急救技術 R1路景竹 95/03/31
R195/03/31
Chain of Survival
Early Access Early Defibrillation
Early CPR Early Advanced care
Outline
Major changes of 2005 AHA guidelines in defibrillation and ALS
BLS Management of tachycardia Management of pulseless arrest
- VFSCA:
:
,
-
-30:2-CPR-
-15:2-()CPR--
Push fast: 100 Push hard: 1.5-2 Chest recoil: complete chest wall recoil No interruption!
Shock First or CPR First
Witnessed sudden cardiac arrest: AED as soon as possible.
Not witnessed SCA: 5 cycles of CPR before checking ECG and attempting defibrillation.
1-Shock or 3-Shock
Interruption of chest compression No published human or animal studies
compared 1-shock protocol with 6-stacked shock protocol.
Animal study: frequent or long interruption of chest compression post-resuscitation myocardial dysfunction, reduced survival rate!
1-Shock or 3-Shock
Interruption of chest compression: decreased probability of conversion of VF to another rhythm
Chest compression by healthcare providers: only 51-76% of total CPR time.
3-shock protocol delays up to 37 seconds between the first shock to fist post-shock compression.
1-shock + immediate CPR!
Tachycardia
First Step
Tachycardia :
?
SSS synchronized, sedation, shock 100, 200, 300, 360 PSVT: 50J AF : 50J Af : 100J Monomorphic VT 100J Polymorphic VT: 200J (Vf
VT
QRS R
QRS
T Vf
12 lead EKG
QRS ( =0.12
n-QRS ST, PSVTAf, AF, MAT
w-QRS VT, unknown originAf+ aberrancy
Af+ WPWpolymorphic VT Torsades de pointes
QRS
n-QRS ST underlyingPSVT adenosine 6-12-12
Af, AF, MAT control rateDiltiazem -bloker
Sinus Tachycardia
Sinus Tachycardia
HR>100
Painanalgesia Anxietysedation Hyperdynamic state-blockade Hypovolemiavolume replacement
PSVT
PSVT Vagal maneuver Adenosine 6mg (ClassI)
12mg 12mg
(1-3)20mlsaline 3mg :
(ClassIIa) Verapamil 2.5-5mg iv 2 Diltiazem 15-20mg(0.25 mg/kg) iv2 -bloker COPDCHF
Verapamil1. 15-305mg10mg
Max: 20mg2. 155mg
30mg
Diltiazem1520mg25mg(0.35 mg/kg)5-15mg/h
Atrial Flutter
AtrialAtrial FibrillationFibrillation
A.fib: Evaluation and Treatment
1. ?3. WPW ?4. 48 ?
1. 2. ( Control rate )3. ( Convert rhythm)4.
QRS : VT Amiodarone
SVT with aberrancy Adenosine
: Af with aberrancy AfAf with WPW Amiodaronepolymorphic VT AmiodaronePolymorphic VTtorsades de pointes Mg
Wide-Complex Tachycardia
MonomorphicMonomorphic VTVT
VT:VT:Amiodarone
Polymorphic VTPolymorphic VT
VT: VT: QT interval QT interval ?: amiodarone treat ischemia, correct e-: correct electrolytes: Magnesium,
overdrive pacing, isoproterenol, QT interval
Wolff-Parkinson-White Syndrome
WPW with A.fibrillationAmiodarone
What kinds of anti-arrhythmic drugs are harmful to this condition?
AABBCCD D
Amiodarone 150mg IVF 10 6 hr 1mg/min
18 hr 0.5mg/min500ml run 34ml/hr (6)
17ml/hr (18)500ml run 50ml/hr
25ml/hr
2.2g/24hrs (15) 10150mg IVF
MgSO4 MgSO4 1-2g
Torsades de pointes (class IIa)
pulse : D5W 10ml IF 5-20minpulse torsades D5W 100ml IF 5-60min
y
*ABC**()*
QRS
QRS
**Adenosine 6IV12IV12
(A.fib)(AF)(MAT)**(Diltiazem-Blockers-BlockersCHF)
(reentry SVT)**Adenosine(Diltiazem-Blockers)
(AF)(EAT)(JT)
*(Diltiazem-Blockers-Blockers
)**
(VT)
*Amiodarone150 IV 10
2.2g/24hr*
(SVT+Aberrancy)*Adenosine (7)
(A.fib+Aberrancy)*(11)(A.fib+WPW)** (AdenosineDigoxinDiltiazemVerapamil)*(Amiodarone150 IV 10)
torsades de pointes (Magnesium , 1~2g 5~60)
6 12
13 147
8
9 10
11
*4
***
6H-/6T-()()
Summary
1. 2. 12 lead EKGQRS3.
QRS
n-QRS ST underlyingPSVT adenosine 6-12-12
Af, AF, MAT control rateDiltiazem -bloker
QRS : VT Amiodarone
SVT with aberrancy Adenosine
: Af with aberrancy AfAf with WPW Amiodaronepolymorphic VT AmiodaronePolymorphic VTtorsades de pointes Mg
SSS synchronized, sedation, shock 100, 200, 300, 360
PSVT: 50J AF : 50J Af :100J monomorphic VT 100J Polymorphic VT: 200J (Vf
Pulseless Arrest
Pulseless Arrest
1. VF2. Pulseless VT3. PEA4. Asystole
1. CPR VF / pulseless VT
2. CPR PEA / asystole
CPR5cycle
360J200J (120~200J)
1. (biphasic)85%VF!
2. PEA CPR!
CPRCPR
On endo 30:2 100/min
8~10/min
(rhythm pulse)
pulse1.VF/pulseless VT (CPR)2.Asystole/PEA CPR
pulse ROSC (post-R care)
Bosmin: 1mg / 3~5 Vasopressin: 40UBosmin)
Amiodarone 300mg IV then 150mg IV
Lidocaine 1-1.5mg/kg then0.5-0.75mg/kg
Max: 3mg/kg
MgSO4 1-2g (D5W 10ml IF 5-20min)(Torsades de pointes) class IIapulse torsades D5W 100ml IF 5-60min
CPR
2005!
Summary (VF/pulseless VT) S-CPR-endo S: 360J C: CPR Epi 1mg -SC SCcheck Vaso 40 -SC Amio 300-SC Amio 150-SC Lido 1.5mg/kg- SC Lido 0.75mg/kg-SC Lido 0.75mg/kg-SC Mg 2g -SC
Asystole/PEA
CPR Bosmin 1mg 3~5 Vasopressin 40U
Bosmin)
Atropine 1mg 3~5(Max: 3mg)
2005: Vassopressin Asystole/PEA ! 40U!
PEA
6H-/
6T-()()
Pulseless Arrest
BLSCPR
/
Asystole/PEAVF/VT
CPRIV/IOVasopreesor*Epinephrine 1 IV/IO 3~5 Vasopreessin 40U IV/IO Epinephrine
Atropine 1 IV/IOAsystolePEA 3~5(3)
*(120~200(J))200(J)*AED*360(J)CPR
CPR
*()200(J)*AED*360(J)CPR
CPR
1
2
3 9
410
5
6
11
CPR
CPR IV/IOVasopreesor*Epinephrine 1 IV/IO 3~5 Vasopreessin 40U IV/IO Epinephrine
Atropine 1 IV/IOAsystolePEA 3~5(3)
(120~200(J))200(J)*AED*360(J)CPR
CPR
*()200(J)*AED*360(J)CPRIV/IOCPRVasopreesor()*Epinephrine 1 IV/IO 3~5 *Vasopreessin 40U IV/IO Epinephrine
*Asystole10*10*
4
CPR
CPR
CPR
5
6
11
1312
7
8
CPP
CPR
IV/IOCPRVasopreesor()*Epinephrine 1 IV/IO 3~5 *Vasopreessin 40U IV/IO Epinephrine
*Asystole10*10*
4
CPR
*()200(J)*AED*360(J)CPRCPR() Amiodarone(300 IV/IO 150 IV/IO ) Lidocaine(1~1.5 /0.5~0.75 / IV/IO33 /) Torsades de pointesMagnesium 1~2g IV/IOCPR5
CPR
1312
7
8
CPP*(100/)***CPR3025 (2)**
*CPR8~10*2
*6H-/6T-()()
Chain of SurvivalOutline- Shock First or CPR First1-Shock or 3-Shock1-Shock or 3-Shock1-shock + immediate CPR!TachycardiaFirst StepQRSSinus TachycardiaSinus TachycardiaPSVTPSVTAtrial FlutterAtrial FibrillationA.fib: Evaluation and TreatmentQRS Wide-Complex TachycardiaMonomorphic VTPolymorphic VTWolff-Parkinson-White SyndromeWPW with A.fibrillationAmiodaroneAmiodaroneMgSO4SummaryQRSQRS Pulseless ArrestPulseless ArrestSummary (VF/pulseless VT)Asystole/PEAPEA