压1/3。
3.人工通气时，避免过度通气，以免引起患者胃部胀气。
4.如患者没有人工气道，吹气时稍停按压；有建立人工气道者，吹气时可不暂停按压。
（6）按压频率：100次/分~120次/分
（7）按压过程中要观察患者的面色；
9.检查清除口鼻腔分泌物，取下义齿。
10.人工呼吸：以压额抬颌法充分开放气道，简易呼吸器连接氧气，调节氧流量至少8-10L/min（有氧情况下）。以“EC”或者“OK”手法固定面罩，使面罩与患者面部紧密衔接无漏气，送气时间>1s，使胸廓抬举，潮气量400-600ml（无氧情况下潮气量500-600ml），频率为10-12次/分。
心肺复苏（成人，简易呼吸气囊）
项目
具体内容
分值
目的
5%
对呼吸停止、心跳停搏的患者，进行人工呼吸和胸外按压，以维持呼吸和循环功能。

2015版AHA心肺复苏(步骤)

右侧，一拳之隔
防止压伤患者的胳膊！
仰卧便于施救
（1）.乳中线定位法一岁以下两乳头连线下方
确定按压位置
胸骨下半部
按压手法要领：
按压的手法
下手指上翘
身体直、手臂直。有没有呼吸
十指交叉十指交叉
5-6cm
胸部按压： ●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，借助上半身的重力进行按压。

复苏有效指标

自主心跳恢复散大的瞳孔回缩变小，对光反应恢复意识好转肌张力增加自主呼吸恢复吞咽动作出现
终止复苏指标

复苏成功，转入下一阶段治疗复苏失败，其参考指标如下：
心脏死亡：经 30 分钟 BLS 和 ACLS 抢救，心脏毫无电活动，可考虑停止复苏术。脑死亡：目前我国尚无明确的“脑死亡”诊断标准，故需慎重执行，以避免不必要的医疗纠纷。注意社会和伦理问题！
高质量人工通气需注意

应：给予患者足够的通气（ 30次按压后 2次人工呼吸，每次呼吸超过 1 秒，潮气量以能够使胸廓扩张为准，不需要作深呼吸）不应：给予过量通气，（即呼吸次数太多，或呼吸用力过度）以免出现胃胀、反流、误吸在气管插管等高级气道后，每 6秒钟给一次通气，即每分钟 10 次，同时进行持续胸外按压
共勉！！
Thanks for your patience！
感谢
大家关注
聆听
^_^

开放气道
开放气道之前清理口腔
（将病人头偏向一侧）
开放气道方法：

仰头举颏法——

心肺复苏2015版新标准

心肺复苏2015年国际新标准操作流程CPR2015-10-13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。

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125px）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，频率10-12次/分。

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。

心肺复苏术(2015版)

• 用于消除心室颤动时称为电除颤。
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2021/8/6
根据电流脉冲通过心脏的方向：
单相波除颤仪
双相波除颤仪
根据电极板放置位置：
体外除颤仪
体内除颤仪
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根据脉冲发放与R波关系可分为同步与非同步
• ⑴同步电复律：
• ⑵非同步电复律：
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电复律/除颤能量选择
进行除颤。
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2015年心肺复苏指南
• 一旦发现患者没有反应，医护人员必须立
即呼救同时检查呼吸和脉搏，然后再启动
应急反应系统或请求支援。
• 旧指南发现患者没有反应，医护人员立即
呼救，再检查呼吸和脉搏。
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2015年心肺复苏指南
• 生存链「一分为二」
63
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继续
5个周期CPR
高级心血管生命支持ACLS
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心脏电复律
• 心脏电复律是利用外源性电流治疗心律失
常的一种方法。
• 通过电击心脏来终止心房纤颤、心房扑动
、室上性心动过速、室性心动过速和心室
纤颤等快速型心律失常恢复正常心律的一
种有效方法。包括电复律和电除颤。
• 用于转复各种快速心律时称为电复律。
O.5O-0.75 mg／kg静脉注射，直到最大量为3mg／kg
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高级心血管生命支持ACLS
• CPR标准用药
心室停搏与电机械分离
肾上腺素1mg静脉注射,每3-5分钟重复一次
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高级心血管生命支持ACLS

2015版AHA心肺复苏(完整通俗版)

1. 快速反应，团队协作
• 施救者应同时进行几个步骤，如同时检查呼吸和脉搏，以缩短开始首次按压的时间；
• 由多名施救者形成综合小组，同时完成多个步骤和评估（分别由施救者实施急救反应系统；胸外按压、进行通气或取得球囊面罩进行人工呼吸、设置除颤器同时进行）。
2. 生存链「一分为二」
AHA 成人生存链分为两链：一链为院内急救体系，另一链为院外急救体系。
• 如果当患者的心律不适合电除颤时，应尽早给予肾上腺素。
• 有研究发现，针对不适合电除颤的心律时，及早给予肾上腺素可以增加存活出院率和神经功能完好存活率。
10、及早冠脉造影
• 新指南建议，所有疑似心源性心脏骤停患者，无论是ST段抬高的院外心脏骤停患者，还是疑似心源性心脏骤停而没有心电图ST 段抬高的患者，也无论其是否昏迷，都应实施急诊冠状动脉血管造影。
1.确认现场安全
判断现场的安全性,在紧急情况下通过实地感受、眼睛观察、耳朵听声、鼻子嗅味等来对异常情况做出判断。
事发地点，先想安全，防止次生扩大
2.判断意识
• 拍打双肩，凑近耳边大声呼唤：“喂！你怎么了？”
• 如均无反应，则确定为意识丧失
轻拍重喊
3、呼救
• 镇定 • 大声喊叫来人 • 自己或吩咐他人拨打电话，
11、及早PCI
• 患者若在急诊科出现ST段抬高心肌梗死(STEMI)，而医院不能进行冠脉介入治疗(PCI)，应立即转移到PCI中心，而不应在最初的医院先立即接受溶栓治疗。
•
如果SEMEI患者不能及时转诊至能够进行
PCI的医院，可以将先接受溶栓治疗，在溶栓治
疗后最初的3到6小时内，最多24小时内，对所有
一、心脏骤停复苏过程中气管插管后，急救人员应该多久给一次通气？

心肺复苏2015年国际新标准操作流程CRP

心肺复苏2015年国际新标准操作流程CRP 2015年10月，心脏美国学会（AHA）心肺复苏新指南强调如何做到快速行动、合理培训、使用现代科技及团队协怍来增加心脏骤停患者的生存率。

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。

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！，院外手机呼120急救。

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）。

以上呼吸、脉搏可在10秒内同时完成。

5、松解衣领及裤带。

口腔无分泌物，无假牙。

8、人工呼吸：1）、院内插管。

应用简易呼吸器，双手挤压气囊，每次送气400-600ml，频率10-12次/分（6秒钟一次）。

2）、院外人工呼吸。

按压30次，口对口人工呼吸2次。

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）。

2015版心肺复苏流程、更新要点Word版

BLS医务人员成人心脏骤停流程（2015版）判断意识：呼唤患者同时轻拍肩部，患者无反应呼叫旁人帮忙，通过移动通讯设备启动应急反应系统取得除颤仪AED及急救设备(如果独自一人且没有手机则离开患者启动应急系统并取得AED然后开始心肺复苏)判断呼吸、脉搏——检查是否无呼吸或仅是喘息并同时检查脉搏（能否在10秒内明确感觉到脉搏）无呼吸、有脉搏给予人工呼吸10-12次/分，启动应急反应系统，每2分钟检查1次脉搏，如无脉搏开始心肺复苏，如可能有阿片药过量情况给予纳洛酮心肺复苏开始30:2的复苏周期，如有可能尽早使用AED(自动体外除颤仪)取复苏体位——去枕仰卧位置于硬板或平地上胸外按压——按压部位：胸骨下1/2段或剑突上2指处按压方式：双手掌根重叠，十指相紧扣，双臂绷直，垂直按压胸骨，每次按压后使胸廓充分回弹，不可在按压后倚靠在患者胸上按压深度： 5-6cm按压频率： 100-120次/分尽量减少中断（限制在10秒内）人工呼吸——打开气道清理呼吸道口对口人工呼吸2次，每次吹气时间超过1秒吹气是否有效以胸廓有起伏为标准，避免过度通气CPR循环——胸外按压与人工呼吸比30：2，每5个循环约2分钟判断呼循环体征1次。

持续半小时无效宣布死亡。

出现复苏有效指征进行下一步。

有高级气道的按压-通气比：以100-120次/分速率持续按压，每6秒给予1次呼吸（10次/分）AED到达检查心律是否可电击心律是否进行一次电击立即继续心肺复苏立即继续心肺复苏持续约2分钟持续约2分钟（直至AED提示需分析心律）持续直至高级生命支持团队接管或患者开始活动1、CPR有效指征：意识转清、自主呼吸恢复、劲动脉有搏动、瞳孔由大缩小、口唇甲床转红润。

2、在病房口对口人工呼吸用呼吸囊。

3、鼓励经过培训的施救者同时进行几个步骤（即同时检查脉搏和呼吸），以缩短开始首次胸部按压的时间。

4、由多名经过训练有素的施救者组成的综合小组可以采取一套精心设计的方法，同时完成多个步骤和评估，而不用如单一施救者那样依次完成（例如由1名施救者启动急救反应体系，第2名施救者开始胸外按压，第三名进行通气或者取得球囊面罩进行人工呼吸，第4名取回并设置好除颤器）。

2015AHA心肺复苏

类固醇对于常规治疗复苏无反应时，可酌情使用类固醇激素。氢可/甲强龙，未推荐剂量甲强龙：30mg/kg，>30 min ivgtt 4-6h 氢可：100-200mg+NS500ml ivgtt

10.心肺复苏中药物的使用

利多卡因指南更新中被提及两次。第1次：成人高级生命支持有关 ROSC 后使用利多卡因的研究存在矛盾，不建议常规使用利多卡因。但是室颤/无脉性室性心动过速导致心脏骤停，在出现 ROSC 后，可以考虑立即开始或继续使用利多卡因。第2次：儿童高级生命支持提升了利多卡因在治疗电击难以纠正的室颤或无脉性室性心动过速的心律失常中的作用，与胺碘酮同等级
2015版成人心血管急救生存链
院内心脏骤停
成人心血管急救生存链
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
11
院外复苏

建议：在有可能目击者的院外心脏骤停发生率相对较高的公共场所，实施PAD 更新：如果患者没有反应与呼吸或者呼吸不正常，施救者和调度员应假设患者发生心脏骤停

8.心肺复苏的替代技术和辅助装置

不建议例行使用ITD辅助传统心肺复苏无证据表明使用机械胸外按压装置相对于人工按压更有优势，但是可在特殊条件下运用：施救者有限，时间长，低温，移动救护车，血管造影室，准备体外复苏期间
9.ECRP

对于发生心脏骤停且怀疑病因可逆的选定患者，可以考虑ECRP替代CRP

10.心肺复苏中药物的使用

利多卡因利多卡因用法：起始剂量 1-1.5 mg/kg 静推（一般用 50-100 mg），静脉注射 2-3 min。根据患者反应，5-10 min 后可再用 0.50.75 mg/kg 静推，1 h 内最大剂量不得超过 300 mg。利多卡因易引起除颤后心脏停搏，使用时应予以注意。

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双手抬颌法仰头抬颈法
口对口人工呼吸动作要点
捏鼻子
看胸是否起伏！
人工呼吸
球囊—活瓣-面罩装置人工呼吸
用一指手将面罩置于患者的脸部，用鼻梁来做正确位置的依据。将中指、无名指、小指放在下颌部，用同一只手的拇指和食指按在面罩上，保持头部后仰、下颌抬高以保持气道通畅，以及面罩密闭，用另一只手挤压气囊，并观察胸部以确定由适当的通气。以2秒钟给予呼吸。气管插管后呼吸频率10次/分。
• 自己或吩咐他人拨打电话，
获得AED
• 告知科室、楼层、床号
右侧，一拳之隔
防止压伤患者的胳膊！
仰卧便于施救
一岁以下两乳头连线下方
（1）.乳中线定位法
确定按压位置
胸骨下半部
按压的手法要领：
按压的手法
下手指上翘
身体直、手臂直。
有
没
有
十十指指交交叉叉
呼吸
胸部按压： ●按压方法：
1.确认现场安全
判断现场的安全性,在紧急情况下通过实地感受、眼睛观察、耳朵听声、鼻子嗅味等来对异常情况做出判断。
事发地点，先想安全，防止次生扩大
2.判断意识
• 拍打双肩，凑近耳边大声呼唤：“喂！你怎么了？”
• 如均无反应，则确定为意识丧失
轻拍重喊
3、呼救
• 镇定 • 大声喊叫来人
来人呐！救命啊！
5分钟是大脑的G（葡萄糖）和ATP（三磷酸腺苷）储存耗竭的时限！
三、时间就是生命！
心脏骤停的严重后果以分秒来计算： ● 3～5 秒：黑蒙 ● 5～10 秒：昏厥 ● 15 秒左右： Adams-Stokes综合征发作 ● 10～20 秒：意识丧失 ● 30～60 秒：瞳孔散大
● 60 秒： 3 呼吸渐停止
以下为该指南的14大更新要点：
1. 快速反应，团队协作
• 施救者应同时进行几个步骤，如同时检查呼吸和脉搏，以缩短开始首次按压的时间；
• 由多名施救者形成综合小组，同时完成多个步骤和评估（分别由施救者实施急救反应系统；胸外按压、进行通气或取得球囊面罩进行人工呼吸、设置除颤器同时进行）。
2. 生存链「一分为二」
施以挽救其生命。即胸外按压形成暂时的人工循环，电击除颤转复心室颤动，促使心脏恢复自主
搏动，人工呼吸纠正缺氧，并努力恢复自主呼吸。
— 中国心肺复苏指南
二、病理生理
心脏骤停后，主要损害（缺氧所致）依次为
大脑 -→心肺系统 -→肾脏及内分泌……
脑组织占体重的 2% 静息时耗氧量占人体氧总摄取量的 20% 血液供应3量为心排出量的 15% 大脑只能有氧代谢，没有氧储备。
11、及早PCI
• 患者若在急诊科出现ST段抬高心肌梗死(STEMI)，而医院不能进行冠脉介入治疗(PCI)，应立即转移到PCI中心，而不应在最初的医院先立即接受溶栓治疗。
• 如果SEMEI患者不能及时转诊至能够进行PCI 的医院，可以将先接受溶栓治疗，在溶栓治疗后最初的3到6小时内，最多24小时内，对所有患者尽早转诊，进行常规血管造影，不建议只在患者因缺血需要血管造影时，才转诊。
2015心肺复苏指南（AHA）
浙江医院呼吸与危重医学科
内容
• 心肺复苏的概念 • 2015版心肺复苏指南更新要点 • 心肺复苏步骤
内容
• 心肺复苏的概念 • 2015版心肺复苏指南更新要点 • 心肺复苏步骤
一、定义
复苏：( Resuscitation ) 复活、苏醒 = 死而复生
心肺复苏：(Cardio-Pulmonary Resuscitation = CPR ) 是针对心脏、呼吸骤停者所采取的急救措
别再使劲按了！费劲！
• 新指南规定，胸部按压在整个心肺复苏中的目标比例为至少60%。
• 指南把心肺复苏与驾车行驶进行了比较。在驾车行驶时，一天行驶的里程数不仅受行驶速度影响，还受中途停顿的次数和时间影响。以60英里/小时的速度不中断行驶，则实际行驶距离为一小时60英里。以60英里每小时的速度行驶，但中途停顿10分钟，则实际行驶距离为―小时的英里。停顿越频繁，停顿时间越长，则实际行驶里程越少。
AHA 成人生存链分为两链：一链为院内急救体系，另一链为院外急救体系。
院外急救
手机时代，充分利用社会媒体呼叫施救者，手机等现代化电子设备能够在院外急救中发挥重要作用
院内急救
院内急救应以团队形式实施心肺复苏：早期预警系统、快速反应小组（RRT）和紧急医疗团队系统（MET）。
3、按压深度变更
共勉！！！
Thanks for your patience！
• 旧版指南仅指出，急救人员和院内专业救援人员都可为心骤停患者实施胸外按压和人工呼吸。
7、除颤
10 年的指南中，在 AED 就绪时，应先进行 1.5 - 3 分钟的 CPR, 然后再除颤。最新版则提出：当施救者可以立即取得 AED 时，对于成人心脏骤停患者，应尽快使用除颤器；若不能立刻取得 AED，应该在他人前往获取以及转变 AED 的时候开始心肺复苏，在设备提供后尽快尝试进行除颤。
一、心脏骤停复苏过程中气管插管后，急救人员应该多久给一次通气？
在气管插管后，管理呼吸道人员要在不影响胸外按压前提下，每 6～8 秒钟给一次通气，即每分钟 8 ～10 次
• 二、哪个部位放置电极或除颤板是最有效的？
• 右侧锁骨中线锁骨下 • 左侧腋中线第5肋间
呼吁
美国每年有 20 万例院内心脏骤停发生。 CPR 培训是基础必会的课程。然而，研究显示，这一技能会在接受培训后数月内逐渐生疏。所以应进行反复、高频的培训来保证院内持续掌握，并熟悉如何将患者转运到最高质量的心血管急救部门。
4、按压的频率
• 按压频率规定为100～120次/分。 • 原指南仅仅规定了每分钟按压频率不
少于100次/分，但一项大样本的注册研究发现，如果按压频率(超过140次/分)过快，按压幅度则不足。 • 指南也指出，在心肺复苏过程中，施救者应该以适当的速率(100至120次/分)和深度进行有效按压，同时尽可能减少胸部按压中断的次数和持续时间。
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，借助上半身的重力进行按压。
频率：100-120/分
深度：5-6厘米
5-6cm
掌根不要离开胸壁放松要充分
2013.11.19呼吸内科科会讲稿吴滨
开放气道
开放气道之前清理口腔（将病人头偏向一侧）
开放气道方法：
仰头举颏法
Байду номын сангаас
12、低温治疗
• 所有在心脏骤停后恢复自主循环的昏迷，即对语言指令缺乏有意义的反应的成年患者，都应采用目标温度管理(TTM)，选定在 32到36度之间，并至少维持24小时。
13、及早EMMS
• 一旦发现患者没有反应，医护人员必须立即呼救同时检查呼吸和脉搏，然后再启动应急反应系统或请求支援。
14、C-A-B 顺序仍需坚持
对于施救顺序，最新的指南重申应遵循 10 年版指南内容，即单一施救者的施救顺序：应先开始胸外按压再进行人工呼吸（C - A - B），减少首次按压的延时；30 次胸外按压后做 2 次人工呼吸。
内容
• 心肺复苏的概念 • 2015版心肺复苏指南更新要点 • 心肺复苏步骤
• 如果当患者的心律不适合电除颤时，应尽早给予肾上腺素。
• 有研究发现，针对不适合电除颤的心律时，及早给予肾上腺素可以增加存活出院率和神经功能完好存活率。
10、及早冠脉造影
• 新指南建议，所有疑似心源性心脏骤停患者，无论是ST段抬高的院外心脏骤停患者，还是疑似心源性心脏骤停而没有心电图ST 段抬高的患者，也无论其是否昏迷，都应实施急诊冠状动脉血管造影。
● 1～2 分钟：瞳孔固定、二便失禁 ● 3 分钟：开始出现脑水肿 ● 6 分钟：开始出现脑细胞死亡 ● 8 分钟： “脑死亡”
●心肺复苏的——“黄金8分钟”
三、时间就是生命！！
心脏骤停时间内复苏 CPR成功率
1min
>90%
4min
>60%
6min 38min
>40% >20%
10min
几乎0 %
8. 瘾君子的福音
若患者有疑似生命危险或与阿片类药物相关的紧急情况，应给与纳洛酮。瘾君子的福音！对于已知或疑似阿片类药物成瘾的患者，如果无反应且呼吸正常，但有脉搏，可由经过正规培训的非专业施救者和 BLS 施救者给与肌肉注射或鼻内给予纳洛酮。
9、加压素被「除名」
• 10 年版指南认为一剂静脉 / 骨内推注的 40 单位加压素科替代第一或第二剂肾上腺素治疗心脏骤停。而新版则指出，联合使用加压素和肾上腺素，相比使用标准剂量的肾上腺素在治疗心脏骤停时没有优势。给与加压素相对使用肾上腺素也没有优势，因此，加压素已被新版指南「除名」。
• 首次规定按压深度的上限：在胸外按压时，按压深度至少5厘米，但应避免超过6厘米。
• 旧指南仅仅规定了按压深度不低于5厘米。新指南认为，按压深度不应超过6厘米，超过此深度可能会出现并发症，但指南也指出，大多数胸外按压不是过深，而是过浅。
• 对于儿童(包括婴儿[小于一岁]至青春期开始的儿童)，按压深度胸部前后径的三分之一，大约相当于婴儿4厘米，儿童5厘米。对于青少年即应采用成人的按压深度，即5～6厘米。
即：每延长1分钟施救，成活率就下降10%！
内容
• 心肺复苏的概念 • 2015版心肺复苏指南更新要点 • 心肺复苏步骤
前言
2015 年 10 月 15 日，新版《美国心脏学会 CPR 和 ECC 指南》隆重登场。时隔 5 年，AHA 会对指南的哪些部分进行更改？是否提出了颠覆性的观点？在新的心肺复苏指南中强调如何做到快速行动、合理培训、使用现代科技及团队协作来增加心脏骤停患者的生存几率

2015版AHA心肺复苏(完整通俗版)

2015年心肺复苏指南课件

心肺复苏2015年国际新标准操作流程CPR

2015 AHA心肺复苏指南

2015年心肺复苏指南(1)

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2015年版心肺复苏

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心肺复苏术(2015版)

2015版AHA心肺复苏(完整通俗版)

心肺复苏2015年国际新标准操作流程CRP

2015版心肺复苏流程、更新要点Word版

最新版2015心肺复苏指南

2015AHA心肺复苏