2015年AHA心肺复苏指南
2015年AHA心肺复苏指南
➢ 医生在科室内猝死都无法生存，民众靠谁？
低自主循环恢复率/成活率原因
• 80%心脏呼吸骤停发生在院外或家庭 • 第一目击者多不是医务人员 • CPR知识缺乏（未普及）
– 无法对CA的快速识别/确认 – 没有尽快启动EMSS – 无调度指导下的CPR – 没有高质量CPR – 缺少自动体外除颤仪或者不会使用
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提要
• 背景及流行病学 • 相关概念 • CPR历史及指南演变 • CPR技术及实施 • 国内研究状况
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一、背景及流行病学
• 心脏骤停（SCA）发病数不断增加
–每年心血管疾病死亡人数>13,500000 –OHCA发生率20-140/10万人
• 心肺复苏（CPR）成功率没有明显提高
–恢复自主循环约14%~30% –OHCA存活率2%-11%、长期存活率低于5% –美国每年CA发生率>50万，存活率<15% –中国80%以上CA发生在家中和院外，不足1%被救活 –每年54万死于心脏猝死
• 在研经费 ＞ 300万
• 省市级科技进步奖6项
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急诊医学实验室
• 急诊医学实验室是徐州市重点实验室， • 现有5位专职科研人员，其中教授1人、
博士3人/硕士2人，海外经历3人； • 实验室建筑面积300多平方米； • 拥有一流的实验设备和条件； • 设备总值＞ 400万元，其中5万元以上设
备数十台件。
2015年4月13日， 淮北市人民医院一名医生在“早上交班 前突发心梗，抢救无效死亡”，年仅40多岁。
2015年4月12日， 首医附属北京友谊医院心外科副主任医 师李大连突发心脏病猝死，年仅48岁。
2015-AHA心肺复苏及心血管急救指南
成人基础生命支持 及心肺复苏质量：医护人员 BLS
关键问题和重大变更的总结
同时检查呼吸和脉搏，以缩短开始首次胸部 按压的时间
评估院外心脏骤停胸外按压频率与预后的 关系
2005.12~2007.05，在北美多中心研究 纳入大于20岁院外心脏骤停患者3098例
Circulation. 2012;125:3004-3012.
125 恢复自主循环（ROSC）最高
P=0.012
Circulation. 2012;125:3004-3012.
Resuscitation 85 (2014) 182– 188
存活组与死亡组按压深度比较
深度（mm）
54
53.6
51 48.8
48
45 存活组
死亡组 Resuscitation 85 (2014) 182– 188
Logistic 回归分析
Resuscitation 85 (2014) 182– 188
按压频率与出院生存率的关系
P=0.63
Circulation. 2012;125:3004-3012.
更大型的多中心研究— ROC PRIMED二次分析
北美260个EMS机构，回顾性研究 June 2007 to November 2009 总共18036例患者，有按压频率和深度记录
的6399例（62%） 评估按压频率与预后的关系
对于院外成人心脏骤停，在急救人员到来前， 单纯胸外按压式心肺复苏与同时进行按压和人 工呼吸的心肺复苏相比，存活率相近。
2015 心肺复苏指南
基于芬兰坦佩雷医学院开展的170例CPR损伤性分析报告 综合损伤率 28% 27% 49%
按压深度范围 5cm 5-6cm >6cm
推荐标准：(最高级别：Class I,LOE C-LD)
在徒手CPR中，按压深度不超过6cm
如不使用CPR监护及反馈装置，可能难于判断按压深度，并很难确认按压 深度上限
更新5：按压后离开胸壁
每次按压后，双手离开胸壁，以使胸廓充分回 弹
胸廓回弹
基于3项研究胸廓回弹不足与灌注压降低有关 按压间隙依靠在患者胸部→妨碍胸廓充分回弹→胸腔 内↑→静脉回流、灌注压、心肌血流↓→复苏存活率↓ 推荐标准：(级别很高：Class IIa,LOE C-LD)
在被按压间隙不依靠在患者胸上，让胸廓充分回弹
仍坚持C-A-B顺序
2105 AHA成人CPR指南
7大主要更新
更新1：强调快速反应，团队协作
施救者应同时进行几个步骤 由多名施救者形成综合小组 合力完成多个步骤和评估 包括： 急救反应系统、胸外按压、通气或取球囊面罩/ 人工呼吸、取除颤器等
覆盖院外院内的应急反应体系
呼吁成立院内的应急反应体系 院外急救有赖于城市急救中心的体系 院内反应时间标准： 有心电监护：（室颤发作——电击）<3分钟 无心电监护：（室颤发作——电击）<5分钟 在除颤的准备过程中均应同时开始 CPR！
更新4：别再使劲按了！
2010年： 频率》100次/分，深度》5cm 2015年： 频率100-120次/分,5cm《深度》6cm
提高复苏质量的同时减轻损伤
按压频率：100-120次/分钟
基于美国复苏联盟分析10371例心肺复苏数据， 发现： 按压频率范围 100-119次/分钟 120-139次/分钟 按压深度不足率 35% 50%
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AHA国际心肺复苏指南
2015年版心肺复苏指南重点更新
1. 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；
2. 手机时代，充分利用社会媒体呼叫施救者，手机等现 代化电子设备能够发挥重要作用；
3. 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）。
专业人员该怎么做
BLS 中成人高质量心肺复苏的注意事项
1. 基本原则： 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、取回并设置好除颤器同时 进行）；
5.为帮助患者预防大脑退化损伤，目标温度管理方面，最新证据显示 温度范围可以扩宽到 32-36 摄氏度并维持至少 24 小时；
6. 对于呼吸衰竭伴有肌紧张，且带有胎便的新生儿，目前还没有充 足证据支持常规气管插管。新指南建议在辐射加温器下进行心肺复苏 以帮助新生儿更快地获得氧气供应。
2. 高质量的心肺复苏
靠 在患者胸上；
（2）. 减少按压中断：胸外按压在整体心肺复苏中的目标比例至少 为 60%；
（3）. 若紧急医疗系统采用包括持续胸部按压的综合救治干预，对 院外心脏骤停者可以考虑在综合救治中使用被动通气技术；
2015年AHA国际心肺复苏指南
电除颤选择时机
电除颤能量选择
电除颤电极片位置
2015年版心肺复苏指南要点：快速行动 + 团 队协作是救命关键
10 月 15 日，美国心脏学会（AHA）在 2010 版心肺复苏 指南的基础上进行了更新，新版指南发布在 Circulation 杂志上。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。
心肺复苏最新标准2015
心肺复苏最新标准2015心肺复苏（CPR）是一种急救措施，用于在心脏停止跳动或呼吸停止时维持血液循环。
2015年，美国心脏协会（AHA）发布了最新的心肺复苏指南，对心肺复苏的操作标准进行了更新。
这些更新的标准旨在提高心肺复苏的成功率，并为急救人员和医护人员提供更清晰、更简单的操作指南。
根据最新的心肺复苏标准，以下是一些重要的变化和更新：1. 胸外按压深度，AHA建议在心肺复苏时，胸外按压的深度至少应达到5厘米（2英寸），最大深度不超过6厘米（2.4英寸）。
这一变化旨在确保足够的血液被推动到患者的大血管和重要器官，从而提高心肺复苏的有效性。
2. 胸外按压速率，AHA建议在心肺复苏时，胸外按压的速率应为每分钟100-120次。
这一变化旨在确保按压的速率与心脏跳动的频率相匹配，从而最大限度地提高心肺复苏的成功率。
3. 呼吸比例，AHA建议在心肺复苏时，每进行30次胸外按压后，应进行2次人工呼吸。
这一变化旨在减少胸外按压和人工呼吸之间的转换时间，从而提高心肺复苏的连续性和效率。
4. 自动体外除颤器（AED）的使用，AHA强调在心肺复苏中使用AED的重要性。
AED能够检测心律失常并提供电击治疗，因此在心肺复苏过程中及时使用AED可以提高患者的生存率。
5. 高质量心肺复苏的重要性，AHA强调了高质量心肺复苏的重要性，包括按压深度、按压速率、呼吸比例、胸外按压的连续性和中断时间的最小化等。
这些因素都对心肺复苏的成功率产生重要影响。
综上所述，2015年最新的心肺复苏标准对心肺复苏的操作提出了更严格的要求，旨在提高心肺复苏的成功率和患者的生存率。
因此，对于急救人员和医护人员来说，熟悉并严格遵守这些最新标准是至关重要的。
只有在紧急情况下能够迅速、准确地进行心肺复苏，才能最大限度地挽救患者的生命。
希望通过这些最新标准的推广和实施，能够为更多患者带来生的希望。
2015年心肺复苏指南
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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。
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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。
电击除颤后应立即恢复心肺复苏 (不要 检查心律或脉搏，直接开始胸外按 压）， 2 分钟后再进行下一次心律检查
三、美国每年约有 30 万人发生心脏骤停。 随着急救技术的发展，出院存活率已 提升 3 % 到 9.6%。但是，如果在现场自主循环 没有恢复，那么存活率又占多 少呢？
如果在现场自主循环没有恢复，只有 0.9% 的患者存活率
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四、根据目前最新的美国心脏协会心肺复苏 指南（ACLS)，在对心室颤动或无脉 搏室 性心动过速的患者进行电击除颤后，紧接 着的步骤应该是什么？
1、评估
2、呼救
3、放平患者，心脏按压
4、疏通气道
2021/3/7
仰头抬颏
口对鼻 人工呼吸
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5、口对口人工呼吸
高级心血管生命支持 ACLS
▪ 指由专业急救、医护人员应用急救器材和药品所 实施的一系列复苏措施，主要包括人工气道的建 立、机械通气、循环辅助仪器、药物和液体的应 用、电除颤、病情和疗效评估、复苏后脏器功能 的维持等。
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纳洛酮
2015美国AHA心肺复苏指南更新总结资料
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。 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%。
2015年美国AHA心肺复苏指南更新3
为保证每次按压后使胸廓充分回弹，施救者在按压间隙， 双手应离开患者胸壁。 原指南仅建议，每次按压后，施救者应让胸廓完全回弹， 以使心脏在下次按压前完全充盈。
如果在两次按压之间，施救者依靠在患者胸壁上，会妨碍 患者的胸壁会弹。
2015年美国AHA心肺复苏指南更新4
新版无论是否因心脏病所导致的心脏骤停，医护人员都应 提供胸外按压和通气。 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。
2015年美国AHA心肺复苏指南
松原市中心医院急诊科
马明宇
2015年美国AHA心肺复苏指南更新1
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。(2.0-2.4英寸) 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。
2015年美国AHA心肺复苏指南更新10
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。
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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）。
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
仁 德翳院·明德翳院
3、按压深度变更
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。
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
仁 德翳院·明德翳院
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。
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
仁 德翳院·明德翳院
6、通 气
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
仁 德翳院·明德翳院
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
仁 德翳院·明德翳院
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
仁 德翳院·明德翳院
药 品
7、除
颤
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。 2010 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。
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
仁 德翳院·明德翳院
第三次：新生儿复苏 此次提及并无改动，而是继续延用 2010 版建议的用法和剂量
第四次：过敏反应
对于危及生命的过敏反应，应给予肾上腺素。更新后的指南设 定了第二剂肾上腺素的使用时间：在若对第一剂无反应，而高 级生命支持要 5 到 10 min 后才能到达的前提下，给予第二剂 肾上腺素。
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
仁 德翳院·明德翳院
1. 快速反应，团队协作是救命的关键
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）。
仁 德翳院·明德翳院
加压素
新版指南中的重要更改，也是第一个「炮灰」的 药物就是加压素。因无论单用加压素，还是联合 使用加压素和肾上腺素，相对于单独使用肾上腺 素并无优势。所以为简化流程，将加压素从成人 CPR 流程中去除。
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
仁 德翳院·明德翳院
2. 生存链「一分为二」
院内急救体系 院外急救体系
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
仁 德翳院·明德翳院
肾上腺素
肾上腺素作为抢救用药中的顶梁柱，在新版指南中就曾四次提到。
第一次：成人高级心血管生命支持
对于心律不可电击，转而接受肾上腺素治疗的心脏骤停患者，建议尽 早使用肾上腺素。但需要注意的是无论使用哪种血管加压药物，在心 脏骤停后的救治中，应避免和立即纠正低血压。使得收缩压不低于 90 mmHg，平均动脉压不低于 65 mmHg，否则会造成患者死亡率增加和功 能恢复率减少。 第二次：儿童高级心血管生命支持 儿童心脏骤停过程中可以给予肾上腺素。自主循环恢复后，应使用输 液和正性肌力药 / 血管加压药，使得收缩压维持在患者年龄段的第五 百分位以上。
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
仁 德翳院·明德翳院
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STMEI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。
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
仁 德翳院·明德翳院
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
仁 德翳院·明德翳急救
---------非专业人士该怎么做
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
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
仁 德翳院·明德翳院
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
仁 德翳院·明德翳院
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。
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
仁德传院 大医精诚
2015AHA心肺复苏指南更新解读
仁德翳院·明德翳院 since 1889
2010版心肺复苏—BLS(CAB)
内容 识别 建议 无反应，没有呼吸或不能正常呼吸（仅仅是喘息） 10s内未扪及脉搏（医务人员） 心肺复苏程序 C→A→B
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
仁 德翳院·明德翳院
5、离开胸壁
为保证每次按压后使胸廓充分回弹，施救者在按 压间隙，双手应离开患者胸壁。
原指南仅建议，每次按压后，施救者应让胸廓完 全回弹，以使心脏在下次按压前完全充盈。如果 在两次按压之间，施救者依靠在患者胸壁上，会 妨碍患者的胸壁会弹。
仁 德翳院·明德翳院
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。
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
对于心脏骤停的患者抢救时，标准的复苏措 施固然重要，抢救用药也必不可少，正所谓 「医药不分家」。让我们一起来看看，从今 以后，抢救用药哪些药物依然好使，哪些药 物沦为禁忌吧！
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
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 以下为该指南的14大更新要点：
仁 德翳院·明德翳院
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
仁 德翳院·明德翳院
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
仁 德翳院·明德翳院
宜宾市第二人民医院
宜宾市中医医院·宜宾市传染病医院 The Second People`s Hospital of Yibin
仁 德翳院·明德翳院
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。