院内心肺复苏Utstein模式注册研究

目的应用心肺复苏Utstein指南模式评价心脏骤停原因及其心肺复苏复苏结果。方法按照心肺复苏Utstein评价指南设计心肺复苏注册登记表,在2008年1月至2009年12月期间,对海南省人民医院急诊科、重症医学科、心内科、海南省医疗保健中心心肺复苏和心脏骤停患者及其结果进行前瞻性描述性研究。结果在295例心脏骤停中,院外心脏骤停与院内心脏骤停分别为137例、158例,其心脏骤停心脏原因分别为49例（35.7%）、63例（39.9%）;院外心脏骤停非心脏原因中因创伤、淹溺、急性中毒引起心脏骤停高于院内心脏骤停组（P〈0.05）;而院内心脏骤停组因低氧血症/呼吸衰竭、低血压/休克、电解质紊乱引起心脏骤停高于院外心脏骤停组（P〈0.05）。院内心脏骤停复苏ROSC率、成活出院率分别为50.7%、13.9%,院内心源性心脏骤停的ROSC率、成活出院率高于非心源性心脏骤停（P〈0.05）。结论院外、院内心脏骤停原因有明显的差异,院内心源性心脏骤停的ROSC率、成活出院率高于非心源性心脏骤停。     

Impact of emergency percutaneous coronary intervention on outcomes of ST-segment elevation myocardial infarction patients complicated by out-of-hospital cardiac arrest

Background  Cardiac arrest is one of the most serious complications of acute myocardial infarction (AMI), especially in the out-of-hospital patients. There is no general consensus as to whether percutaneous coronary intervention (PCI) is effective in treating ST-segment elevation myocardial infarction (STEMI) patients complicated by out-of-hospital cardiac arrest (OHCA). In our study, we evaluated the efficacy of PCI in treating STEMI patients complicated by OHCA through observing their clinical conditions in hospital; including total mortality, adverse cardiac events, stroke, acute renal failure, and gastrointestinal bleeding events.

Methods  A total of 1827 STEMI patients were enrolled in this study, where 81 were STEMI with OHCA. Between the patients with and without OHCA, and the OHCA patients with and without PCI, we compared the clinical characteristics during hospitalization, including total mortality and incidences of adverse cardiac events, and stroke.

Results  Compared to the patients without OHCA, the OHCA patients had significantly lower systolic blood pressure (P <0.05) and a faster heart rate (P <0.05), and a higher percentage of Killip class IV or Glasgow coma scale (GCS) ≤7 on admission (P <0.001). And the in-hospital mortality was higher in the OHCA patients (55.6% vs. 2.4%, P <0.001). Comparing the OHCA patients without PCI to the patients with PCI, there was no obvious difference of heart rate, blood pressure or the percentage of Killip class IV and GCS ≤7 on admission, but the incidences of cardiogenic shock, stroke were significantly lower in the with-PCI group during hospitalization (P <0.001, P <0.05). And the in-hospital mortality of the OHCA patients receiving PCI was significantly lower (36.7% vs. 84.3%, P <0.001).

Conclusions  During hospitalization, the incidence of adverse events and mortality are higher in the STEMI with OHCA patients, comparing with the STEMI without OHCA. Emergency PCI reduces the incidence of adverse events and decreases mortality during hospitalization, which is effective for treating STEMI with OHCA patients.

     

Quality of resuscitation in hospitals

There is relatively less literature available on in-hospital cardiac arrest (IHCA) as opposed to that of out-of-hospital cardiac arrest (OHCA). Although IHCA and OHCA patients may differ at baseline, they share similar factors that are associated with survival. Important variables need to be standardised for reporting. Principles such as the 'chain of survival' remain applicable in the response. Early escalation protocols and medical emergency teams, together with streamlined activation pathways and staff training, are crucial. Post-resuscitation care bundles should be implemented.     

Circadian rhythm in cardiac arrest: the Singapore experience

INTRODUCTION: There appears to be a circadian rhythm in the timing of cardiovascular and neurovascular events. The majority of studies have been conducted in western populations. This is the first study to look at the peaks and distribution of out-of-hospital cardiac arrest (OHCA) patients in Singapore. METHODS: The Cardiac Arrest and Resuscitation Epidemiology Studies I and II were prospective observation studies on OHCA in Singapore from October 1, 2001 to October 14, 2004. This study analysed data for patients older than 16 years. All data was collected and recorded as per the Utstein style template. Analysis was done for each of the quadrants of the 24-hour clock: 0001-0600, 0601-1200, 1201-1800 and 1801-2400 hours. RESULTS: Of the 2,428 cases, 2,167 OHCA patients qualified for the final analysis. Their mean ages were in the 60s for all the four quadrants, with a male predominance. The two peaks noted were at 0800 and 1900 hours for cardiac causes of death (n = 1,591), and at 0900 and 2000 hours for non-cardiac causes of death (n = 576). At all times of the day, the majority of OHCA occurred in residences and the bystander cardiopulmonary resuscitation rate ranged from 14.6 to 24.3 percent in the different quadrants of the day. CONCLUSION: OHCA has a bimodal distribution in our local cohort of patients. The information obtained will be utilised for fine-tuning emergency medical services strategies, as we strive to improve our current survival rates for OHCA.     

Proposal for establishment of a National Sudden Cardiac Arrest registry

There is a need to establish a National Sudden Cardiac Arrest registry that would track the performance and outcomes of out-of-hospital (OHCA) and in-hospital cardiac arrests (IHCA) in the country. An effective strategy to improve survival from sudden cardiac arrest in Singapore requires a multi-pronged effort targeting the community, Emergency Medical Services (EMS) and the hospitals. The establishment of such a registry is important, as it would enable the tracking of trends and effectiveness of subsequent interventions related to our national strategy for management of both OHCA and IHCA. The quality improvement process of measurement-benchmarking-feedback/change is well established. A key part of this process is data collection. A cardiac arrest registry can be a key tool for quality improvement and serves as an important foundation on which to implement and track planned improvements to cardiac arrest management both in and out of hospital. It would also aid in planning for deployment of resources, interventions and ongoing efforts to improve Singapore's EMS.     

Alcohol,drug misuse and suicide attempts: unrecognised causes of out of hospital cardiac arrests admitted to intensive care units

Aim  To assess the contribution of alcohol, drug abuse and suicide attempts to out of hospital cardiac arrests (OHCA) who are admitted to our intensive care unit (ICU). Methods  Retrospective review of all OHCA admitted to the ICU over a 2-year period. Results  There were 26 OHCA. Six patients survived, all of whom had a cardiac aetiology for their arrest. Ten patients arrested due to external factors (drug misuse n = 4, alcohol excess n = 1, suicide attempts n = 4 and accidental choking n = 1). All of the patients who arrested secondary to external factors were young (37.2 ± 13.58 years), 90% were male and all died in hospital. All of the cases of drug misuse involved cocaine. Conclusion  Alcohol, drug misuse and suicide attempts contribute significantly to the number of OHCA which are admitted to ICU. Moreover, cocaine usage has contributed to a number of OHCA in our study.     

An essential review of Singapore’s response to out-of-hospital cardiac arrests: improvements over a ten-year period

Care for patients who experience out-of-hospital cardiac arrest (OHCA) has rapidly evolved in the past decade. Increased sophistication of care in the community, emergency medical services (EMS) and hospital setting is associated with improved patient-centred outcomes. Notably, Utstein survival doubled from 11.6% to 23.1% between 2011 and 2016. These achievements involved collaboration between policymakers, clinicians and researchers, and were made possible by a strategic interplay of policy, research and implementation. We review the development and current state of OHCA in Singapore using primary population-based data from the Pan-Asian Resuscitation Outcomes Study and an unstructured search of research databases. We discuss the roles of important milestones in policy, community, dispatch, EMS and hospital interventions. Finally, we relate these interventions to relevant processes and outcomes, such as the relationship between the strategic implementation of bystander cardiopulmonary resuscitation and placement of automated external defibrillator with return of spontaneous circulation, survival to discharge and survival with favourable neurological outcomes.     

Improving the quality of CPR in the community

Bystander cardiopulmonary resuscitation (CPR) is important for survival from out-of-hospital cardiac arrest (OHCA). However, recent research indicates that the quality of CPR is an important and often overlooked factor affecting survival. Individual factors, training, awareness, technique and rescuer fatigue may influence the quality of CPR. Quality components of CPR include rate, ratio, depth and ventilation-compression ratio. The new 2010 CPR guidelines advocate a ratio of compressions to ventilations of 30:2, with a rate of at least 100 compressions per minute. Depth of compression should be at least 5 cm. Rescuers should allow complete recoil of the chest. Locally, limited information is available regarding the quality of CPR being performed for OHCA. Strategies to improve the quality of CPR include research, training, education as well as incorporating appropriate technologies that measure and feedback the quality of CPR. These technologies are at the heart of recent advances, as they now make it feasible to provide routine feedback to rescuers providing CPR, through the integration of feedback devices into training equipment, defibrillators and standalone CPR assist devices.     

A Review of Compression,Ventilation, Defibrillation,Drug Treatment,and Targeted Temperature Management in Cardiopulmonary Resuscitation

Objective:

Important studies of cardiopulmonary resuscitation (CPR) techniques influence the development of new guidelines. We systematically reviewed the efficacy of some important studies of CPR.

Data Sources:

The data analyzed in this review are mainly from articles included in PubMed and EMBASE, published from 1964 to 2014.

Study Selection:

Original articles and critical reviews about CPR techniques were selected for review.

Results:

The survival rate after out-of-hospital cardiac arrest (OHCA) is improving. This improvement is associated with the performance of uninterrupted chest compressions and simple airway management procedures during bystander CPR. Real-time feedback devices can be used to improve the quality of CPR. The recommended dose, timing, and indications for adrenaline (epinephrine) use may change. The appropriate target temperature for targeted temperature management is still unclear.

Conclusions:

New studies over the past 5 years have evaluated various aspects of CPR in OHCA. Some of these studies were high-quality randomized controlled trials, which may help to improve the scientific understanding of resuscitation techniques and result in changes to CPR guidelines.     

Improved survival outcome with continuous chest compressions with ventilation compared to 5:1 compressions-to-ventilations mechanical cardiopulmonary resuscitation in out-of-hospital cardiac arrest

BackgroundFewer pauses and better chest compression quality are thought to improve overall survival following cardiac arrest. This study aimed to measure the outcomes of adult nontraumatic out-of-hospital cardiac arrests (OHCAs) treated with 5:1 compressions-to-ventilations (Thumper 1007) or continuous chest compressions with ventilation (Thumper 1008 CCV) mechanical cardiopulmonary resuscitation (CPR) within a specified period of time.MethodsA retrospective observational cohort study of 515 adults with OHCA was conducted at the emergency department of an urban tertiary hospital. There were 307 patients in the Thumper 1007 phase (January 2008 to December 2009) and 208 patients in the Thumper 1008 CCV phase (January 2010 to May 2011). Return of spontaneous circulation (ROSC) and survival to hospital discharge were the primary outcome measures.ResultsPatients in the Thumper 1007 and Thumper 1008 CCV phases had comparable results with the following exceptions: less hypertension (42.4% vs. 62.0%), cerebrovascular accidents (11.4% vs. 25.0%), and faster emergency medical service response time intervals (mean, 3.7 vs. 4.5 minutes) with the Thumper 1007. The average ambulance transport time was 6.1 minutes in both phases. The rates of ROSC [35.1% vs. 23.5%; adjusted odds ratio (OR), 1.616; 95% confidence interval (CI), 1.073–2.432] and survival to hospital discharge (10.1% vs. 4.2%; adjusted OR 2.431; 95% CI, 1.154–5.120) were significantly higher with the Thumper 1008 CCV than with the Thumper 1007. Favorable neurologic outcome upon discharge, defined as cerebral performance category scores of 1 (good performance) or 2 (moderate disability), was not significantly different between the two phases [1.6% (5/307) vs. 1.9% (4/208); p = 0.802]. The Thumper 1008 CCV provided significantly faster average chest compression rates and shorter no-chest compression intervals than the Thumper 1007 after activation.ConclusionIn an emergency department with short ambulance transport times, continuous chest compressions with ventilation through mechanical CPR showed improved outcomes, including ROSC and survival to hospital discharge, in an adult with OHCA. However, there are a variety of confounding influences that may affect the validity of conclusions that have been drawn.     

医院非专业急救者基本生命支持技能模拟培训的实践与思考

院外心脏骤停已成为社会公共卫生健康重点关注的问题之一,由非专业急救者实施的基本生命支持对挽救生命有重要意义。根据《国际心肺复苏与心血管急救指南》为非专业急救者设置并实施科学、规范、有效的培训课程是值得探索的课题。我院近2年对院内非专业急救者的心肺复苏技能模拟培训进行了尝试,取得了一些管理和实施经验：     

Clinical evaluation of the use of laryngeal tube versus laryngeal mask airway for out-of-hospital cardiac arrest by paramedics in Singapore

INTRODUCTIONIt remains unclear which advanced airway device has better placement success and fewer adverse events in out-of-hospital cardiac arrests (OHCAs). This study aimed to evaluate the efficacy of the VBM laryngeal tube (LT) against the laryngeal mask airway (LMA) in OHCAs managed by emergency ambulances in Singapore.METHODSThis was a real-world, prospective, cluster-randomised crossover study. All OHCA patients above 13 years of age who were suitable for resuscitation were randomised to receive either LT or LMA. The primary outcome was placement success. Per-protocol analysis was performed, and the association between outcomes and airway device group was compared using multivariate binomial logistic regression analysis.RESULTSOf 965 patients with OHCAs from March 2016 to January 2018, 905 met the inclusion criteria, of whom 502 (55.5%) were randomised to receive LT while 403 (44.5%) were randomised to receive LMA. Only 174 patients in the LT group actually received the device owing to noncompliance. Placement success rate for LT was lower than for LMA (adjusted odds ratio [OR] 0.52, 95% confidence interval [CI] 0.31–0.90). Complications were more likely when using LT (OR 2.82,0 95% CI 1.64–4.86). Adjusted OR for prehospital return of spontaneous circulation (ROSC) was similar in both groups. A modified intention-to-treat analysis showed similar outcomes to the per-protocol analysis between the groups.CONCLUSIONLT was associated with poorer placement success and higher complication rates than LMA. The likelihood of prehospital ROSC was similar between the two groups. Familiarity bias and a low compliance rate to LT were the main limitations of this study.     

超声引导下心包置管在急性心包填塞中的应用

目的 探讨实时超声引导下心包置管引流在心脏介入术中并发急性心包填塞的应用价值.方法 对20例在心脏介入术中并发的由超声心动图或及X线透视证实的急性心包填塞患者在实时超声引导下心尖部或心前区置人中心静脉导管抽吸或及引流.结果 20例急性心包填塞患者全部安全有效置管成功,患者经抽吸或引流后症状迅速缓解,得到有效救治.操作简单、快捷、并发症少.结论 急性心包填塞是心脏介入诊疗过程中严重的并发症,及时和有效处理非常重要,在实时超声引导下经皮穿刺心包置管引流是治疗急性心包填塞的有效方法,而且方法简单、安全、有效,便于临床应用.     

生理性心脏起搏的研究现状

人工心脏起搏显著改善了缓慢性心律失常患者的存活率和生活质量。在人工心脏起搏的发展历程中 ,生理性心脏起搏克服了非生理性心脏起搏的固有弊端 ,使起搏后的心脏功能状态更接近于正常的生理功能。植入生理性心脏起搏器是目前人工心脏起搏的发展发向     

Evaluation of a Novel Integrated Sensor System for Synchronous Measurement of Cardiac Vibrations and Cardiac Potentials

The measurement of human body vibrations as a result of heart beating, simultaneously with cardiac potentials have been demonstrated in past studies to bring additional value to diagnostic cardiology through the detection of irregularities in the mechanical movement of the heart. The equipment currently available to the medical community is either large and bulky or difficult to synchronize. To address this problem, a novel integrated sensor system has been developed to record cardiac vibration and cardiac potential simultaneously and synchronously from a single compact site on the chest. The developed sensor system is lightweight, small in size, and suitable for mounting on active moving patients. The sensor is evaluated for its adequacy in measuring cardiac vibrations and potentials. In this evaluation, 45 independent signal recording are studied from 15 volunteers, and the morphology of the recorded signals are analyzed qualitatively (by visual inspection) and quantitatively (by computational methods) against larger devices used in established cardiac vibration studies (reference devices). It is found that the cardiac vibration signals acquired by the integrated sensor has 92.37% and 81.76% identically identifiable systolic and diastolic cardiac complexes, respectively, when compared to the cardiac vibration signals recorded simultaneously from the reference device. Further, the cardiac potential signals acquired by the integrated sensor show a high correlation coefficient of 0.8912 and a high estimated signal-to-noise-ratio of 22.00 dB when compared to the reference electrocardiograph (non-standard leads) acquired through a common clinical machine. The results suggest that the tiny, wearable, integrated sensor system that synchronously measures cardiac vibrations and cardiac potentials may be practical for use as an alternative or assistive cardiac diagnostic tool.     

糖尿病/肥胖相关的炎症,心肌细胞死亡及心肌病

糖尿病心肌病（DCM）是糖尿病引发的一种慢性心肌病理改变。在这一慢性病理过程中,急性心肌反应如心肌细胞死亡起关键性的启动作用。除了高血糖,炎症反应也是引起糖尿病性心肌病心肌细胞死亡的一个重要因素。研究证实,糖尿病或肥胖经常可导致全身包括心脏中的肿瘤坏死因子-α（TGF—α）,白介素-18和血小板激活抑制因子-1（PAI—1）的升高。这些细胞因子引起心肌细胞死亡的机制主要是与氧化和／或氮化损伤相关。金属硫蛋白做为一个有效的抗氧化剂,可以保护心肌免受氧化应激损伤以及细胞因子引发的心肌细胞死亡,从而有效地防止DCM的发生。应用特异性的超氧化抑制荆可以完全阻断细胞因子导致的心肌细胞死亡,所以抑制氧化应激可以有效防止心肌死亡。因此,糖尿病诱发的炎症因子通过氧化应激反应所诱发的心肌细胞死亡是糖尿病心肌病（DCM）发生发展中的重要始动因子。     

Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk

THIS IS THE FIRST OF 2 ARTICLES EVALUATING cardiac events in patients undergoing noncardiac surgery. In this article, we review the magnitude of the problem, the pathophysiology of these events, approaches to risk assessment and communication of risk. The number of patients undergoing noncardiac surgery worldwide is growing, and annually 500 000 to 900 000 of these patients experience perioperative cardiac death, nonfatal myocardial infarction (MI) or nonfatal cardiac arrest. Although the evidence is limited, a substantial proportion of fatal perioperative MIs may not share the same pathophysiology as nonoperative MIs. A clearer understanding of the pathophysiology is needed to direct future research evaluating prophylactic, acute and long-term interventions. Researchers have developed tools to facilitate the estimation of perioperative cardiac risk. Studies suggest that the Lee index is the most accurate generic perioperative cardiac risk index. The limitations of the studies evaluating the ability of noninvasive cardiac tests to predict perioperative cardiac risk reveals considerable uncertainty as to the role of these popular tests. Similarly, there is uncertainty as to the predictive accuracy of the American College of Cardiology / American Heart Association algorithm for cardiac risk assessment. Patients are likely to benefit from improved estimation and communication of cardiac risk because the majority of noncardiac surgeries are elective and accurate risk estimation is important to allow informed patient and physician decision-making.     

心脏起搏器对老年非心脏手术围术期的心脏保护作用

目的 探讨心脏起搏器对老年非心脏手术围术期的心脏保护作用。方法 对２５例安装起搏器后行非心脏手术的老年冠心病患者的临床资料进行了回顾分析。结果 安装心脏起搏器的非心脏手术患者无危及生命的严重心律失常和急性心梗发生，且心律失常和心肌缺血和发生率较未安装起搏器者少。结论 安装心脏起搏器对老年冠心病患者非心脏手术围术期的心律失常和心肌缺血的预防及心脏保护作用有重要意义。     

老年人心律失常368例临床分析

目的 探讨老年人心律失常发生规律,为预防和治疗心律失常提供参考.方法 以2000年1月～2006年8月我院心电图室检出心律失常患者368例为对象,常规12导联心电图检查.观察各类型心律失常与患者性别、年龄、基础疾病的相关关系.结果 在各类型心律失常中以房性心律失常为多见,占51.6%,且各类型心律失常发生率与性别比较,差异无统计学意义(P＞0.05).随着年龄的增长,单纯性房性心律失常所占比例有所下降.70岁以下人群发生率明显高于70岁以上人群比较,差异有统计学意义(P＜0.05);而混合性心律失常及传导阻滞所占比例有上升趋势.心律失常基础疾病以冠心病(占46.47%)、慢性肺心病(占24.18%)为主.结论 房性心律失常可能是老年心脏病变较早的信号,改善心肌的供血与供氧,是防治老年人心律失常的重要措施.     

原位心脏移植术式的初步探讨

心脏移植是治疗各种终末期心脏病的有效方法.目前原位心脏移植的术式主要有三种.本文将比较标准法、双腔法、全心脏法原位心脏移植的手术方法和术后心脏功能与血流动力学变化的不同,并对其各自的优缺点进行讨论.