2010年AHA心肺复苏指南
2010国际心肺复苏与心血管急救指南
非专业人员不进行脉搏检查
3.革命性的修改:流程更换
更加强调了胸外按压的重要性！
2005年 A.保持气道通畅 B.人工呼吸 C.胸外按压 2010年 C.胸外按压 A.保持气道通畅 B.人工呼吸
成年人及儿科病人（包括儿童及婴幼儿， 但不包括新生儿）
3.心肺复苏程序变化：C-A-B 代替 A-B-C
4.团队合作！
第八部分 高级心血管生命支持ALS
高级心血管生命支持是在基础生命支持的基础上，应用辅助 设备、特殊技术等建立更为有效的通气和血运循环 主要内容:
1.气道管理、通气支持以及治疗缓慢型和快速型心律失常 2.治疗心脏骤停(药物治疗等) 3.改善心脏骤停后自主循环恢复的患者预后的措施(第九部分)
2. 弱化了脉搏的检查
医务人员在检查反应时应该快速检查是否没有呼吸或不能正常呼吸 （即无呼吸或仅仅是喘息）。然后，该人员会启动急救系统并找到 AED（或由其他人员寻找） 医务人员检查脉搏的时间不应超过10秒，如果10秒内没有明确触摸到 脉搏，应开始心肺复苏并使用 AED（如果有的话）
声门上气道(喉罩、食管-气管联合导管和喉管)，由受过培 训的人员实施CPR时声门上气道可以替代球囊-面罩通气 和气管插管 气管插管
8.1 气道管理辅助措施和通气
1.球囊-面罩通气:
当放置高级气道有延误或不成功时，球囊-面罩通气尤其 有帮助；
抢救人员应确保用仰头-抬颏法充分开放气道，提起下巴 紧贴面罩，手持面罩紧贴脸，使面罩与口密闭；
以上建议旨在支持尽早进行心肺复苏和早期除颤， 特别是在发生心脏骤停时现场有AED或除颤器的情 况下
成人BLS在ICU中的应用
2010心肺复苏指南
2010心肺复苏指南亮点 2010心肺复苏指南亮点
生存链的变化 CPR操作顺序的变化 CPR操作顺序的变化 强调胸外按压的重要性 取消“ 取消“一听二看三感觉 胸外按压频率的变化 胸外按压的深度的变化 救援者应避免停止胸外按压和过度通气。 救援者应避免停止胸外按压和过度通气。 强烈建议普通施救者仅做胸外按压的CPR CPR， 强烈建议普通施救者仅做胸外按压的CPR，弱化人工呼吸 的作用。 的作用。 肾上腺素用法用量不变，不推荐对心脏停搏或PEA( PEA(无脉性 肾上腺素用法用量不变，不推荐对心脏停搏或PEA(无脉性 电活动）者常规使用阿托品。 电活动）者常规使用阿托品。
早期识别成人心脏骤停是建立在评估患者的反应以 及有没有正常的呼吸。 及有没有正常的呼吸。 心脏骤停患者一开始可能有叹气样呼吸或者甚至表 现为癫痫样发作。 现为癫痫样发作。这种非典型表现可能使施救者困 导致呼救或开始CPR延迟。 CPR延迟 惑，导致呼救或开始CPR延迟。 培训的重点必须集中在使救援者警觉心脏骤停的特 殊表现。 殊表现。
CPR操作顺序的变化 CPR操作顺序的变化
A-B-C→→C-A-B C→→C2010（ ）：C ★2010（新）：C-A-B 胸外按压→ 开放气道→ 即：C胸外按压→A开放气道→B人工呼吸 2005（ ）：A ●2005（旧）：A-B-C 开放气道→ 人工呼吸→ 即：A开放气道→B人工呼吸→C胸外按压 该顺序的改变适用于成人、儿童和婴幼儿，但 该顺序的改变适用于成人、儿童和婴幼儿， 不适用于新生儿。对于新生儿， 不适用于新生儿。对于新生儿，心脏骤停的最可 能的原因为呼吸因素导致的，复苏程序应当为A 能的原因为呼吸因素导致的，复苏程序应当为A顺序，除非已知是心脏原因导致的。 B-C顺序，除非已知是心脏原因导致的。
2010美国心脏协会AHA心肺复苏CPR及心血管急救ECC指南的学习
2.伦理学问题
与复苏有关的伦理学问题非常复杂，这些问题出现的环境不同 （院内或院外）、涉及不同的操作者（非专业施救者或医务人 员）并且涉及到开始或停止基础生命支持和/或高级生命支持。 所有医务人员在为需要复苏的个人提供治疗时，都需要考虑伦 理、法律和文化因素。虽然操作者在复苏过程中会参与决策， 但他们应该综合科学、个人或其代理者的意愿以及当地的政策或法律规 定。
D:\医学资料\心肺复苏讲稿\QQ截图20110712235818.jpg
7.CA后的治疗
“心脏骤停后治疗”是《2010 美国心脏协会心肺复苏及心血管急救指南》中的新增部 分 为提高在恢复自主循环后收入院的心脏骤停患者的存活率，应当通过统一的方式实施综 合、结构化、完整、多学科的心脏骤停后治疗体系（方块图 3）。治疗应包括心肺复苏和 神经系统支持。应根据指征提供低温治疗和经皮冠状动脉介入术 (PCI)。由于在心脏骤 停后往往会发生癫痫症状，应进行脑电图检查以诊断癫痫并尽快给出解读，并在昏迷 患者恢复自主循环后频繁或持续地进行监测。 D:\医学资料\心肺复苏讲稿\QQ截图20110713000441.jpg
6.ACLS
2010 版心血管病高级生命支持 (ACLS) 中的主要更改如下： • 建议进行二氧化碳波形图定量分析，以确认并监测气管插管位 置和心肺复苏质量。 • 简化了传统心脏骤停流程，并提出了替代的概念性设计流程以 强调高质量心肺复苏的重要性。 • 进一步强调了生理参数监测以优化心肺复苏质量并检测是否恢 复自主循环。 • 不再建议在治疗无脉性心电活动 (PEA)/心搏停止时常规性地使 用阿托品。
o-two呼吸机使用方法的演示： F:\心肺复苏讲稿\AVSEQ01.DAT
谢谢！
8.ACS患者病情稳定化治疗
2010AHA心肺复苏指南解读
①按压时除掌根部贴在胸骨外，手指也压在胸壁上，这容易 引起肋骨或肋骨肋软骨交界处骨折。 ②按压定位不正确。向下错位易使剑突受压折断而致肝破裂。 向两侧错位易致肋骨或肋骨肋软骨交界处骨折，导致气胸、 血胸。 ③抢救者按压时肘部弯曲，因而用力不垂直，按压力量减弱， 按压深度达不到5cm（图）。 ④冲击式按压、猛压，其效果差，且易导致骨折。 ⑤放松时抬手离开胸骨定位点，造成下次按压部位错误，引 起骨折。 ⑥放松时未能使胸部充分松弛，胸部仍承受压力，使血液难 以回到心脏。 ⑦按压速度不自主地加快或减慢，影响了按压效果。 ⑧两手掌不是重叠放臵，而呈交叉放臵。
1、吹气应有足够的气量，以使胸廓抬起，但一般不超过 1200mL。 2、吹气时间宜短，以占1次呼吸周期的1/3为宜；吹气频 率，8-10次/分。 3、操作前先清除患者口腔及咽部的分泌物或堵塞物。 4、有义牙者应取下义牙。遇舌后坠的患者，应用舌钳将 舌拉出口腔外，或用通气管吹气。 5、对婴幼儿，则对口鼻同时吹气更易施行 6、若患者尚有微弱呼吸，人工呼吸应与患者的自主呼吸 同步进行。 7、注意防止交叉感染。 8、通气适当的指征是看到患者胸部起伏并于呼气时听到 及感到有气体逸出。
中断按压时间不超过10s 确认气管导管位臵 ： 临床评价：双侧胸廓有无对称起伏 两侧腋中线听诊两肺呼吸音是否对称 上腹部听诊：不应该有呼吸音 呼吸CO2监测或者食管探测
潮气量：500～600ml，胸廓明显 起伏 送气时间大于1s 频率：8～10次/分 避免过度通气
基 础 生 命 支 持 总 结
1.能扪及大动脉搏动，收缩压>60mmHg 2.患者面色、口唇、甲床、皮肤等色泽转红 3.散大的瞳孔再度缩小 4.呼吸改善或出现自主呼吸 5.心电显示明显的RS波 6.昏迷变浅，出现各种反射，肢体出现无意识的 挣扎动作.
2010版心肺复苏指南
2010版心肺复苏指南首先评估现场环境安全1、意识的判断：用双手轻拍病人双肩，问:“喂！你怎么了？”告知无反应。
2、检查呼吸：观察病人胸部起伏5-10秒（1001、1002、1003、1004、1005…）告知无呼吸3、呼救：来人啊！喊医生！推抢救车！除颤仪！4、判断是否有颈动脉搏动：用右手的中指和食指从气管正中环状软骨划向近侧颈动脉搏动处，告之无搏动（数1001，1002，1003，1004，1005…判断五秒以上10秒以下）。
5、松解衣领及裤带。
6、胸外心脏按压：两乳头连线中点（胸骨中下1/3处），用左手掌跟紧贴病人的胸部，两手重叠，左手五指翘起，双臂深直，用上身力量用力按压30次（按压频率至少100次∕分，按压深度至少5cm）7、打开气道：仰头抬颌法。
口腔无分泌物，无假牙。
8、人工呼吸：应用简易呼吸器，一手以“CE”手法固定，一手挤压简易呼吸器，每次送气400-600ml。
9、持续2分钟的高效率的CPR：以心脏按压：人工呼吸=30:2的比例进行，操作5个周期。
（心脏按压开始送气结束）10、判断复苏是否有效（听是否有呼吸音，同时触摸是否有颈动脉博动）。
11、整理病人，进一步生命支持。
提高抢救成功率的主要因素：1、将重点继续放在高质量的CPR上2、按压频率至少100次/分（区别于大约100次/分）3、胸骨下陷深度至少5 ㎝4、按压后保证胸骨完全回弹5、胸外按压时最大限度地减少中断6、避免过度通气心肺复苏 = (清理呼吸道) + 人工呼吸 + 胸外按压 + 后续的专业用药据美国近年统计，每年心血管病人死亡数达百万人，约占总死亡病因1/2。
而因心脏停搏突然死亡者60-70%发生在院前。
因此，美国成年人中约有85%的人有兴趣参加CPR初步训练，结果使40%心脏骤停者复苏成功，每年抢救了约20万人的生命。
心脏跳动停止者，如在4分钟内实施初步的CPR，在8分钟内由专业人员进一步心脏救生，死而复生的可能性最大，因此时间就是生命，速度是关键，初步的CPR按ABC进行。
美国心脏学会AHA心肺复苏
或胆碱能药物中毒导致的心动过缓 碳酸氢钠：无明确指针不应给予
复苏时的监测
ETCO2 ：ETCO2和CO之间有很强的相关性，可以反映心 脏按压的有效性。有研究显示成人高级心肺复苏1520分钟ETCO2处于低值（≤15mmHg）,强烈暗示恢复自 主循环的可能性低。
谢谢
MAP≧65 mmHg、CVP 8 ～ 12 cmH2O、SVO2≧70%、 Hct＞30%、尿量＞1ml/（kg.h）、Lac接近正常
PCAC---体温
治疗性低温： ➢ 尽早将昏迷患者中心温度降至32 ～ 34℃持续
12 ～ 24h ➢ 早期头部冰帽降温 ➢ 快速输注冰水 30ml/kg，让中心温度降低1.5度 ➢ 防止发热
儿科BLS
简化流程，删除检查呼吸，不再强调脉搏检查 无生命迹象+10秒内不能触及脉搏即应开始CPR HR＜60次/分伴低灌注征象即应开始CPR
儿科BLS
新的证据强调了通气在儿科CPR中的重要作用 传统CPR（按压+通气）更具有优势
医务人员更应该为心跳骤停小儿提供传统CPR
儿科BLS
儿科患者复苏流程为CAB 按压深度：婴幼儿4cm，儿童5cm 按压通气比：
儿科ACLS---通道
骨内通道（IO）
快速、安全、有效 血型、交叉配血、血气分析 所有经静脉给予的药物 起效时间、药物剂量与静脉相同 输血、输液
儿科ACLS---通道
经气管导管
可经气管给予脂溶性药物，如：利多卡因、肾上腺素、阿托品、 纳洛酮。禁止给予非脂溶性药物药物，如碳酸氢钠和钙剂
心尖-后部
ACLS---团队合作
小组合作与分工
2010美国心脏协会心肺复苏及心血管急救指
CPR2010指南
压心吹起比例儿童及婴儿
——气道未受保护 • 一位急救员的压心吹气比例是30:2，而两位急救员的压心 吹气比例为15:2，原因是因为儿童及婴儿的心跳骤停的主 因是气道阻塞及呼吸骤停，所以压心吹气的次数可以相应 的减少至15:2。 ------气道已经受到保护 • 情况和成人一样，CPR不需要按比例，压心频率以每分钟 100次不停顿进行，而吹气者亦是每分钟做8-10次吹气 （约6-8s做一次吹气），检查心电及脉搏是在2分钟后。 • 为避免急救者过度疲劳，专家建议应为每2分钟转换压心 者一次，而转换的时间不应超过5s。
心房颤动(atrial fibrillation, AF)
无P波, 代之以“ f ” 波, 350～600 次/分； QRS-T波基本正常； 心室律（R-R 间期）绝对不等； 心室率 100-180次/分(未治疗者)。 频率
窦性心动过速(sinus tachycardia)
• 逐渐加快和减慢、P波与窦律相同
高级生命支持技术（ACLS） 3急救药物
• ——抗心律失常药应该在第二或第三次除 颤后施行，指南建议在处理VF时仍然首先 采用胺碘酮，因为仍然有较多的研究证明 胺碘酮比利多卡因更有效。 • ——抗心律迟缓方面的药，仍然采用阿托 品，但剂量略有调整（0.5-1.0mg，1mg/kg 一般50mg）。 • ——室上速所采用的药物仍然是腺苷
高级生命支持技术（ACLS） 1除颤
1.指南建议，每次除颤后应立即施行2分钟 CPR才检查心电及脉搏。 2.除颤的程序为： （1）除颤一次 （2）CPR2分钟 （3）检查脉搏及心电 （4）重复此循环 3.除颤成功：通常定义为放电后终止VF至少5 秒钟
高级生命支持技术（ACLS） 2高级人工气道
2010年美国心脏病学会心肺复苏指南(英文版)
ISSN: 1524-4539Copyright © 2010 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online72514Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TXDOI: 10.1161/CIRCULATIONAHA.110.9708892010;122;S640-S656Circulation HoekCallaway, Brett Cucchiara, Jeffrey D. Ferguson, Thomas D. Rea and Terry L. VandenMark S. Link, Laurie J. Morrison, Robert E. O'Connor, Michael Shuster, Clifton W. Marc D. Berg, John E. Billi, Brian Eigel, Robert W. Hickey, Monica E. Kleinman,Neumar, Mary Ann Peberdy, Jeffrey M. Perlman, Elizabeth Sinz, Andrew H. Travers, Farhan Bhanji, Diana M. Cave, Edward C. Jauch, Peter J. Kudenchuk, Robert W.Schexnayder, Robin Hemphill, Ricardo A. Samson, John Kattwinkel, Robert A. Berg, John M. Field, Mary Fran Hazinski, Michael R. Sayre, Leon Chameides, Stephen M. Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 1: Executive Summary: 2010 American Heart Association Guidelines for/cgi/content/full/122/18_suppl_3/S640located on the World Wide Web at:The online version of this article, along with updated information and services, is/reprints Reprints: Information about reprints can be found online atjournalpermissions@ 410-528-8550. E-mail:Fax:Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters/subscriptions/Subscriptions: Information about subscribing to Circulation is online atPart1:Executive Summary2010American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care John M.Field,Co-Chair*;Mary Fran Hazinski,Co-Chair*;Michael R.Sayre;Leon Chameides; Stephen M.Schexnayder;Robin Hemphill;Ricardo A.Samson;John Kattwinkel;Robert A.Berg;Farhan Bhanji;Diana M.Cave;Edward C.Jauch;Peter J.Kudenchuk;Robert W.Neumar;Mary Ann Peberdy;Jeffrey M.Perlman;Elizabeth Sinz;Andrew H.Travers;Marc D.Berg; John E.Billi;Brian Eigel;Robert W.Hickey;Monica E.Kleinman;Mark S.Link;Laurie J.Morrison; Robert E.O’Connor;Michael Shuster;Clifton W.Callaway;Brett Cucchiara;Jeffrey D.Ferguson;Thomas D.Rea;Terry L.Vanden HoekT he publication of the2010American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care marks the50th anniversary of modern CPR.In1960Kouwenhoven,Knickerbocker,and Jude documented14patients who survived cardiac arrest with the application of closed chest cardiac massage.1That same year,at the meeting of the Maryland Medical Society in Ocean City,MD,the combination of chest compressions and rescue breathing was introduced.2Two years later,in1962, direct-current,monophasic waveform defibrillation was de-scribed.3In1966the American Heart Association(AHA) developed the first cardiopulmonary resuscitation(CPR) guidelines,which have been followed by periodic updates.4 During the past50years the fundamentals of early recogni-tion and activation,early CPR,early defibrillation,and early access to emergency medical care have saved hundreds of thousands of lives around the world.These lives demonstrate the importance of resuscitation research and clinical transla-tion and are cause to celebrate this50th anniversary of CPR. Challenges remain if we are to fulfill the potential offered by the pioneer resuscitation scientists.We know that there is a striking disparity in survival outcomes from cardiac arrest across systems of care,with some systems reporting5-fold higher survival rates than others.5–9Although technology, such as that incorporated in automated external defibrillators (AEDs),has contributed to increased survival from cardiac arrest,no initial intervention can be delivered to the victim of cardiac arrest unless bystanders are ready,willing,and able to act.Moreover,to be successful,the actions of bystanders and other care providers must occur within a system that coordi-nates and integrates each facet of care into a comprehensive whole,focusing on survival to discharge from the hospital.This executive summary highlights the major changes and most provocative recommendations in the2010AHA Guide-lines for CPR and Emergency Cardiovascular Care(ECC). The scientists and healthcare providers participating in a comprehensive evidence evaluation process analyzed the sequence and priorities of the steps of CPR in light of current scientific advances to identify factors with the greatest potential impact on survival.On the basis of the strength of the available evidence,they developed recommendations to support the interventions that showed the most promise. There was unanimous support for continued emphasis on high-quality CPR,with compressions of adequate rate and depth,allowing complete chest recoil,minimizing inter-ruptions in chest compressions and avoiding excessive ventilation.High-quality CPR is the cornerstone of a system of care that can optimize outcomes beyond return of spontaneous circulation(ROSC).Return to a prior quality of life and functional state of health is the ultimate goal of a resuscitation system of care.The2010AHA Guidelines for CPR and ECC are based on the most current and comprehensive review of resuscitation litera-ture ever published,the2010ILCOR International Consensus on CPR and ECC Science With Treatment Recommendations.10 The2010evidence evaluation process included356resuscita-tion experts from29countries who reviewed,analyzed,evalu-ated,debated,and discussed research and hypotheses through in-person meetings,teleconferences,and online sessions(“web-inars”)during the36-month period before the2010Consensus Conference.The experts produced411scientific evidence re-views on277topics in resuscitation and emergency cardiovas-cular care.The process included structured evidence evaluation, analysis,and cataloging of the literature.It also included rigor-The American Heart Association requests that this document be cited as follows:Field JM,Hazinski MF,Sayre MR,Chameides L,Schexnayder SM, Hemphill R,Samson RA,Kattwinkel J,Berg RA,Bhanji F,Cave DM,Jauch EC,Kudenchuk PJ,Neumar RW,Peberdy MA,Perlman JM,Sinz E,Travers AH,Berg MD,Billi JE,Eigel B,Hickey RW,Kleinman ME,Link MS,Morrison LJ,O’Connor RE,Shuster M,Callaway CW,Cucchiara B,Ferguson JD,Rea TD,Vanden Hoek TL.Part1:executive summary:2010American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.Circulation.2010;122(suppl3):S640–S656.*Co-chairs and equal first co-authors.(Circulation.2010;122[suppl3]:S640–S656.)©2010American Heart Association,Inc.Circulation is available at DOI:10.1161/CIRCULATIONAHA.110.970889ous disclosure and management of potential conflicts of interest, which are detailed in Part2:“Evidence Evaluation and Man-agement of Potential and Perceived Conflicts of Interest.”The recommendations in the2010Guidelines confirm the safety and effectiveness of many approaches,acknowledge ineffectiveness of others,and introduce new treatments based on intensive evidence evaluation and consensus of experts. These new recommendations do not imply that care using past guidelines is either unsafe or ineffective.In addition,it is important to note that they will not apply to all rescuers and all victims in all situations.The leader of a resuscitation attempt may need to adapt application of these recommenda-tions to unique circumstances.New Developments in Resuscitation ScienceSince2005A universal compression-ventilation ratio of30:2performed by lone rescuers for victims of all ages was one of the most controversial topics discussed during the2005International Consensus Conference,and it was a major change in the2005 AHA Guidelines for CPR and ECC.11In2005rates of survival to hospital discharge from witnessed out-of-hospital sudden cardiac arrest due to ventricular fibrillation(VF)were low,averagingՅ6%worldwide with little improvement in the years immediately preceding the2005conference.5Two studies published just before the2005International Consen-sus Conference documented poor quality of CPR performed in both out-of-hospital and in-hospital resuscitations.12,13The changes in the compression-ventilation ratio and in the defibrillation sequence(from3stacked shocks to1shock followed by immediate CPR)were recommended to mini-mize interruptions in chest compressions.11–13There have been many developments in resuscitation science since2005,and these are highlighted below. Emergency Medical Services Systems andCPR QualityEmergency medical services(EMS)systems and healthcare providers should identify and strengthen“weak links”in the Chain of Survival.There is evidence of considerable regional variation in the reported incidence and outcome from cardiac arrest within the United States.5,14This evidence supports the importance of accurately identifying each instance of treated cardiac arrest and measuring outcomes and suggests additional opportunities for improving survival rates in many communities. Recent studies have demonstrated improved outcome from out-of-hospital cardiac arrest,particularly from shockable rhythms,and have reaffirmed the importance of a stronger emphasis on compressions of adequate rate and depth,allowing complete chest recoil after each compression,minimizing interrup-tions in compressions and avoiding excessive ventilation.15–22 Implementation of new resuscitation guidelines has been shown to improve outcomes.18,20–22A means of expediting guidelines implementation(a process that may take from18 months to4years23–26)is needed.Impediments to implemen-tation include delays in instruction(eg,time needed to produce new training materials and update instructors and providers),technology upgrades(eg,reprogramming AEDs), and decision making(eg,coordination with allied agencies and government regulators,medical direction,and participa-tion in research).Documenting the Effects of CPR Performance by Lay RescuersDuring the past5years there has been an effort to simplify CPR recommendations and emphasize the fundamental importance of high-quality rge observational studies from investiga-tors in member countries of the Resuscitation Council of Asia (the newest member of ILCOR)27,28–30and other studies31,32 have provided important information about the positive impact of bystander CPR on survival after out-of-hospital cardiac arrest. For most adults with out-of-hospital cardiac arrest,bystander CPR with chest compression only(Hands-Only CPR)appears to achieve outcomes similar to those of conventional CPR(com-pressions with rescue breathing).28–32However,for children, conventional CPR is superior.27CPR QualityMinimizing the interval between stopping chest compressions and delivering a shock(ie,minimizing the preshock pause) improves the chances of shock success33,34and patient sur-vival.33–35Data downloaded from CPR-sensing and feedback-enabled defibrillators provide valuable information to resus-citation teams,which can improve CPR quality.36These data are driving major changes in the training of in-hospital resuscitation teams and out-of-hospital healthcare providers. In-Hospital CPR RegistriesThe National Registry of CardioPulmonary Resuscitation (NRCPR)37and other large databases are providing new infor-mation about the epidemiology and outcomes of in-hospital resuscitation in adults and children.8,38–44Although observa-tional in nature,registries provide valuable descriptive informa-tion to better characterize cardiac arrest and resuscitation out-comes as well as identify areas for further research. Deemphasis on Devices and Advanced Cardiovascular Life Support Drugs During Cardiac ArrestAt the time of the2010International Consensus Conference there were still insufficient data to demonstrate that any drugs or mechanical CPR devices improve long-term outcome after cardiac arrest.45Clearly further studies,adequately powered to detect clinically important outcome differences with these interventions,are needed.Importance of Post–Cardiac Arrest Care Organized post–cardiac arrest care with an emphasis on multidisciplinary programs that focus on optimizing hemo-dynamic,neurologic,and metabolic function(including ther-apeutic hypothermia)may improve survival to hospital dis-charge among victims who achieve ROSC following cardiac arrest either in-or out-of-hospital.46–48Although it is not yet possible to determine the individual effect of many of these therapies,when bundled as an integrated system of care,their deployment may well improve outcomes.Therapeutic hypothermia is one intervention that has been shown to improve outcome for comatose adult victims of Field et al Part1:Executive Summary S641witnessed out-of-hospital cardiac arrest when the presenting rhythm was VF.49,50Since2005,two nonrandomized studies with concurrent controls as well as other studies using historic controls have indicated the possible benefit of hypo-thermia following in-and out-of-hospital cardiac arrest from all other initial rhythms in adults.46,51–56Hypothermia has also been shown to be effective in improving intact neurologic survival in neonates with hypoxic-ischemic encephalopa-thy,57–61and the results of a prospective multicenter pediatric study of therapeutic hypothermia after cardiac arrest are eagerly awaited.Many studies have attempted to identify comatose post–cardiac arrest patients who have no prospect for meaningful neurologic recovery,and decision rules for prognostication of poor outcome have been proposed.62Therapeutic hypother-mia changes the specificity of prognostication decision rules that were previously established from studies of post–cardiac arrest patients not treated with hypothermia.Recent reports have documented occasional good outcomes in post–cardiac arrest patients who were treated with therapeutic hypother-mia,despite neurologic exam or neuroelectrophysiologic studies that predicted poor outcome.63,64Education and ImplementationThe quality of rescuer education and frequency of retraining are critical factors in improving the effectiveness of resusci-tation.65–83Ideally retraining should not be limited to2-year intervals.More frequent renewal of skills is needed,with a commitment to maintenance of certification similar to that embraced by many healthcare-credentialing organizations. Resuscitation interventions are often performed simulta-neously,and rescuers must be able to work collaboratively to minimize interruptions in chest compressions.Teamwork and leadership skills continue to be important,particularly for advanced cardiovascular life support(ACLS)and pediatric advanced life support(PALS)providers.36,84–89 Community and hospital-based resuscitation programs should systematically monitor cardiac arrests,the level of resuscitation care provided,and outcome.The cycle of measurement,interpretation,feedback,and continuous qual-ity improvement provides fundamental information necessary to optimize resuscitation care and should help to narrow the knowledge and clinical gaps between ideal and actual resus-citation performance.Highlights of the2010GuidelinesThe Change From“A-B-C”to“C-A-B”The newest development in the2010AHA Guidelines for CPR and ECC is a change in the basic life support(BLS)sequence of steps from“A-B-C”(Airway,Breathing,Chest compressions)to “C-A-B”(Chest compressions,Airway,Breathing)for adults and pediatric patients(children and infants,excluding newly borns).Although the experts agreed that it is important to reduce time to first chest compressions,they were aware that a change in something as established as the A-B-C sequence would require re-education of everyone who has ever learned CPR.The 2010AHA Guidelines for CPR and ECC recommend this change for the following reasons:●The vast majority of cardiac arrests occur in adults,and the highest survival rates from cardiac arrest are reported among patients of all ages with witnessed arrest and a rhythm of VF or pulseless ventricular tachycardia(VT).In these patients the critical initial elements of CPR are chest compressions and early defibrillation.90●In the A-B-C sequence chest compressions are often delayed while the responder opens the airway to give mouth-to-mouth breaths or retrieves a barrier device or other ventilation equipment.By changing the sequence to C-A-B,chest compressions will be initiated sooner and ventilation only minimally delayed until completion of the first cycle of chest compressions(30compressions should be accomplished in approximately18seconds).●Fewer than50%of persons in cardiac arrest receive bystander CPR.There are probably many reasons for this,but one impediment may be the A-B-C sequence,which starts with the procedures that rescuers find most difficult:opening the airway and delivering rescue breaths.Starting with chest compressions might ensure that more victims receive CPR and that rescuers who are unable or unwilling to provide ventilations will at least perform chest compressions.●It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrest.For example,if a lone healthcare provider sees a victim suddenly collapse,the provider may assume that the victim has suffered a sudden VF cardiac arrest;once the provider has verified that the victim is unresponsive and not breathing or is only gasping,the provider should immediately activate the emergency response system,get and use an AED,and give CPR.But for a presumed victim of drowning or other likely asphyxial arrest the priority would be to provide about5cycles(about2minutes)of conventional CPR(including rescue breathing)before ac-tivating the emergency response system.Also,in newly born infants,arrest is more likely to be of a respiratory etiology,and resuscitation should be attempted with the A-B-C sequence unless there is a known cardiac etiology. Ethical IssuesThe ethical issues surrounding resuscitation are complex and vary across settings(in-or out-of-hospital),providers(basic or advanced),and whether to start or how to terminate CPR.Recent work suggests that acknowledgment of a verbal do-not-attempt-resuscitation order(DNAR)in addition to the current stan-dard—a written,signed,and dated DNAR document—may decrease the number of futile resuscitation attempts.91,92This is an important first step in expanding the clinical decision rule pertaining to when to start resuscitation in out-of-hospital car-diac arrest.However,there is insufficient evidence to support this approach without further validation.When only BLS-trained EMS personnel are available, termination of resuscitative efforts should be guided by a validated termination of resuscitation rule that reduces the transport rate of attempted resuscitations without compro-mising the care of potentially viable patients.93Advanced life support(ALS)EMS providers may use the same termination of resuscitation rule94–99or a derived nonvali-dated rule specific to ALS providers that when applied willS642Circulation November2,2010decrease the number of futile transports to the emergency department(ED).95,97–100Certain characteristics of a neonatal in-hospital cardiac arrest are associated with death,and these may be helpful in guiding physicians in the decision to start and stop a neonatal resuscitation attempt.101–104There is more variability in ter-minating resuscitation rates across systems and physicians when clinical decision rules are not followed,suggesting that these validated and generalized rules may promote uniformity in access to resuscitation attempts and full protocol care.105 Offering select family members the opportunity to be present during the resuscitation and designating staff within the team to respond to their questions and offer comfort may enhance the emotional support provided to the family during cardiac arrest and after termination of a resuscitation attempt. Identifying patients during the post–cardiac arrest period who do not have the potential for meaningful neurologic recovery is a major clinical challenge that requires further research.Caution is advised when considering limiting care or withdrawing life-sustaining therapy.Characteristics or test results that are predictive of poor outcome in post–cardiac arrest patients not treated with therapeutic hypothermia may not be as predictive of poor outcome after administration of therapeutic hypothermia. Because of the growing need for transplant tissue and organs,all provider teams who treat postarrest patients should also plan and implement a system of tissue and organ donation that is timely, effective,and supportive of family members for the subset of patients in whom brain death is confirmed or for organ donation after cardiac arrest.Resuscitation research is challenging.It must be scientifically rigorous while confronting ethical,regulatory,and public rela-tions concerns that arise from the need to conduct such research with exception to informed consent.Regulatory requirements, community notification,and consultation requirements often impose expensive and time-consuming demands that may not only delay important research but also render it cost-prohibitive, with little significant evidence that these measures effectively address the concerns about research.106–109Basic Life SupportBLS is the foundation for saving lives following cardiac arrest.Fundamental aspects of adult BLS include immediate recognition of sudden cardiac arrest and activation of the emergency response system,early performance of high-quality CPR,and rapid defibrillation when appropriate.The 2010AHA Guidelines for CPR and ECC contain several important changes but also have areas of continued emphasis based on evidence presented in prior years.Key Changes in the2010AHA Guidelines for CPRand ECC●The BLS algorithm has been simplified,and“Look,Listen and Feel”has been removed from the algorithm.Performance of these steps is inconsistent and time consuming.For this reason the2010AHA Guidelines for CPR and ECC stress immediate activation of the emergency response system and starting chest compressions for any unresponsive adult victim with no breathing or no normal breathing(ie,only gasps).●Encourage Hands-Only(compression only)CPR for the untrained lay rescuer.Hands-Only CPR is easier to perform by those with no training and can be more readily guided by dispatchers over the telephone.●Initiate chest compressions before giving rescue breaths(C-A-B rather than A-B-C).Chest compressions can be started immediately,whereas positioning the head,attaining a seal for mouth-to-mouth rescue breathing,or obtaining or assembling a bag-mask device for rescue breathing all take time.Begin-ning CPR with30compressions rather than2ventilations leads to a shorter delay to first compression.●There is an increased focus on methods to ensure that high-quality CPR is performed.Adequate chest compres-sions require that compressions be provided at the appro-priate depth and rate,allowing complete recoil of the chest after each compression and an emphasis on minimizing any pauses in compressions and avoiding excessive ventilation. Training should focus on ensuring that chest compressions are performed correctly.The recommended depth of com-pression for adult victims has increased from a depth of11⁄2 to2inches to a depth of at least2inches.●Many tasks performed by healthcare providers during resus-citation attempts,such as chest compressions,airway man-agement,rescue breathing,rhythm detection,shock delivery, and drug administration(if appropriate),can be performed concurrently by an integrated team of highly trained rescuers in appropriate settings.Some resuscitations start with a lone rescuer who calls for help,resulting in the arrival of additional team members.Healthcare provider training should focus on building the team as each member arrives or quickly delegat-ing roles if multiple rescuers are present.As additional personnel arrive,responsibilities for tasks that would ordi-narily be performed sequentially by fewer rescuers may now be delegated to a team of providers who should perform them simultaneously.Key Points of Continued Emphasis for the2010AHA Guidelines for CPR and ECC●Early recognition of sudden cardiac arrest in adults is based on assessing responsiveness and the absence of normal breathing.Victims of cardiac arrest may initially have gasping respirations or even appear to be having a seizure. These atypical presentations may confuse a rescuer,caus-ing a delay in calling for help or beginning CPR.Training should focus on alerting potential rescuers to the unusual presentations of sudden cardiac arrest.●Minimize interruptions in effective chest compressions until ROSC or termination of resuscitative efforts.Any unnecessary interruptions in chest compressions(including longer than necessary pauses for rescue breathing)de-creases CPR effectiveness.●Minimize the importance of pulse checks by healthcare providers.Detection of a pulse can be difficult,and even highly trained healthcare providers often incorrectly assess the presence or absence of a pulse when blood pressure is abnormally low or absent.Healthcare providers should take no more than10seconds to determine if a pulse is present. Chest compressions delivered to patients subsequently found not to be in cardiac arrest rarely lead to significant Field et al Part1:Executive Summary S643injury.110The lay rescuer should activate the emergency response system if he or she finds an unresponsive adult. The lay rescuer should not attempt to check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses,is unresponsive,and is not breathing or not breathing normally(ie,only gasping).CPR Techniques and DevicesAlternatives to conventional manual CPR have been devel-oped in an effort to enhance perfusion during resuscitation from cardiac arrest and to improve pared with conventional CPR,these techniques and devices typically require more personnel,training,and equipment,or apply to a specific setting.Some alternative CPR techniques and devices may improve hemodynamics or short-term survival when used by well-trained providers in selected patients. Several devices have been the focus of recent clinical trials. Use of the impedance threshold device(ITD)improved ROSC and short-term survival when used in adults with out-of-hospital cardiac arrest,but there was no significant improvement in either survival to hospital discharge or neurologically-intact survival to discharge.111One multicenter,prospective,randomized con-trolled trial112,112a comparing load-distributing band CPR(Auto-pulse)with manual CPR for out-of-hospital cardiac arrest demonstrated no improvement in4-hour survival and worse neurologic outcome when the device was used.More research is needed to determine if site-specific factors113or experience with deployment of the device114influence effectiveness of the load-distributing band CPR device.Case series employing me-chanical piston devices have reported variable degrees of success.115–119To prevent delays and maximize efficiency,initial training, ongoing monitoring,and retraining programs should be offered on a frequent basis to providers using CPR devices. To date,no adjunct has consistently been shown to be superior to standard conventional(manual)CPR for out-of-hospital BLS,and no device other than a defibrillator has consistently improved long-term survival from out-of-hospital cardiac arrest.Electrical TherapiesThe2010AHA Guidelines for CPR and ECC have been updated to reflect new data on the use of pacing in bradycar-dia,and on cardioversion and defibrillation for tachycardic rhythm disturbances.Integration of AEDs into a system of care is critical in the Chain of Survival in public places outside of hospitals.To give the victim the best chance of survival,3actions must occur within the first moments of a cardiac arrest120:activation of the EMS system,121provision of CPR,and operation of a defibrillator.122One area of continued interest is whether delivering a longer period of CPR before defibrillation improves out-comes in cardiac arrest.In early studies,survival was im-proved when1.5to3minutes of CPR preceded defibrillation for patients with cardiac arrest ofϾ4to5minutes duration prior to EMS arrival.123,124However,in2more recent randomized controlled trials,CPR performed before defibril-lation did not improve outcome.125,126IfՆ2rescuers are present CPR should be performed while a defibrillator is being obtained and readied for use.The1-shock protocol for VF has not been changed. Evidence has accumulated that even short interruptions in CPR are harmful.Thus,rescuers should minimize the interval between stopping compressions and delivering shocks and should resume CPR immediately after shock delivery. Over the last decade biphasic waveforms have been shown to be more effective than monophasic waveforms in cardio-version and defibrillation.127–135However,there are no clin-ical data comparing one specific biphasic waveform with another.Whether escalating or fixed subsequent doses of energy are superior has not been tested with different wave-forms.However,if higher energy levels are available in the device at hand,they may be considered if initial shocks are unsuccessful in terminating the arrhythmia.In the last5to10years a number of randomized trials have compared biphasic with monophasic cardioversion in atrial fibrillation.The efficacy of shock energies for cardioversion of atrial fibrillation is waveform-specific and can vary from120to 200J depending on the defibrillator manufacturer.Thus,the recommended initial biphasic energy dose for cardioversion of atrial fibrillation is120to200J using the manufacturer’s recommended setting.136–140If the initial shock fails,providers should increase the dose in a stepwise fashion.Cardiover-sion of adult atrial flutter and other supraventricular tachycardias generally requires less energy;an initial energy of50J to100J is often sufficient.140If the initial shock fails,providers should increase the dose in a stepwise fashion.141Adult cardioversion of atrial fibrilla-tion with monophasic waveforms should begin at200J and increase in a stepwise fashion if not successful. Transcutaneous pacing has also been the focus of several recent trials.Pacing is not generally recommended for pa-tients in asystolic cardiac arrest.Three randomized controlled trials142–144indicate no improvement in rate of admission to hospital or survival to hospital discharge when paramedics or physicians attempted pacing in patients with cardiac arrest due to asystole in the prehospital or hospital(ED)setting. However,it is reasonable for healthcare providers to be prepared to initiate pacing in patients with bradyarrhythmias in the event the heart rate does not respond to atropine or other chronotropic(rate-accelerating)drugs.145,146 Advanced Cardiovascular Life SupportACLS affects multiple links in the Chain of Survival,including interventions to prevent cardiac arrest,treat cardiac arrest,and improve outcomes of patients who achieve ROSC after cardiac arrest.The2010AHA Guidelines for CPR and ECC continue to emphasize that the foundation of successful ACLS is good BLS, beginning with prompt high-quality CPR with minimal interrup-tions,and for VF/pulseless VT,attempted defibrillation within minutes of collapse.The new fifth link in the Chain of Survival and Part9:“Post–Cardiac Arrest Care”(expanded from a subsection of the ACLS part of the2005AHA Guidelines for CPR and ECC)emphasize the importance of comprehensive multidisciplinary care that begins with recognition of cardiac arrest and continues after ROSC through hospital discharge and beyond.Key ACLS assessments and interventions provide anS644Circulation November2,2010。
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不开始CPR的原则
实施CPR会对抢救者本人产生严重损伤或致命 性风险
明显不可逆死亡征象（尸僵、尸斑、断头） 事先签署不希望复苏声明
青岛市中心医院ICU 李长江
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终止复苏的标准
心脏骤停发生时无EMS或其他目击者 3个周期CPR和AED分析后
仍无自主循环恢复（转运前） 未用AED除颤（复苏时未产生可除 颤心律）（转运前）
2010年AHA心肺复苏和心血管急救指南
2010 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
李长江 青岛市中心医院ICU
心肺复苏的历史
1960年，Kouwenhoven心脏骤停后闭式经胸心脏按压 Maryland医学会，胸外按压+人工呼吸
除颤
尽快连接并使用除颤器或AED 尽可能缩短电击前后的胸外按压中断 每次电击后立即从按压开始CPR
青岛市中心医院ICU 李长江
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生存链
立即识别心脏骤停并启动急救系统（EMS）
着重胸外按压的早期CPR 快速 除颤 有效的高级生命支持 综合的心脏骤停后治疗
青岛市中心医院ICU 李长江
高频率胸外按压
没有充分证据推荐，但可考虑
“咳嗽”CPR
清醒患者在目睹的非灌注心律发生后立即有力的自 主咳嗽，短期增加胸内压，并能产生高于常规胸外 按压的全身血压，使患者短暂维持意识。
咳嗽CPR应仅限于清醒、有监护的患者
青岛市中心医院ICU 李长江
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CPR技术
心前区重击
心前区叩击不用于非目睹的院外心脏骤停
15
AED除颤
自动体外除颤器（automated external defibrillator，AED）
青岛市中心医院ICU 李长江
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青岛市中心医院ICU 李长江
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除颤时注意事项
先电击还是先CPR？
VF几分钟，心肌氧和代谢底物耗竭，胸外按压能够 输送氧气和营养物质，提高除颤成功率
电击一次还是三次？
没有足够的证据反对或推荐目睹发作的心脏骤停使 用心前区叩击
青岛市中心医院ICU 李长江
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2010年指南的亮点
从“A-B-C”到“C-A-B”的转变
复苏成功率最高的是有目击的心脏骤停，主要是VF或 无脉室速，这些病人初始CPR最重要的是胸外按压和 早期除颤
“A-B-C”顺序中，胸外按压常因开放气道、口对口呼 吸等而延迟，“C-A-B”顺序，开始胸外按压时间缩短， 而通气仅仅延迟了一个按压循环（30次，约18s）
如果符合所有标准， 考虑终止复苏
如有任何一项标准不符合， 应继续复苏和转运
青岛市中心医院ICU 李长江
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CPR概述
成人、儿童、婴儿关键基础生命支持（BLS）步骤总结
识别
无反应（所有年龄） 没有呼吸或不能正常呼吸（仅仅是叹息） 所有年龄，在10秒内未扪及脉搏（限医务人员）
心肺复苏程序
C-（BLS）步骤总结
按压中断
尽可能减少胸外按压的中断 尽可能将中断控制在10秒以内
气道
仰头抬颏法（医务人员怀疑有外伤：推压下颌法）
按压-通气比率（置入高级气道之前）
成人1～2名施救者，30:2 婴幼儿单人施救者，30:2 ；2名医务人员，15:2
青岛市中心医院ICU 李长江
1962年，直流电单相波除颤法 1966年，AHA第一个心肺复苏（CPR）指南 2010年，CPR 50周年
青岛市中心医院ICU 李长江
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心肺复苏应用
5月28日7时50分左右，在
南京地铁一号线开往迈皋 桥方向的列车上，一名年 轻男乘客突然晕厥倒地， 周围乘客和地铁工作人员 纷纷伸出援手施救。关键 时刻，一名自称护士的女 乘客上前，采用娴熟而专 业的手法对倒地男子进行 胸外按压和人工呼吸，将 晕厥男子救醒
13
成人基础生命支持（BLS）流程
青岛市中心医院ICU 李长江
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人工呼吸
突发VF心脏骤停，CPR最初几分钟血氧含量仍然够用， 因此，强调在气道及呼吸前开始胸外按压
心脏骤停时间较长的患者，血流和肺内的氧气耗尽， 通气及按压同样重要
对于窒息性骤停，如溺水，通气及按压同样重要
青岛市中心医院ICU 李长江
开放气道、口对口人工呼吸，使施救者难以开始
（仅不到50%的心脏骤停者接受了目击者CPR）
青岛市中心医院ICU 李长江
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2010 AHA指南的关键变化
基础生命支持（BLS）简化，删除“看、听、感觉”， 对无反应且无呼吸或无正常呼吸（叹息样呼吸）的成 人，立即启动急救反应系统（EMS）并开始胸外按压。 施救者不应试图检查脉搏，而应推定发生了心脏骤停
青岛市中心医院ICU 李长江
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成人、儿童、婴儿关键基础生命支持（BLS）步骤总结
按压频率
每分钟至少100次
按压幅度
成人至少5cm 儿童达到胸部前后径的1/3，或近5cm 婴幼儿达到胸部前后径的1/3，或近4cm
胸廓回弹
保证每次按压后胸廓回弹， 医务人员每2分钟交换一次按压
青岛市中心医院ICU 李长江
单次除颤方案比连续3次方案有明显的益处，
推荐：使用1次电击治疗VF，然后立即CPR
除颤波形和能量
单相波除颤：360J
双相波除颤：120～200J，如果不知道制造商推荐剂 量，应考虑使用最大能量除颤
NOTE:儿童2～4J/kg,应≤10J/kg或成人最大剂量
青岛市中心医院ICU 李长江
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CPR技术
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成人、儿童、婴儿关键基础生命支持（BLS）步骤总结
通气
在施救者未经培训或不熟练的情况下，仅胸外按压
高级气道通气（医务人员）
6～8秒1次呼吸（每分钟8～10次） 与胸外按压不同步 大约每次呼吸1秒时间 明显的胸廓隆起
青岛市中心医院ICU 李长江
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成人、儿童、婴儿关键基础生命支持（BLS）步骤总结
鼓励未经培训的普通施救者仅实施胸外按压的CPR （hand-only CPR）
人工呼吸前即开始胸外按压（C-A-B)
高质量的CPR:按压深度至少5cm，频率至少100次/分, 每次按压后胸廓完全回复，强调最少的按压中断和避 免过度通气
强调医务人员团队合作
青岛市中心医院ICU 李长江
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