2010年心肺复苏指南(完整版)
心肺复苏指南(2010年版)
AMSA 技术用于除颤治疗 有望能在 2010 年的心肺复苏指南中得
以推荐
• Weil 心脏医学研究院近年对于 VF波形的分析研 究取得突破性进展
• 组合心电波形幅度与频率数值的幅度谱面积 (AMSA) 技术 , 根据 VF 波形分 析决定优先除颤、 还是先行 CPR 后再除 颤
• 整合 AMSA 技术的新一代智能商品化自动体外除 颤器现已进入临床试验阶段
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图1 美国心脏协会 2010 年《心肺复苏指南》制定进程 （注 :ILCOR, 国际复苏联络委员会）
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（一）心肺复苏优先次序的选择
• 专家达成的共识：
• 及早除颤的重要性达成共 识 • 现有指南建议当院外心跳骤停事件 被目击或者发
生院内心跳骤停事件时 , 假如在现场可以立刻获 得 AED 或者人工除颤器 , 急救人员应当立刻进行 CPR和尽早使用 除颤器
• 有人提出在猝死二级预防中应使用胺腆酮
• 猝死高危者一级预防 ; 心梗或心衰者射血分数 (EF)<35%; 微伏 T 波电交替 ; 频发非持 续性室 速没有条件接自动除颤器 (ICD) 植入治疗的患者
• 胺腆酮和硫酸镁合用
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美托洛尔
• 交感风暴 ----反复发作性的室性心 动过 速 / 心室颤动
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2. 恶性心律失常的药物治疗
• 2005 美国心脏协会 《心肺复苏指南》建 议:
• CPR时 , 如果 24 次电击、持续的心肺复苏 和应 用血管升压药物之后室性心动过速和 心室颤动仍然存在 , 应考虑给予抗心律 失 常药物
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胺腆酮
• 近年各相关指南建议胺腆酮作为治疗恶性心律失 常的首选药物
2010版心肺复苏指南
2019/3/10
CPR2010国际新指南
修改要点-7
7.不建议在心脏停止时常规作环状软骨按压
理由：虽然环状软骨按压可在球囊面罩通气期间避 免发生胃胀气，并减少胃酸反流与吸入的风险， 但也可能阻碍通气 。
可能延迟或阻碍高级呼吸道装置的放置 仍可能发生吸入情形
要适当训练施救者使用此操作法很困难 。
2019/3/10
CPR2010国际新指南
新指南BLS部分
2019/3/10
2019/3/10
CPR2010国际新指南
关于判断
医务人员在检查反应时应该快速检查有无呼吸或不能正
常呼吸（即无呼吸或仅是喘息） 然后该人员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）
已从流程中去除“看、听和感觉呼吸”
2019/3/10
CPR2010国际新指南
修改要点-1
1. 应提高急救人员与非专业施救者对心脏 停止的辨识能力
医务人员应电话指导非专业施救者于患者「没 有反应，沒有呼吸或沒有正常呼吸 (即仅有喘 息)」时开始 CPR，而无需检查脉搏对医务人 员亦不强调一定要先检查清楚脉搏（如10秒钟 内没有明确触摸到脉搏，则应开始CPR） 理由：紧急情况下，通常无法准确地判断脉搏 是否存在，特别是脉搏细弱时 。
2019/3/10
CPR2010国际新指南
修改要点-10
10. 儿童和婴儿使用AED 在无法取得手动除颤仪及配备剂量衰减 功能的AED时，可使用普通AED 理由：适用于婴儿和儿童有效除颤的最 低能量剂量及安全除颤的上限均不明确， 但＞4 J/Kg (最大 9 J/Kg) 的剂量可有效 为儿童和动物实验模型的小儿心脏除颤， 且不会有显著的副反应
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。
2010心肺复苏指南
2010
CPR
总结
• 几个数字的变化
– 除颤能量不变，但更强调CPR – 肾上腺素用法用量不变，不推荐对心脏停搏或无脉电 活动（PEA）者常规使用阿托品 – 维持自主循环恢复 （ROSC）的血氧饱和度在94%98% – 血糖超过10mmol/L即应控制，但强调应避免低血糖 – 强化按压的重要性，按压间断时间不超过5s
2010 CPR
成人基础生命支持简化流程
2010
CPR
医务人员基础生命支持
• 专门培训从而提高对心脏骤停的识别能力并指示 未经培训的非专业施救者进行单纯胸外按压 • 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），启动急救系统并找到 AED （或由其他人员寻找）。检查脉搏的时间不应超 过 10 秒，应开始心肺复苏并使用 AED • 通常不建议在通气过程中采用环状软骨加压 • 继续强调需要缩短从最后一次按压到给予电击之 间的时间，以及给予电击到电击后立即恢复按压 之间的时间 • 进一步强调通过团队形式给予心肺复苏
2010 CPR
伦理学问题
• 对于接受低温治疗的心脏骤停后成人患者，建议 在心脏骤停的三天后，观察是否有神经损伤症状 并在适当地点完成电生理研究、生物标记和成像 • 目前，支持撤去生命支持的决策的证据有限。医 生应在为心脏骤停采用低温治疗后的 72 小时后 记录所有可行的预后检查结果，并根据该检查结 果做出最合理的临床判断，以便在适当情况下做 出撤去生命支持的决策。 • 心脏骤停后至少 24 小时后对体感诱发电位双侧 未出现 N20 波峰，且心脏骤停后至少三天后无角 膜反射和瞳孔反射。
2010
CPR
主要原则
• 生存链：由四早生存链改为五个链环：
– – – – – 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
2010心肺复苏指南
类型
房颤 房扑 阵发性室上速 单形性VT 多形性VT VF
单相波 100～ 200→200 50～100J
100 J 200J 360J
能量 双相波
备注
100～120→120～ 200
50～100J
递增 递增
同步 同步
100 J 200J
递增 同步 递增 非同步
非同步
内容
建议
识别
无反应，没有呼吸或不能正常呼吸 （仅仅是喘息）
性电活动）者常规使用阿托品。
生存链的变化
★2010（新）： 1、立即识别心脏骤停，激活急救系统 2、尽早 实施CPR，突出胸外按压 3、快速除颤 4、有 效地高级生命支持 5、综合的心脏骤停后治疗
●2005（旧）： 1、早期识别，激活EMS 2、早期CPR 3、早期 除颤 4、早期高级生命支持（ACLS） 应及时识别无反应征象，立即激活应急救援系统。 如无呼吸，应立即进行胸外按压。
胸部按压（C，compression） 开放气道（A，airway） 人复苏—BLS(CAB)
C：
部位： 胸骨下1/2处
胸骨中下部
双乳头之间
频率：100次/分→至少100次/分
按压幅度：胸骨下陷4～5cm→至少5cm
压下后应让胸廓完全回复
压下与松开的时间基本相等
强调胸外按压的重要性
★2010(新)： 明确：如果旁观者没有经过心肺复苏术培训，可以 提供只有胸外按压的CPR。 即“用力按，快速 按”，在胸部中心按压，直至受害者被专业抢救者 接管。
训练有素的救援人员，应该至少为被救者提供 胸外按压。 另外，如果能够执行人工呼吸，按压 和呼吸比例按照30：2进行。在到达抢救室前，抢 救者应持续实施CPR ●2005（旧）： 没有区别抢救者是否受过培训。 仅建议旁观者可以 在指导下行胸外按压。
2010国际心肺复苏指南
基础生命支持—BLS
• 非医务人员亦可实施，开始的时间越早越好 • 目前国际上普遍采用的ＢＬＳ手法是根据１９８０年
日内瓦国际会议决定的，由美国心脏病学会经历数次 国际心肺复苏会议不断改进完善所颁布的标准 • 2005第二次国际心肺复苏会议仍然推荐ＢＬＳ按照英 文字母Ａ、Ｂ、Ｃ、的顺序进行：A-气道；Ｂ－呼吸 支持；Ｃ－循环支持。
心跳骤停的心电图分型
• 心室停搏（伴或不伴心房静止） 心 肌完全失去电活动能力，心电图上表 现为一条直线。常见窦性、房性、结 性冲动不能达到心室，且心室内起搏 点不能发出冲动。
气道阻塞的常见病因
呼吸道阻塞系指呼吸器官（口、鼻、 咽、喉、气管、支气管、细支气管和肺 泡）的任何部位发生阻塞或狭窄，阻碍 气体交换，或呼吸道邻近器官病变引起 的呼吸道阻塞，以至发生阻塞性呼吸困 难的总称。
无氧缺血时脑细胞损伤的进程
脑循环中断： • 10秒—— 脑氧储备耗尽 • 20-30秒—— 脑电活动消失 • 4分钟 ——脑内葡萄糖耗尽，糖无氧代谢停止 • 5分钟——脑内ATP枯竭，能量代谢完全停止 • 4-6分钟——脑神经元发生不可逆的病理改变 • 6小时—— 脑组织均匀性溶解
心跳骤停的常见病因
心肺复苏
A：即判断有无意识、畅通呼吸道。
a) 使病人去枕后仰于地面或硬板床上，解开衣领 及裤带；
b) 畅通呼吸通道，清理口腔、鼻腔异物或分泌物 、假牙等；
c) 开放气道手法：仰面抬颌法、仰面抬颈法、托 下颌法。
开放气道手法
• 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。
心肺复苏
B：即人工呼吸 人工呼吸就是用人工的方法帮助病人呼吸， 是心肺复苏基本技术之一。
2010年心肺复苏指南(标准版)
参数（深度、频率、呼吸比） 参数（深度、频率、呼吸比）
•深度：≥ 5cm •频率：≥ 100次/分 •比例：按压和放松间 隔比为50%，胸廓完 全回弹，按压呼吸比 30：2 •过程：间断确保最短， 避免过度通气。
高质量的胸外按压
开放气道
证明没有颈部外伤\托颌法无法开放气道 仰头举颏法（head tilt-chin lift） 怀疑有颈椎损伤 托颌法(jaw thrust)
4:进行 次按压和 次人工呼吸循环，要求 进行30次按压和 次人工呼吸循环， 进行 次按压和2次人工呼吸循环 按压≥100/min，幅度 5cm，胸廓完全回弹， 按压 ，幅度≥ ，胸廓完全回弹， 间断确保最短， 间断确保最短，避免过度通气
现场心肺复苏的流程(BLS的D)
5：AED/除颤仪到达 ： 除颤仪到达
2010年心生产应急实训科研出江基地
开始复苏的时间是关键： 开始复苏的时间是关键：
4分钟内开始复苏者，约50%可被救活； 分钟内开始复苏者， 50%可被救活； 内开始复苏者 分钟开始复苏者 10%可以救活； 开始复苏者， 4 ～6分钟开始复苏者，10%可以救活； 超过6分钟者存活率仅4 超过6分钟者存活率仅4%； 者存活率仅 10分钟 以上开始复苏者 存活可能性极小。 10 分钟以上开始复苏者 ， 存活可能性极小 。 分钟 以上开始复苏者，
呼救，启动EMSS-据因灵活救治顺序
•启动EMS系统（让其他在现场人员呼叫 120） •仅有一个抢救人员，面对任何原因引起的 心脏骤停患者，应先给5周期CPR（约2分 钟），再去启动EMS。
判断脉搏
急救人员一手食指和中指并拢， 以患者喉结为标志，沿甲状 软骨向靠近急救人员一侧的 滑行到胸锁乳突肌凹陷处 注意事项：用力不能太大、时 间<10秒、不能确定时以心 博停止处理、注意假阳性
2010中国心肺复苏指南
中国心肺复苏指南中华医学会急诊医学分会复苏组心肺复苏(CPR)是针对心脏、呼吸骤停所采取的抢救措施。
即胸外按压形成暂时的人工循环，快速电除颤转复心室颤动(VF),促使心脏恢复自主搏动；采用人工呼吸以纠正缺氧，并努力恢复自主呼吸。
一、成人基本生命支持（ABLS）（一）基本生命支持（BLS）适应症1．呼吸骤停很多原因可造成呼吸骤停，包括溺水、卒中、气道异物阻塞、吸入烟雾、会厌炎、药物过量。
电击伤、窒息、创伤，以及各种原因引起的昏迷。
原发性呼吸停止后1分钟，心脏也将停止跳动，此时做胸外按压的数分钟内仍可得到已氧合的血液供应。
当呼吸骤停或自主呼吸不足时，保证气道通畅，进行紧急人工通气非常重要，可防止心脏发生停博。
心脏骤停早期，可出现无效的“叹息样”呼吸动作，但不能与有效的呼吸动作相混淆。
2．心脏骤停除了上述能引起呼吸骤停并进而引起心跳骤停的原因外，还包括急性心肌梗死、严重的心律失常如室颤、重型颅脑损伤、心脏或大血管破裂引起的大失血。
药物或毒物中毒。
严重的电解质紊乱如高血钾或低血钾等。
心脏骤停时血液循环停止，各重要脏器失去氧供，如不能在数分钟内恢复血供，大脑等生命重要器官将发生不可逆的损害。
（二）现场复苏程序BLS的判断阶段极其关键，患者只有经准确的判断后，才能接受更进一步的CPR（纠正体位、开放气道。
人工通气或胸外按压）。
判断时间要求非常短暂、迅速。
l．判断患者反应当目击者如非医务人员，发现患者没有呼吸、不咳嗽。
对刺激无任何反应（如眨眼或肢体移动等），即可判定呼吸心跳停止，并立即开始CPR.。
2．启动EMS拔打急救电话后立即开始CPR。
对溺水、严重创伤、中毒应先CPR再电话呼救，并由医生在电话里提供初步的救治指导。
如果有多人在场，启动EMSS与CPR应同时进行.3．患者的体位须使患者仰卧在坚固的平（地）面上，如要将患者翻转，颈部应与躯干始终保持在同一个轴面上，如果患者有头颈部创伤或怀疑有颈部损伤，只有在绝对必要时才能移动患者，对有脊髓损伤的患者不适当地搬动可能造成截瘫。
心肺复苏2010指南
碳酸氢钠
• 适应症：
• 有效通气及胸外心脏按压10分钟后，PH 值仍低于 7.2
• 心跳骤停前已存在代谢性酸中毒 • 伴有严重的高钾血症
2010心肺复苏方法
呼救
C (circulation)
心外按压的作用原理：
• 胸泵机制 胸外按压造成胸内压升高，动静脉均承受压 力，但动脉的对抗力大于静脉，在按压时保持开放， 主动脉收缩而将血液泵入大循环；而大静脉则被压陷， 回流停止；放松按压时胸内压下降，静脉回流心脏， 动脉停止泵血，回流的动脉血被主动脉瓣阻挡，血液 不能返流入心脏，部分可从冠状动脉开口流入心脏冠 状动脉 。
电除颤
2010年的指南未对除颤、电复律和起搏进行很大的修 改，强调在给与高质量的心肺复苏同时早期除颤是提 高心肺复苏存活率的关键。
电除颤
• 对一个室颤患者来说，能否成功地被给予电除颤，使 其存活，决定于从室颤发生到进行首次电除颤治疗的 时间。
• 应尽早除颤，5分钟之内开始。除颤延迟1分钟，存活 率降低7—10%，超过10分钟再除，存活率仅为2—5%。
• 心泵机制 超声技术已经证实，在按压时，心脏内的瓣 膜出现与生理情况一致的交替开放与关闭。
定位1
• 两乳头连线中点
定位2
• 定位在剑突上方2横指处
要点
★按压部位 ★姿势 ★按压与放松
间隔相等 ★幅度及频率 ★按压/通气比
率
胸外按压
• 双手指交叉垂直按 压胸骨。
• 心脏按压的 • 频率:至少100次/
分 • 深度：至少5cm
2010心肺复苏方法
2010心肺复苏方法
一手的鱼际处紧贴 在按压部位上，双 手重叠握紧，双臂 绷直，双肩在病人 胸骨上方正中，垂 直向下按压，按压 力量应足以使胸骨 下沉大于5 厘米， 压下后放松，但双 手不要离开胸壁。 反复操作，频率大 于100次/分钟
2010心肺复苏指南
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。
CPR-指南2010
6、当心脏手术或开胸心脏按摩而需作心脏 直接电击除颤时，所需专有小型电极板，一 块置于右心室面；另一种置于心尖部，心脏 表面洒上生理盐水，电极板紧贴心室壁。 7、如室颤为细颤，除颤前应予以肾上腺素 1㎎， 使之转为粗颤再行电除颤。
• 植入性心脏复律除颤器： • 如考虑患者有威胁生命、需电击的心律失常 危险或曾经发生过此类情况，则应植入心脏 复律除颤器。ICD释放电量水平低，对救援 者无伤害。
• 院内复苏的设备要求：所有临床区域应能立 即获得复苏设备及药物，利于对心跳呼吸骤 停患者的快速复苏。应标准化摆放。
2010复苏指南
关键点二 高级生命支持治疗 • 评估节律、感触脉搏前先给予2min的 CPR。 • 每3--5min给予肾上腺素1mg,直到ROSC 后。 • 心前区捶击：不强调其作用。当医师看 见的室颤且手边无除颤仪时可捶击。 • 静脉通路：外周给药后至少给20ml液体 冲洗。或建立骨髓腔通道。
2、安放电极处的皮肤应涂导电糊，也可用盐 水纱布，紧急时甚至可用清水，但绝对禁用 酒精，否则可引起皮肤灼伤。 3、消瘦而肋间隙明显凹陷而致电极与皮肤接 触不良者宜用盐水纱布，并可多用几层，可 改善皮肤与电极的接触。 4、两个电极板之间要保持干燥，避免因导电 糊或盐水相连而造成短路。 5、也应保持电极板把手的干燥。不能被导电 糊或盐水污染， 以免伤及操作者。
徒手成人心肺复苏术（CPR）
• 适应症：各种原因所致的循环障碍。包括心 搏骤停、心室颤动及心搏微弱。 • 禁忌症：1、胸壁开放性损伤。 2、肋骨骨折。 3、胸廓畸形或心包填塞。 4、凡已明确心、肺、脑等重要器官功能衰竭 无法逆转者，可不行复苏术。
徒手成人心肺复苏术（CPR）
• CPR终止指标： 1、恢复自主呼吸和心跳。 2、证实患者死亡。 3、CPR30分以上，检查病人仍无反应，无呼 吸、无脉搏、瞳孔无回缩。 根据具体情况可适当延长，如年龄、疾病等。 电击伤、溺水1—2小时。
2010心肺复苏指南
体位：仰卧,头后仰体位 抢救者位于患者头顶 端。 手法：EC手法固定面罩 1、C法—左手拇指和食指将面罩紧扣于患者 口鼻部， 固定面罩，保持面罩密闭无漏气。 2、E法—中指,无名指和小指放在病人下颌 角处,向前上托起下颌，保持气道通畅。 3、用右手挤压气囊1L球囊的1/2—2/3,胸 廓扩张，超过1s,有心跳时：10~12次/分钟 （间隔5～6秒钟）
确保人工呼吸、人工循环有效
仰头-抬颏法
将一手小鱼际臵于患 者前额部，用力使 头部后仰，另一手 臵于下颏骨骨性部 分向上抬颏。使下 颌尖、耳垂连线与 地面垂直。
托颌法 将肘部支撑在患者所处的平面上，双手 放置在患者头部两侧并握紧下颌角，同 时用力向上托起下颌。如果需要进行人 工呼吸，则将下颌持续上托，用拇指把 口唇分开，用面颊贴紧患者的鼻孔进行 口对口呼吸。托颌法因其难以掌握和实 施，常常不能有效的开放气道，还可能 导致脊髓损伤，因而不建议基础救助者 采用。
快速有力工 掌根
重叠 交叉 垂直
下陷至少为5cm 按压速率持续平稳至少为100次/分保 证每次按压后胸部回弹 尽可能减少胸外按压的中断 避免过度通气
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：幼儿至少2.5～3.5厘米， 婴儿至少1.5～2.5厘米 按压频率：每分钟至少100次。
美国：30-40万/年 欧洲：60万/年 日本：4万/年 中国：260万/年 台湾：4400 /年，世界之最（总人口2000万） 所以，现场的紧急救护系统成为生死的关键。
多没有预兆 约80%发生在院外 发生时间短 约在1小时内死亡
心肺复苏操作规范(2010届版)
人基本生命支持操作规范（2010年版）【目的】当病人呼吸停止、心脏停搏时，现场对病人实施胸外心脏按压、人工呼吸及电除颤，以维持和促进呼吸、循环功能的恢复。
【操作方法及程序】1、判断意识并观察有无自主呼吸（或正常呼吸）摇晃或拍肩并大声呼叫病人（意识丧失：呼之不应，推之不动）。
观察自主呼吸，叹息样呼吸是无效呼吸。
2、呼救单人急救时先呼救后抢救，两人或多人时，一人抢救，一人协助通知。
3、体位去枕仰卧、肢体不扭曲，脊椎外伤时整体翻转（头、颈与身体同轴转动），放在地面或硬床板上（软床垫硬板）。
解衣露胸、解开腰带。
4、判断循环触摸同侧颈动脉搏动：触摸部位为气管两侧2～3cm，胸锁乳突肌前缘凹陷处，轻触，靠近检查者一侧更容易判断，判断时间要小于l0秒，判断不清时按无脉搏对待。
5、胸外按压（1）术者体位：根据个人身高及病人位置高低采用踏脚凳或跪式等体位。
定位方法：一只手的食、中指放在肋缘下，沿肋骨缘向上滑到剑突与胸骨交界处，把另一只手掌根靠在定位手指上方（胸骨下1/2）定位手重叠在另一只手上，手指交叉掌根紧贴胸骨。
男性也可定位于两乳头连线和胸骨交界处。
（2）按压姿势：双臂绷直不得弯曲，与胸部垂直，以髋关节为支点，腰部挺直，用上半身重量往下压，按压后必须完全解除压力，胸部弹回原位。
（3）按压力量：胸骨下陷大于5cm。
（4）按压频率：至少100次／min。
（5）按压与放松：比例适当(1：1)，放松时手不能离开胸壁。
（6）按压与人工呼吸的比例：单人或双人操作的心脏按压与人工呼吸的比例均为30：2。
气管插管后，按压和人工呼吸可不同步，此时人工呼吸频率8-10次/分，按压频率大于100次／min。
如果自主循环恢复后，人工呼吸次数是10-12次/分。
6、开放气道、人工呼吸开放气道方法：（1）仰头举颏法，清除可见口鼻分泌物、异物、活动性义齿。
（2）托颌法：用于怀疑颈椎骨折病人，如果此法不能将气道完全开放，仍可采用仰头举颏法。
2010心肺复苏指南
2010心肺复苏方法
2010 • 急诊 • 基地 • 培训
2010 • 急诊 • 基地 • 培训
• 手术过程中心搏骤停的发现 （1）不能测出血压和脉搏；（2）术者发现
心脏停跳、大动脉搏动消失； （3）延长手术切口仍不出血。 • 外伤时心脏停搏的发现
对严重创伤病人的检查应注意呼吸、心跳 是否停止，股动脉和颈动脉是否搏动。
2010 • 急诊 • 基地 • 培训
• 心搏骤停的临床征象: 病人突然意识丧失，大动脉搏动消失，凭这 两点存在，即可诊断为心搏骤停。
较大； (3) 对于大多数院外心脏骤停患者，均未由任何旁观者
对其进行心肺复苏。
《2010 指南》中作出了一些更改建议，以尝试解决这些问 题，同时提出有关重视心脏骤停后治疗的新建议，以提高 心脏骤停的存活率。
《2010 指南》 主要是针对的是所有施救者，包括医务人 员或非专业施救者的基础生命支持 (BLS)。
3.专业施救者成人、儿童、婴儿（新生儿 除外）心肺复苏变化
• 由于心脏骤停患者可能会出现短时间的癫痫发作或濒死喘息，并导致可能 的施救者无法分辨，专业施救者应注意识别心脏骤停的表现，从而提高对心脏骤 停的识别能力。
•
医务人员在检查患者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。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）。
2010 • 急诊 • 基地 • 培训
2.非专业施救者成人、儿童、婴儿（新生儿 除外）心肺复苏变化
简化了通用的成人基础生命支持流程图.
2010年心肺复苏指南(完整版)
胸外按压不当可发生：肋骨骨折、胸骨骨折、肋骨及肋软骨脱离、气胸、血胸、肺挫 伤、 肝或脾脏撕裂及脂肪栓塞等并发症。
医务人员基础生命支持
• 胸外按压禁忌症：
严重的胸廓畸形，张力性气胸，多发肋骨骨折，心包填塞，胸 主动脉瘤破裂等，都不适合行胸外按压，以免加重病情，可改用开胸 行胸内心脏按压。
婴儿：约4cm, 至少为胸部厚度的1/3
频率≧ 100次/分 频率≧ 100次/分
e. 环境要求
除非患者处于危险环境或者其创伤需要外科处理，不要搬动患者， 确定环境安全后，实施心外按压； 患者应以仰卧位躺在硬质平面（质的胸外按压
医务人员基础生命支持
高品质的胸外按压注意事项
心脏呼吸骤停的可逆原因
5H 5T
心肺复苏终点的问题
心肺复苏终点的问题
院前基础心肺复苏的终止：
抢救人员开始心肺复苏后，应持续至发生以下情况： 1. 恢复有效的自主循环; 2. 治疗已转交给高级抢救队伍接手 ; 3. 抢救人员由于自身筋疲力尽不能继续复苏、继续复苏
将置抢救人员于非常危险境地时; 4. 发现提示不可逆性死亡的可靠和有效的标准（尸僵、
强调了心肺 复苏术中脑 和神经系统 功能的恢复， 诞生了心肺 脑复苏的新 标准
发展为心肺 复苏学，每 隔5年更新 心肺复苏指 南
心肺复苏急救成人生存链
基础生命支持
高级气道管理 药物治疗 有效监测
高级生命支持
医务人员基础生命支持 高级心血管生命支持 心肺复苏终点的判断
医务人员基础生命支持
如何识别心跳骤停 1. 意识丧失无反应
用阿托品
心肺复苏术(2010年指南)
2010 • 急诊 • 基地 • 培训
2010 • 急诊 • 基地 • 培训
2010 • 急诊 • 基地 • 培训
2010 • 急诊 • 基地 • 培训
A2开放气道
抬举下颌法
2010 • 急诊 • 基地 • 培训
2010 • 急诊 • 基地 • 培训
Breathing
简易呼吸囊辅助呼吸： E-C手法 • 选择适合的面罩 • 操作者在患者头侧 • 提起下颌（保持气道 的开放） • 固定面罩以防漏气 • 适量通气（使胸廓较 明显抬高）
2010 外按压频率由2005年的100次/min改为 “至少100次/min” • 按压深度由2005年的4-5cm改为“至少5cm” • 人工呼吸频率不变、按压与呼吸比不变 • 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，对普通目击者要求 对ABC改变为“CAB”，其重要性是减少开 始首次胸外按压的时间
•
2010 • 急诊 • 基地 • 培训
特殊情况下的心肺复苏３
淹溺
淹溺最主要的危害是低氧血症 通气支持及再灌注应尽快进行 BLS仍然按传统的A-B-C顺序进行
2010 • 急诊 • 基地 • 培训
特殊情况下的心肺复苏３
淹溺
• 水中救起：注意 自身安全，不必 常规颈椎固定。
2010 • 急诊 • 基地 • 培训
• 复温方式的选择： • 有灌注心律的轻度低体温者 -被动复温 • 有灌注心律的中度低体温者 -主动体外复温 • 重度低体温和无灌注心律心脏骤停者 -主动体内复温
2010 • 急诊 • 基地 • 培训
特殊情况下的心肺复苏４低温
• 未出现心脏呼吸骤停，重点复温 • 一旦出现心脏呼吸骤停，CPR与复温同等重要 • 人工通气尽可能予以加温（32-34°C）加湿氧气 面罩通气。 • 低温时除颤效果差，中心体温<30°C时，VF立即 除颤一次，如仍VF，则继续CPR与复温，等30°C 以上再次除颤 • 应积极CPR同时将患者转运至有复温设备和条件的 医院救治。
2010国际心肺复苏指南-
2010版CPR最主要改动
4、BLS其他注意事项 保证每次按压后胸部回弹 强化按压的重要性，按压间断时间不超过5s 避免过度通气 取消“看、听和感觉呼吸” 心脏按压的速度与深度 进一步强调实施高
强调黄金4分钟
心跳呼吸骤停的诊断
• 病人意识突然丧失，昏倒于任何场合； • 大动脉无搏动； • 呼吸停止； • 面色苍白或紫绀，瞳孔散大； • 心电图：一直线、心室颤动和心电机械分
离。
心脏骤停的类型
1、心室颤动 2、无脉性室速 3、心脏停搏 4、心电机械分离
CPR的三个阶段
基本生命支持（BLS） 进一步生命支持（ACLS） 延续生命支持（PLS）
三个阶段——核心技术
·第一阶段——第一个CABD
(基础生命支持,BLS) 公众普及
C心脏按压 A开放气道 B人工呼吸 D除颤
·第二阶段——第二个ABCD
(进一步生命支持,ACLS) 专业人员普及
A 气管插管
B 正压通气
C 心律血压药物
D 鉴别诊断
·第三阶段——（延续生命支持PLS，脑保护）
复苏后的处理与评估，进一步的病因治疗
质量的心肺复苏
2010版CPR最主要改动
5、不再强调脉搏检查： 如果在 10 秒钟之内没有触摸到脉搏或
不确定已触摸到脉搏，即可开始胸外按压 。要确定是否有脉搏可能比较困难，特别 是在急救时，研究显示医务人员和非专业 施救者都不能可靠地检测到脉搏。
2010版CPR最主要改动
6、单纯胸外按压：在施救者未经培训或经过 培训但不熟练的情况下。
2010版CPR最主要改动
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当托颌法不能保证气道通畅时仍应使用仰头抬颌法（可能加重颈椎损伤）。
医务婴儿颈部置于正中体位（嗅物位、闻花香），外耳道与婴儿肩部在一个水平 上，此时气道可保持最大限度通畅。
• 婴儿头部过于伸展，可能造成气道阻塞。
医务人员基础生命支持
3. 人工呼吸 口对口人工呼吸
球囊面罩呼吸
气管插管
医务人员基础生命支持
单人复苏通气
• 建议单人复苏时采用口对面罩人工呼吸（低感染风险）。 单人复苏时使用球囊面罩，需经专门培训。
• 施救者呼出的气体含 有17%氧气和4%的二氧化碳， 这种氧含量可满足患者的需 要。有条件时，应补充氧气， 提供氧浓度。
注意：两手手指跷起(扣在一起)离开胸壁
医务人员基础生命支持
c. 胸外按压姿势
适用于成人及儿童，对非常小的儿童也可以用单手按压。
≧5cm
医务人员基础生命支持
c. 胸外按压姿势 —婴儿
图1. 婴儿双拇指环绕法胸外按压（2名施救者）
医务人员基础生命支持
d.按压深度与频率： 快速有力、持续平稳
成人：下陷≧5cm 频率≧ 100次/分 儿童：约5cm，至少为胸部厚度的1/3 频率≧ 100次/分 婴儿：约4cm, 至少为胸部厚度的1/3 频率≧ 100次/分
e. 环境要求
除非患者处于危险环境或者其创伤需要外科处理，不要搬动患者， 确定环境安全后，实施心外按压； 患者应以仰卧位躺在硬质平面（如平板或地面）。
医务人员基础生命支持
高品质的胸外按压
医务人员基础生命支持
高品质的胸外按压注意事项
每2min（5个按压-通气循环）更换按压者，以减少疲劳对胸外按压的幅度 和频率的影响；
注：更改了旧指南的“ABC”流 程
医务人员基础生命支持
1. 胸外按压
医务人员基础生命支持
1.胸外按压
原理： 胸外按压
胸泵 人工循环
医务人员基础生命支持
1. 胸外按压——要点
a. 按压部位 成人：两乳连线中点 胸骨中下1/3交界 1岁至青春期儿童：按压部位同成人 婴儿：胸部中央，两乳连线正下方
1.胸外按压 按压要点 b. 以掌根按压
判断方法：轻轻拍打患者双肩，高声呼喊“喂，你怎么了？”如认识，可直呼 其姓名，如无反应，说明意识丧失。
2. 没有呼吸或者不能正常呼吸（仅仅是喘息）
立即呼救 启动救护体系,AED 医院内：通知更多的医生护士(4~6人)，准备急救药品、器械和设备
3. 医务人员检查脉搏的时间<10s 不能明确感觉到脉搏
CPR
2. 开放气道 普通患者：仰头抬颏法
用一只手按压患者者的前额，使头部后仰，同时另一只手的食指及中指置于 其下颏骨骨性部分向上抬颏。使下颌尖、耳垂连线与地面垂直。 注意： 不要使劲按压颏骨下的软组织，因为这样可能会堵塞气道；
不要使用拇指提起颏骨； 不要完全封闭患者的嘴巴。
医务人员基础生命支持
2.开放气道 颈椎损伤患者：托颌法（双上颌上提法）
强调了心肺 复苏术中脑 和神经系统 功能的恢复， 诞生了心肺 脑复苏的新 标准
发展为心肺 复苏学，每 隔5年更新 心肺复苏指 南
心肺复苏急救成人生存链
基础生命支持
高级气道管理 药物治疗 有效监测
高级生命支持
医务人员基础生命支持 高级心血管生命支持 心肺复苏终点的判断
医务人员基础生命支持
如何识别心跳骤停 1. 意识丧失无反应
胸外按压不当可发生：肋骨骨折、胸骨骨折、肋骨及肋软骨脱离、气胸、血胸、肺挫 伤、 肝或脾脏撕裂及脂肪栓塞等并发症。
医务人员基础生命支持
• 胸外按压禁忌症：
严重的胸廓畸形，张力性气胸，多发肋骨骨折，心包填塞，胸 主动脉瘤破裂等，都不适合行胸外按压，以免加重病情，可改用开胸 行胸内心脏按压。
医务人员基础生命支持
●心跳骤停:黑朦，意识障碍，突然倒地 ● 15 秒: 抽搐 ● 30 秒: 呼吸停止 ● 1～2分钟 : 瞳孔固定 ● 4分钟 : 糖无氧代谢停止 ● 5分钟 : 脑内ATP枯竭、能量代谢完全停止 ● 6分钟 : 神经元不可逆性损伤
心肺复苏黄金5分钟
时间就是生命
复苏的成功率与开始CPR的时间密切相关
医务人员基础生命支持
• 双人复苏通气——球囊面罩
要求：选择适合面罩；操作者在患者头侧；Ｅ－Ｃ手法；
提下颌、开放气道；固定面罩防止漏气；适量通气。
球囊总容积：1600ml 单手最大压缩：950ml 双手最大压缩：1350ml
1500ml
心肺复苏黄金5分钟
心肺复苏的发展历史
1950
1960
1966
1985
2000 2019 2019
美国的Peter Safar和
James Elam 医生开始采 用人工呼吸 来复苏病人
封闭式胸部 心脏按压与 人工呼吸相 结合，心肺 复苏术诞生
ZOLL提出 电击除颤， 和人工呼吸 胸外按压构 成了现代心 肺复苏术
2019年心肺复苏指南
生命之痛
2019年10月17日，北京“首都高校马拉松挑战赛” 2人猝死， 图为参赛选手北京交通大学的刘红斌。警察及围观群众面对大学生 猝死的无奈与无助。
呼吸心跳骤停
• 原因：急病，创伤， 中毒，溺水，触电
• 最常见的原因：心脏 急症猝死
时间就是生命
心搏骤停的严重后果以秒计算
注：非医务人员只需完成1、2项
脉搏检查
• 成人触摸颈动脉 • 儿童（1~青春期）触摸颈动脉或股动脉 • 婴儿触摸肱动脉（上臂内侧，肘和肩膀之间）
儿童与婴儿在无脉搏，或脉搏<60次/分并伴有血流灌注不足的体征，应立即 开始CPR
医务人员基础生命支持
心肺复苏流程
“C” 先给予胸外按压 “A” 通畅气道 “B” 人工呼吸 胸外按压与人工呼吸比率30:2
胸外按压时尽可能减少中断：每次更换按压者应在5s内完成；在实施保持 气道通畅措施，评估循环呼吸，或除颤时中断时间应不超过10s。
按压间歇的放松期，操作者应不加任何压力，以保证胸部的充分回弹；同 时，手掌不离开按压部位的胸壁，以免移位。
④按压定位要准确，按压时手指不能用力、手掌不能移位。 ⑤ 按压需均匀、连贯、有节奏地进行，切忌突然急促地撞击。