海南省多中心心肺复苏Utstien模式注册研究

目的 本研究以心肺复苏乌斯坦因(Utstein)评估模式评价海南省13家医院心搏骤停患者流行病学特征、心肺复苏结果及其影响因素。方法 在Utstein指南基础上设计“海南省心肺复苏Utstein注册登记表”,在2007年1月1日至2010年12月31日期间对海南省13家医院急诊科心搏骤停心肺复苏患者实施注册登记。通过方差分析等统计学方法,对心肺复苏患者实施前瞻性描述性研究。结果 1125例心搏骤停患者男性占73.8％,女性26.2％,年龄为(53.9±13.1)岁,既往病史以冠心病最为多见,其次为高血压病;自主循环恢复率为23.8％,成活出院为7.4％。自主循环恢复和成活出院的患者中发病l min内获得心肺复苏患者所占比例分别为41.8％和49.4％。院内心搏骤停(IHCA)患者和院外心搏骤停(OHCA)患者ROSC率分别为36.3％,11.6％,成活出院率分别为11.5％,3.3％。心室纤颤/无脉性室性心动过速患者188例(16.7％),其自主循环恢复率及成活出院率分别为58.0％,21.8％。心源性心搏骤停448例(39.8％);其中院内与院外心搏骤停患者自主循环恢复率分别为36.3％,11.6％,成活出院率分别为11.5％,3.3％。非心源性心搏骤停677例(60.2％)。三级医院和二级医院自主循环恢复率分别为69.8％和30.2％,成活出院率分别为7.4％和7.3％。结论 心搏骤停更常见于男性。慢性疾病在本组患者中普遍存在,其中以冠心病和高血压病最为多见。院内心搏骤停患者自主循环恢复和成活出院率均明显高于院外心搏骤停患者。心室纤颤/无脉室性心动过速患者心肺复苏自主循环恢复及成活出院率高于其他类型初始心律的患者。缩短心肺复苏启动时间有助于提高自主循环恢复率及成活出院率。     

463例院内心肺复苏Utstein模式注册研究

目的 应用心肺复苏(CPR)Utstein指南模式原则评价CPR效果与影响因素.方法 按照CPRUtstein评价指南设计CPR注册登记表,应用注册研究方法,研究院内463例(包括成人和儿童)CPR患者流行病学特征,CPR效果与影响因素.结果 心搏、呼吸骤停患者中男320例,占69.1%,女143例,占30.9%;依次以45～54岁、55～64岁、65～74岁为3个高发年龄组.既往史中以心血管系统、脑血管系统为主,分别占36.3%(168例)和9.9%(46例).心搏、呼吸骤停初始心律为心室纤颤74例,占16.O%;院内CPR患者自主循环恢复(ROSC)率为34.6%(160例)、成功复苏率为16.6%(77例),存活出院率为10.4%(48例).273例急诊室(院内)出现心搏、呼吸骤停并启动CPR者ROSC率[47.6%(130例)]、存活出院率[13.9%(38例)]明显高于190例入急诊室前(院前)已发生心搏、呼吸骤患者[15.8%(30例),5.3%(10例),P均<0.013]结论CPR评价Utstein指南模式的运用能较好地评价CPR效果与影响因素.其研究结果能与国际CPRUtstein模式注册研究结果进行横向比较,但院内CPR存活出院率仍偏低,需进一步提高CPR的效果.     

基于Utstein模式的院内不同地点心肺复苏结果对照研究

目的 应用心肺复苏(cardiopulmonary resuscitation,CPR)结果评估Utstein模式指南评价并对比院内不同地点心脏骤停患者实施CPR的结果.方法 按照CPR结果评估Utstein模式指南设计CPR注册登记表,选择2008年1月-2010年12月在我院急诊室、普通内科病房及重症监护病房(ICU)出现心脏骤停行CPR的患者注册登记,并进行对比研究.结果 同期共280例在医院内因心脏骤停实施CPR,其中急诊室60例(急诊室组),普通内科病房78例(普通病房组),ICU 142例(ICU组).自主循环恢复(ROSC)率急诊室组36.67％(22/60)、普通病房组42.31％ (33/78)、1CU组57.75％ (82/142),ICU组显著高于其他两组(P＜0.05),而急诊室组和普通病房组比较无统计学差异(P＞0.05).成活出院率急诊室组21.67％(13/60)、普通病房组17.95％(14/78)、ICU组26.76％(38/142),3组比较差异无统计学意义(P＞0.05).结论 医院内不同地点心脏骤停的CPR效果有所差异,在ICU内发生心脏骤停并行CPR者ROSC率更高,但成活出院率无显著提高.     

运用反馈装置培训对急诊心搏骤停患者心肺复苏效果的影响

目的:评价运用反馈装置培训对急诊心搏骤停患者心肺复苏有效率的影响.方法:选取2019年4月-2020年4月本院急诊科院前及院内接诊的心搏骤停(Cardiac arrest,CA)患者42例为观察组,回顾性分析2017年12月-2018年12月相同标准的CA患者38例为对照组.运用带反馈装置的高级心肺复苏培训模拟人对急诊...     

急性心肌梗死并发心搏骤停抢救分析

目的探讨急性心肌梗死并发心搏骤停的临床特点及抢救。方法对30例急性心肌梗死并发心搏骤停患者的临床资料进行回顾性分析。结果院内13例AMI并发心搏骤停患者经早期除颤复苏7例恢复自主循环，5例最终生存出院且全为男性患者、心功能I级。院前17例AMI并发心搏骤停患者经现场复苏3例恢复自主循环，最终全部死亡。结论全社会普及AMI及心肺复苏知识，120专业急救，早期除颤，院内高级抢救相结合才能提高AMI并发心搏骤停患者的生存率。     

院前心肺复苏115例结果分析

目的:通过分析院前心肺复苏(CPR)的结果,探讨提高院前心肺复苏成功率的途径。方法:对我院1998年至2002年救治的115例院前心搏骤停者,用Utstein模式进行回顾性统计和分析。结果:经复苏的104例心搏骤停者中,自主循环恢复(ROSC)有8例,复苏率为7.69％,其中2例存活至出院;对比呼救-到达现场间期(CRI)>6min和<6 min两组的复苏率有显著性差异,P<0.05;对比目击者是医务工作者和非医务工作者两组的复苏率有显著性差异,P<0.05 。结论:缩短CRI是提高院前心肺复苏成功率的关键途径;公民中普及CPR;提高医院急救技术和改善急救设备也不容忽视。     

院内心肺复苏中生存链应用现状分析

目前，院内心搏骤停(cardiac attest，CA)行心肺复苏(cardiopulmonary resuscitation，CpR)，国内多行胸外心脏按压，静推肾上腺素等药物，较少采取电除颤及建立人工气道。本文回顾性分析171例发生CA行CPR患者，以便了解“生存链”在院内心肺复苏中的运用现状，发现其薄弱环节，为改善患者预后提供帮助。     

心搏骤停患者心肺复苏率低的原因分析及对策

分析心搏骤停患者心肺复苏率低的原因,提出相应对策。心搏骤停患者心肺复苏率低的主要原因为市民的心肺复苏知晓率低、相关人员缺乏心肺复苏技能、院前急救及转送患者不规范等。主要对策：对市民加强心肺复苏的教育,提高院前急救人员的心肺复苏技能,重视相关人员心肺复苏的技能培训,健全社会保障系统。     

院前心肺复苏临床分析研究

目的：探讨提高院前心肺复苏成功率的途径。方法：对我院1999年10月至2003年12月救治的48例院前心搏骤停者，用Utstein模式进行回顾性统计和分析。结果：经复苏的45例心搏骤停者中，自主循环恢复（ROSC）有4例，复苏率为8，89％，其中1例存活至出院；对比呼救-到达现场间期（CRI）〉6min和〈6min两组的复苏率有显著性差异，P〈0．05；对比目击者是医务工作者和非医务工作者两组的复苏率有显著性差异，P〈0．05。结论：缩短CRI是提高院前心肺复苏成功率的关键途径；公民中普及CPR对提高复苏成功率有重要意义；提高医院急救技术和改善急救设备也不容忽视。     

气管插管时机对心肺复苏成功率的影响

目的:探讨气管插管时机对心肺复苏成功率的影响.方法:将124例呼吸、心搏骤停患者按呼吸心搏骤停至接受气管插管时间、地点分为及时插管组78例和延时插管组46例,及时插管组由院前急救医务人员实施气管插管,延时插管组均由院内医护人员行气管内插管,比较两组临床效果.结果:两组临床效果比较差异有统计学意义(P＜0.05).结论:患者出现呼吸、心搏骤停时及时给予气管插管,有利于提高其心肺复苏成功率.     

Timing and Identification of the Cause and Treatment of a Cardiac Arrest: A Potential Survival Benefit

ObjectiveThe aim of this study was to evaluate how mobile medical teams (MMTs) search for the etiology of a cardiac arrest (CA) and to investigate the association between the discovery of etiology and patient outcome.Subjects and MethodsResuscitations of all adult patients who experienced an in- or out-of-hospital CA between 2016 and 2018 were video recorded. All video recordings were reviewed. The time to start of “cause analysis” and time to treatment by the MMT were analyzed. Also, investigations performed during etiologic evaluation were examined: heteroanamnesis, medical history-taking, clinical examinations, technical investigations, and the use of the 4Hs and 4Ts method.ResultsOf the 139 CA events included in this study, the MMTs performed etiologic evaluation in only 75% of the resuscitations, and in 20% of the evaluations, they did not use the recommended 4Hs and 4Ts method. Medical history-taking and heteroanamnesis were performed in the large majority, but often without clear cause. A presumptive etiology was found in 46.8% of out-of-hospital CAs and 65.2% of in-hospital CAs. A significant association was found between return of spontaneous circulation and the discovery of presumable etiology for out-of-hospital CAs (p < 0.001). The median time to treatment was 492 s (recommended: 130–250 s) for nonshockable rhythms and 422 s (recommended: 270–390 s) for shockable rhythms, up to twice the time advised according to the guidelines.ConclusionThe current approach for etiologic evaluation is not ideal. Further research is needed to establish a more structured and simplified approach.     

NAEMSP 2001 A NNUAL M EETING

Abstract

Recently, emphasis has been placed on the simultaneous implementation of resuscitation interventions currently recommended within the 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). The rate of successful outcomes from out-of-hospital cardiac arrest remains relatively low in most U.S. communities. Accurate measures of these rates are difficult to determine because of ineffective reporting mechanisms. In many cases of acute myocardial infarction, the initial presentation of symptoms is quickly followed by sudden death. Little information exists regarding the system-of-care components most likely to result in successful outcomes. Inconsistent application of these components may be responsible in part for the variability of survival rates among communities. We present a case of acute myocardial infarction followed by sudden cardiac arrest benefiting from the application of coordinated, community-based systems of care.     

A Randomized Controlled Trial of Intravenous Aminophylline for Atropine-resistant Out-of-hospital Asystolic Cardiac Arrest

OBJECTIVES: Myocardial ischemia, during cardiopulmonary arrest, can lead to atropine-resistant bradyasystole from interstitial accumulation of endogenous adenosine. Aminophylline is a nonspecific adenosine receptor antagonist capable of reversing ischemia-induced bradyasystole in a variety of settings. The hypothesis of this study was that aminophylline improves the rate of return of spontaneous circulation (ROSC) in atropine-resistant asystolic out-of-hospital cardiac arrest when used early in the resuscitation effort. METHODS: This was a prospective, randomized, double-blinded, placebo-controlled trial set in an urban emergency medical services system serving a population of 250,000. All non-pregnant, normothermic adults suffering nontraumatic out-of-hospital cardiac arrest (February 1999 to August 2000) with asystole were eligible. Patients remaining in asystole after initial doses of epinephrine and atropine received either aminophylline 250 mg or matching placebo as a bolus injection through a peripheral intravenous line. All other aspects of the attempted resuscitation proceeded in accordance with standard Advanced Cardiac Life Support (ACLS) guidelines. A sample size of 102 patients was calculated to yield a power of 80% to show an absolute improvement of 25% in ROSC. The aminophylline and control groups were compared by calculating 95% confidence intervals (95% CIs) and the data were modeled using logistic regression. RESULTS: The investigators enrolled 112 consecutive patients. One subject was dropped prior to analysis because of missing data. Data for 111 patients were analyzed on an intention-to-treat basis. Baseline characteristics were similar for the two groups. Comparing the control and aminophylline groups, ROSC was achieved in 15.6% (95% CI = 6% to 29%) and 22.7% (95% CI = 13% to 35%), while reversal of asystole occurred in 26.7% (95% CI = 15% to 42%) and 40.9% (95% CI = 29% to 54%), respectively. Group allocation had an odds ratio of 1.8 (95% CI = 0.6 to 5.3) for ROSC. Witnessed arrest was an independent predictor of outcome with an odds ratio of 3.8 (95% CI = 1.3 to 11.2). CONCLUSIONS: Addition of aminophylline appears to be a promising new intervention in the ACLS treatment of atropine-resistant asystolic out-of-hospital cardiac arrest.     

Causes of in-hospital cardiac arrest – Incidences and rate of recognition

Background and methodsDo emergency teams (ETs) consider the underlying causes of in-hospital cardiac arrest (IHCA) during advanced life support (ALS)? In a 4.5-year prospective observational study, an aetiology study group examined 302 episodes of IHCA. The purpose was to investigate the causes and cause-related survival and to evaluate whether these causes were recognised by the ETs.ResultsIn 258 (85%) episodes, the cause of IHCA was reliably determined. The cause was correctly recognised by the ET in 198 of 302 episodes (66%). In the majority of episodes, cardiac causes (156, 60%) or hypoxic causes (51, 20%) were present. The cause-related survival was 30% for cardiac aetiology and 37% for hypoxic aetiology.The initial cardiac rhythm was pulseless electrical activity (PEA) in 144 episodes (48%) followed by asystole in 70 episodes (23%) and combined ventricular fibrillation/ventricular tachycardia (VF/VT) in 83 episodes (27%). Seventy-one patients (25%) survived to hospital discharge. The median delay to cardiopulmonary resuscitation (CPR) was 1 min (inter-quartile range 0–1 min).ConclusionsVarious cardiac and hypoxic aetiologies dominated. In two-thirds of IHCA episodes, the underlying cause was correctly identified by the ET, i.e. according to the findings of the aetiology study group.     

Is the ACLS Score a Valid Prediction Rule for Survival after Cardiac Arrest?

The ACLS (advanced cardiac life support) Score was previously developed to predict survival from out-of-hospital cardiac arrest. Whether the arrest was witnessed, initial cardiac rhythm, performance of bystander cardiopulmonary resuscitation (CPR), and the response time of the paramedic unit were determined to be predictive of survival. However, the ACLS Score has not been validated in other emergency medical services systems. OBJECTIVES: The purpose of this study was to externally validate the ACLS Score in one patient population. METHODS: This was a retrospective cohort study performed at an urban county teaching hospital. The study population consisted of consecutive adult patients treated for out-of-hospital, nontraumatic cardiac arrest, and transported to the authors' institution between November 1, 1994, and September 30, 2001. Patient records for all cardiac arrests during the study period were reviewed. Study variables included witnessed arrest, initial arrest rhythm, bystander CPR, paramedic response time, and survival to hospital discharge. Predicted probability of survival to hospital discharge was calculated for each patient using the ACLS Score. The overall predicted and observed survival rates were compared using Flora's Z score. The Hosmer-Lemeshow test was used to evaluate the model's goodness-of-fit over a range of survival probabilities. RESULTS: Of 754 cardiac arrest patients enrolled in the study period, 575 (76%) patients had documentation that allowed scoring using the ACLS Score. Twenty-five (4%) patients survived to hospital discharge. The predicted number of survivors based on the ACLS Score was 104 (18%), yielding a Flora's Z statistic of -4.46 (p < 0.0001). After categorizing predicted survival probabilities into four categories, the resulting Hosmer-Lemeshow statistic was 210 (p < 10(-6)). Both goodness-of-fit statistics demonstrated extremely poor fit of the model. A receiver operating characteristic (ROC) curve was created, yielding an area under the ROC curve of 0.33 (95% CI = 0.19 to 0.47), signifying extremely poor discrimination. CONCLUSIONS: The previously published ACLS Score was not valid when applied to an external cohort of out-of-hospital cardiac arrest patients. An externally valid model is needed to predict survival to hospital discharge following out-of-hospital cardiac arrest.     

What Is the Quality of Life for Survivors of Cardiac Arrest? A Prospective Study

Objective: To evaluate the quality of life of survivors of in-hospital and out-of-hospital cardiac arrest, and to correlate quality of life with clinically important parameters. Methods: Cohort followed at least six months after hospital discharge. Eligible patients had survived to hospital discharge after sudden cardiac arrest in 1) EDs, wards, and intensive care units of five university hospitals and 2) all locations outside hospitals in two midsized cities. Of 126 patients discharged alive, 30 died before they could be interviewed. Of the 96 patients remaining, 86 (90% of available patients, 68% of survivors to discharge) completed the interview. Quality of life was assessed with the Health Utilities Index Mark 3, which describes health as a utility score on a scale from perfect health (equal to 1.0) to death (equal to 0.) Results: Mean age (±SD) of interviewed survivors was 65 ± 14 years, and 47 (55%) were male; mean time between collapse and initiation of CPR was 2.2 ± 2.6 minutes. Mean utility was 0.72 (±0.22). Utilities were significantly higher among patients who had a shorter duration of resuscitation (mean ? 0.81 for those who received less than 2 minutes of CPR, 0.76 for those who received 3 to 10 minutes, and 0.65 for others, p ? 0.05, r²? 0.07). Mean utilities of survivors were worse than those of the general population (mean ? 0.85 ± 0.16, p < 0.01) and those whose activities were not limited by chronic disease (mean ? 0.91 ± 0.08, p < 0.01). Conclusions: Although overall survival was poor, most survivors had acceptable health-related quality of life. Therefore, concerns about poor quality of life are not a valid reason to abandon efforts to improve the health care system's response to victims of sudden cardiac arrest. Further research is necessary to identify effective strategies for improving both survival and quality of life after cardiac arrest.     

Management of the post-cardiac arrest syndrome

Background

Recent advances in resuscitation science have revolutionized care of the cardiac arrest patient. Dramatic departures from time-honored advanced cardiac life support therapies, such as cardiocerebral resuscitation and bundled post-arrest care, have given rise to a new paradigm of resuscitation practices, which has boosted the rate of neurologically intact survival.

Objectives

This article reviews the pathophysiology of the post-cardiac arrest syndrome, the collective pathophysiology after return of spontaneous circulation, and presents management pearls specifically for the emergency physician. This growing area of scientific inquiry must be managed appropriately to sustain improved outcomes.

Discussion

The emergency physician must understand this pathophysiology, manage resuscitated patients according to the latest evidence, and coordinate with appropriate inpatient resources.

Conclusion

The new approach to cardiac arrest care is predicated on a chain of survival that spans the spectrum of care from the prehospital arena through the emergency, intensive, and inpatient settings. The emergency physician is a crucial link in this chain.     

The presence of an Emergency Airway Response Team and its effects on in-hospital Code Blue

The survival rate from in-hospital cardiac arrest due to pulseless electrical activity (PEA)/asystole in our institution was higher than expected (70%). It was the impression of the Emergency Department-led Code Blue Team (CBT) that many of these patients were actually suffering respiratory arrests before their cardiac events. To address this, the facility developed an early intervention team focused on early airway intervention-the Emergency Airway Response Team (EART). The objective of this study was to assess the effect of early intervention in patients during the "pre-Code Blue" period, specifically with regard to airway stabilization. Our hypothesis was that there would be fewer CBT calls (cardiac arrests) due to PEA and asystole and that the survival from these events would decrease. This was a retrospective review of all cardiac arrests responded to by the CBT and EART for a period of 2 years. Charts were reviewed for the initial presenting rhythm (as defined by the Utstein Format) and event survival for the 12-month period immediately before and immediately after the establishment of the EART (Time Periods 1 and 2, respectively). The total number of CBT calls decreased by 15%, return of spontaneous circulation from any rhythm decreased by 9%, and survival to discharge decreased by 8% (p = non-significant). The number of CBT calls specifically for asystole/PEA decreased by 8%. Deaths in hospital were significantly associated with Period 2 (odds ratio 1.84; 95% confidence interval 1.03-3.28) after adjusting for age, gender, and presenting rhythms. The total number of CBT calls decreased slightly with the creation of the Emergency Airway Response Team. Return of spontaneous circulation and survival to hospital discharge after cardiac arrest due to asystole/PEA were significantly decreased, suggesting early intervention may have benefit.