Bài giảng Hồi sinh tim phổi nâng cao - Hoàng Bùi Hải

Nội dung text: Bài giảng Hồi sinh tim phổi nâng cao - Hoàng Bùi Hải

1. HỒI SINH TIM PHỔI NÂNG CAO BS. Hoàng Bùi Hải BM HSCC- ĐHY Hà Nội 1
2. HSTP Nâng Cao ACLS 2010 Guideline  HSTP cơ bản  Ngừng tim  Nhịp nhanh  Nhịp chậm
3. CPR Changes Emphasise “Push hard, push fast, minimise interruptions; allow full chest recoil, and don’t hyperventilate”
4. Mất ý thức, ngừng thở hoặc thở ngáp Hoạt hóa hệ thống cấp cứu Lấy máy sốc điện Dành cho người Ép tim chưa được đào tạo (nhanh, mạnh, thả hết: ép > 100 l/ph, lún ngực 5 cm) Kiểm tra 2 phút nhịp Cardiopulmonary Resuscitation and Emergency Cardiovascular CareAdult Basic Life Support: 2010 American Heart Association Guidelines
5. Mất ý thức, ngừng thở hoặc thở ngáp Cardiopulmonary Resuscitation and Emergency Cardiovascular CareAdult Gọi cấp cứu Basic Life Support: 2010 American Dành cho nhân viên y tế Heart Association Guidelines Khai thông đƣờng thở Thổi ngạt Bắt mạch cảnh 10s Có mạch 1 lần/m ỗi 5- 2 phút Không có mạch 6s Ép tim (nhanh, mạnh, giãn tối đa); Ép 100 l/ph Thổi ngạt 2 lần Máy khử rung tự động (AED)/Máy sốc điện đến Ép-Thổi Sốc 1 lần Có Sốc điện Không 5 chu kỳ
6. Nguyên lý cơ bản HSTPNC • To provide critical blood flow to the vital organs with high quality chest compressions • Defibrillation as soon as possible provides the best chance of survival in victims with VF or pulseless VT (cf. CPR prior to defib) • Return of spontaneous circulation as rapidly as possible • Intensive care support aimed to achieve the best outcomes
7. HSTPNC – KEY I • High quality chest compressions with minimal interruptions; continuing compressions during defibrillator charging • Single (non-stacked) shocks, but stacked shocks may be considered for HPC witnessed arrest*, during cardiac catheterisation or after cardiac surgery • Precordial thump is de-emphasised • IV or IO drug administration (ETT de-emphasised) *Where a monitor / defibrillator is connected at the time
8. HSTPNC – KEY II • Adrenaline 1mg for VF/VT after the second shock once chest compressions have restarted and then every 3-5 min (alternate blocks of CPR) • Amiodarone 300mg after third shock • Atropine no longer recommended for routine use in asystole or PEA • Less emphasis on early intubation • Capnography to confirm and continually monitor tracheal tube placement, quality of CPR, and to provide early indication of ROSC
9. HỒI SỨC SAU NTH • Recognition that a “post resuscitation care’ protocol may improve survival following ROSC • Avoid hyperoxaemia – oxygen titration to Sa02 94-98% • Primary PCI in appropriate patients with sustained ROSC • Normoglycaemic glucose control (BSL >10 mmol/l should be treated but hypoglycaemia avoided) • Therapeutic hypothermia to include comotose survivors of cardiac arrest of any rhythm
10. Single Shock Defibrillation Strategy • Single shock strategy continues to be recommended to improve outcome by reducing interruption of chest compressions – Monophasic 360J / Biphasic 200 J (Adult) – Monophasic / Biphasic 4J/kg (Paed) • Exception is health professional witnessed VF/VT. – Salvo of three stacked shocks (Mono 360J / Biphasic 200J; with rhythm checks between shocks) – Followed by CPR and single shock strategy if unsuccessful
11. NGỪNG TIM
12. ĐƢỜNG TRUYỀN TĨNH MẠCH  “provision of high-quality CPR and rapid defibrillation are of primary importance and drug administration is of secondary importance”  20ml Bolus after drug
13. ĐƢỜNG TRUYỀN QUA XƢƠNG • Reasonable to establish access if IV access is not readily available
14. MASK THANH QUẢN • CPR more important than airway initially • Put in a supraglottic if intubation is going to be “hard” • LMA • King LT
15. ĐO CO2 KHÍ THỞ RA • 100% sensitive and specific for tracheal intubation • Helps count 8-10 breaths minute • Predictor of outcome
16. KHÔNG Atropin: VÔ TÂM THU VÀ HĐ ĐIỆN VÔ MẠCH • “Available evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit”
17. Thuốc = Máy tạo nhịp • It hurts! • No better than drugs • Ok to go from drugs to TV pacing • NOT ROUTINE in arrest
18. TÌM NGUYÊN NHÂN CÓ THỂ ĐIỀU TRỊ • 5Hs • 5Ts • Hypoxia • Thrombus (MI) • Hypovolemia • Thrombus (PE) • Hyperacidosis • Tension PTX • Hyperkalemia • Toxins • Hypothemia • Tamponade
19. THUỐC CO MẠCH • VF continues after epi and CPR - vasopressor • Amiodarone is first line • Not proven to result in long term outcome • Lidocaine is useless also
20. Epinephrine • Never any evidence that it works! • A Randomized placebo controlled trial of adrenaline in cardiac arrest- the PACA trial • Conclusion: The use of adrenaline in cardiac arrest was associated w significant increase in the proportion of pts achieving ROSC however this improvement did not extend to survival to hospital discharge.
21. Tóm lại- với Ngừng tim • Atropine OUT for PEA/Asystole • CPR first and fast • Airway- supraglottic emerges • Still have amiodarone even though it don’t work • Hope lies in a reversible cause
22. NHỊP NHANH
23. Nhịp nhanh – 5 nguyên tắc 1. Pearl 1: Don’t cardiovert to sinus rhythm 2. Pearl 2: Rates<150 don’t usually cause instability in normal healthy hearts 3. Pearl 3: Many arrhythmias caused by hypoxia- Fix that first 4. Pearl 4: If unstable use electricity- except narrow complex when adenosine may be ok 5. Pearl 5: IF THEY ARE PRETTY STABLE - GET A 12 LEAD ECG
24. Adenosine • “ More rapid and less severe side effects than calcium blockers” • “recent evidence suggests that adenosine is relatively safe for both treatment and diagnosis” in Wide Complex Tachycardia
25. Adenosine • May be considered in the initial diagnosis of stable, undifferentiated, regular, monomorphic, wide-complex tachycardia. Not to be used if the pattern is irregular. • New evidence of safety and potential efficacy. Help diagnose and treat SVT with aberrant conduction.
26. BÀN CÃI • Not for irregular or polymorphic • SVT should slow or convert • VT usually will not
27. Lựa chọn khác cho Nhịp nhanh QRS giãn rộng, đều – Bệnh nhân ổn định • Cardioversion, Procainamide, Amiodarone, Sotalol • Generally only try one! • Procaine 20-50mg/hour (17mg/kg or QRS 50% narrowed, or hypotension)
28. QRS giãn rộng, đều: Amiodarone • An option- better than lidocaine • 150 mg IV over 10 minutes Can repeat 2.2 g IV total in 24 hours
29. QRS giãn rộng – Không đều • Atrial fibrillation • Atrial fib - accessory pathway • Polymorphic VT
30. Nhịp nhanh thất đa hình thái • Defibrillation
31. 3 kiểu NNT đa hình thái 1. Prolonged QT : Magnesium 2. Familial : IV Magnesium Pacing Beta- blockers No Isoprel 3. Ischemic: Amiodarone, BB, revascularization
32. NHỊP NHANH
33. Morphin • Morphine should be given with caution to pts with unstable angina. • Morphine is indicated in STEMI when CP unresponsive to nitrates. • Morphine found to be associated with an increase mortality with angina and unstable angina large registry.
34. NHỊP CHẬM
35. Atropin • Atropine is not recommended for PEA/Asystole. • Use of atropine unlikely to have a therapeutic benefit • First Dose >0.5mg bolus • Repeat every 3-5 minutes • Max Dose 3mg
36. NẾU ATROPIN THẤT BẠI • Transcutaneous Pacing • or • Dopamine 2-10 mcg per minute • Epinephrine 2-10mcg per minute
37. Không dùng Atropine khi nào • Cardiac Transplant- ineffective • or brady Wide complex Type 2 or 3 blocks
38. Chronotropic Drugs • For symptomatic or unstable bradycardia, chronotropic drug infusion are recommended as an alternative to pacing. • Epi, Dopamine acceptable alternative to external transcutaneous pacing when atropine is ineffective.
39. 5 nguyên nhân có thể chữa đƣợc của Hoạt động điện vô mạch • Hypoxia • Tension PTX • Hypovolemia • Cardiac Tamponade • Toxic-Metabolic
40. 5 Xử trí tại khoa Cấp cứu • Oxygenate and Ventilate • Secure IV Access • Look for 3 Causes (ECG, Temp, Vol status) • Epinephrine (1mg q 3mins) • Review all 5 causes
41. 5 Nguyên nhân có thể tìm nhờ Siêu âm • Tamponde • Hypovolemia • Massive PE • Cardiogenic Shock • Normal->Lung view
42. Hoạt động điện vô mạch – Siêu âm 4 buồng tim • Pericardial Effusion + RV Strain=Tamponade • RV Strain=LV Strain=Hypovolemia • RV dil + RA dil vs LV Strain=PE • Poor contractility= Cardiogenic Shock • Nl = Lung view
43. TÓM LẠI 1. HSTP cơ bản tối ƣu 2. Sốc điện đƣợc hay không? 3. Nhịp nhanh hay chậm 4. Tìm nguyên nhân có thể điều trị 5. Chăm sóc sau ngừng tuần hoàn
44. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Circulation. 2010;122:S729-S767 48