心搏呼吸驟?；颊咝姆螐?fù)蘇流程選擇的探討

馬春茂 楊英

（彭州市人民醫(yī)院急診科，四川彭州 611930）

心搏呼吸驟?；颊咝姆螐?fù)蘇流程選擇的探討

馬春茂 楊英

（彭州市人民醫(yī)院急診科，四川彭州 611930）

目的：觀察不同心肺復(fù)蘇流程對(duì)心搏呼吸驟?；颊邚?fù)蘇成功率的影響，為心搏呼吸驟停患者心肺復(fù)蘇流程的選擇提供參考依據(jù)。方法：回顧我院2015年1月至2017年1月期間搶救的心搏呼吸驟停患者情況，對(duì)資料完整的192例患者進(jìn)行分析。按照患者心肺復(fù)蘇流程，將接受胸部按壓-氣道-呼吸（C-A-B）者納入CAB組，將接受電除顫-復(fù)蘇藥物（D）者納入D組，將接受電除顫-復(fù)蘇藥物-胸部按壓（D-C）者納入DC組，將接受氣道-呼吸-胸部按壓-復(fù)蘇藥物（A-B-C-D）者納入ABCD組，比較各組患者復(fù)蘇成功率、復(fù)蘇存活率以及復(fù)蘇成功患者自主循環(huán)恢復(fù)時(shí)間，探討心肺復(fù)蘇流程的優(yōu)化。結(jié)果：CAB組復(fù)蘇成功率、復(fù)蘇存活率均高于另3組，D組、DC組復(fù)蘇成功率、復(fù)蘇存活率均高于ABCD組，差異均有統(tǒng)計(jì)學(xué)意義（P＜0.05）。CAB組自主循環(huán)恢復(fù)時(shí)間低于另3組，D組、DC組自主循環(huán)恢復(fù)時(shí)間亦低于ABCD組，差異均有統(tǒng)計(jì)學(xué)意義（P＜0.05）。結(jié)論：對(duì)于心搏呼吸驟停患者而言，心肺復(fù)蘇流程中強(qiáng)調(diào)胸部按壓的優(yōu)先級(jí)，對(duì)于提高復(fù)蘇成功率、存活率，縮短自主循環(huán)恢復(fù)時(shí)間具有重要意義。

心搏呼吸驟停；心肺復(fù)蘇；流程；成功率

當(dāng)前我國(guó)院外心肺復(fù)蘇的成功率僅為1%～18%，院內(nèi)心肺復(fù)蘇成功率亦只有12%～24%[1]。因此，如何提高心肺復(fù)蘇成功率，一直是我國(guó)乃至全球醫(yī)務(wù)工作者共同面對(duì)的挑戰(zhàn)。心搏呼吸驟停的院內(nèi)發(fā)生率接近50%，多數(shù)患者會(huì)在癥狀發(fā)生后的2 h內(nèi)死亡[2]。復(fù)蘇流程選擇不當(dāng)、癥狀出現(xiàn)后復(fù)蘇開展時(shí)間較晚均被認(rèn)為是影響心肺復(fù)蘇成功率的危險(xiǎn)因素[3-4]。此次研究就心肺復(fù)蘇流程選擇對(duì)心肺復(fù)蘇成功率的影響進(jìn)行了回顧性分析，希望能為優(yōu)化復(fù)蘇流程提供參考。

1 資料與方法

1.1 一般資料

分析2015年1月至2017年1月192例心搏呼吸驟停患者，排除臨床資料不完整者。患者原發(fā)病包括腦源性疾病、心源性疾病、肺源性疾病、腎源性疾病以及創(chuàng)傷中毒性疾病等?；颊呔凑彰绹?guó)心臟協(xié)會(huì)（AHA）指南、國(guó)際心肺復(fù)蘇（CPR）指南及心血管急救（ECC）指南要求接受心肺復(fù)蘇[5-6]，主要操作包括心臟胸外按壓（頻次100～120次/min，深度50～60 mm，按壓放松比1：1，按壓呼吸比30：2）、呼吸道疏通與清理、氣管插管、氣囊面罩呼吸、電除顫、靜脈或氣管內(nèi)注射腎上腺素、吸氧等，每5次心肺復(fù)蘇流程后檢查生命體征，對(duì)于心肺復(fù)蘇成功者，明確其病因并開展預(yù)防再發(fā)的對(duì)癥治療，以及維持血液循環(huán)、維持有效通氣功能、低溫、腦復(fù)蘇、防治繼發(fā)感染等提高長(zhǎng)期生存和神經(jīng)恢復(fù)的治療[7]。按照患者心肺復(fù)蘇流程，將接受胸部按壓-氣道-呼吸（C-A-B）者納入CAB組（n=51），將接受電除顫-復(fù)蘇藥物（D）者納入D組（n=40），將接受電除顫-復(fù)蘇藥物-胸部按壓（D-C）者納入DC組（n=38），將接受氣道-呼吸-胸部按壓-復(fù)蘇藥物（A-B-C-D）者納入ABCD組（n=63）。

1.2 判別標(biāo)準(zhǔn)

復(fù)蘇成功判斷標(biāo)準(zhǔn)[8]：1）自主循環(huán)恢復(fù)，竇性心律恢復(fù)；2）面色由發(fā)紺轉(zhuǎn)為紅潤(rùn)；3）出現(xiàn)規(guī)則或不規(guī)則自主呼吸，或行器械通氣可將血氧飽和度（SpO2）維持在90%以上；4）瞳孔由大變小，眼球活動(dòng)或光反射恢復(fù)；5）腦復(fù)蘇成功，意識(shí)恢復(fù)，生命體征平穩(wěn)，未見嚴(yán)重腦功能障礙遺留。復(fù)蘇存活判斷標(biāo)準(zhǔn)[9]：意識(shí)轉(zhuǎn)為清晰，心肺腦功能基本恢復(fù)至發(fā)病前水平，存活時(shí)間≥2周。

1.3 統(tǒng)計(jì)學(xué)分析

對(duì)本臨床研究的所有數(shù)據(jù)采用SPSS18.0進(jìn)行分析，性別、病因、復(fù)蘇成功率等計(jì)數(shù)資料以（n/%）表示，并采用χ2檢驗(yàn)，年齡、自助循環(huán)恢復(fù)時(shí)間等計(jì)量資料以（）表示，并采用t檢驗(yàn)或F檢驗(yàn)，以P＜0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

2.1 復(fù)蘇率

CAB組復(fù)蘇成功率高于D組、DC組、ABCD組，D組、DC組復(fù)蘇成功率高于ABCD組，差異有統(tǒng)計(jì)學(xué)意義（P＜0.05）。見表1。

表1 四組患者復(fù)蘇成功率比較

CAB組復(fù)蘇存活率9.80%高于其余3組，D組復(fù)蘇存活率5.00%、DC組存活率5.26%高于ABCD組的1.59%，差異有統(tǒng)計(jì)學(xué)意義（P＜0.05）。

2.2 自主循環(huán)恢復(fù)時(shí)間

CAB組自主循環(huán)恢復(fù)時(shí)間為（7.71±2.64）min，低于其余 3 組，D 組、DC 組的（10.35±3.81）min、（10.08±3.44）min亦低于ABCD組的（13.86±4.04）min，差異有統(tǒng)計(jì)學(xué)意義（P＜0.05）。

3 討論

心肺復(fù)蘇是臨床一線急救時(shí)常用且最為重要的措施，由于心臟停搏、呼吸驟停并不意味著患者生命的結(jié)束，故及時(shí)、有效的復(fù)蘇措施能夠促進(jìn)心跳、呼吸以及中樞神經(jīng)功能的恢復(fù)，挽救患者生命[10]。當(dāng)前發(fā)達(dá)國(guó)家每年投入大量資金用于心肺復(fù)蘇知識(shí)、技能的培訓(xùn)與普及，使患者院外搶救成功率達(dá)到60%以上，但這一數(shù)字在我國(guó)仍處于較低水平，且存活患者中僅有20%可獲得完全康復(fù)，多數(shù)患者遺留長(zhǎng)期并發(fā)癥，生活質(zhì)量受到明顯影響[11-12]。

21世紀(jì)初，各類心肺復(fù)蘇指南均支持A-B-C-D流程，即首先注重保持呼吸道通暢，而后實(shí)施人工呼吸、胸外按壓、電除顫和給予復(fù)蘇藥物，經(jīng)過多年實(shí)踐，這一心肺復(fù)蘇流程在救治心搏呼吸驟停患者方面發(fā)揮了巨大作用，但也顯現(xiàn)出某些不足：由于A-B-C-D框架過分強(qiáng)調(diào)呼吸道通暢，院前心肺復(fù)蘇極易出現(xiàn)盲目等待氣管插管現(xiàn)象，造成后續(xù)復(fù)蘇流程滯后，影響救治效果[13]；與此同時(shí)，非專業(yè)醫(yī)務(wù)人員在開展心肺復(fù)蘇時(shí)，實(shí)施口對(duì)口呼吸效果有限，待急救人員到達(dá)后，復(fù)雜的插管過程也使得最佳救治時(shí)機(jī)進(jìn)一步貽誤，最終造成復(fù)蘇失敗、患者死亡[14]。本研究結(jié)果示，接受A-B-C-D規(guī)范流程救治的63例患者，其復(fù)蘇成功率僅為7.94%，自主循環(huán)恢復(fù)時(shí)間最高且死亡率高達(dá)98.41%，說明了傳統(tǒng)框架在心搏呼吸驟停救治環(huán)節(jié)的局限性。

鑒于心肺復(fù)蘇實(shí)踐過程中救助對(duì)象狀況、現(xiàn)場(chǎng)條件的變化以及救援人員多樣，近年來各類指南對(duì)于心肺復(fù)蘇流程的推薦呈多樣化發(fā)展，如2005年心肺復(fù)蘇指南即指出，對(duì)于無意愿或無能力行口對(duì)口呼吸者，可直接跳過這一流程，直接實(shí)施胸外按壓[15]。在這一理念的支持下，當(dāng)前臨床已發(fā)展出C-A-B、D、D-C等多種心肺復(fù)蘇流程，此次研究就各種流程的效果進(jìn)行了對(duì)比，結(jié)果顯示，D、D-C在心搏呼吸驟停救治中的作用均優(yōu)于傳統(tǒng)流程，其可能的機(jī)制為：在未開放氣道的前提下，心搏呼吸驟?；颊叽雍粑?、胸廓被動(dòng)恢復(fù)能夠提供少量氣體交換，也為其他后續(xù)步驟的改善奠定了一定基礎(chǔ)[16]；同時(shí)，口對(duì)口呼吸所致胃內(nèi)容物反流風(fēng)險(xiǎn)上升、有效胸外按壓時(shí)間減少，也是導(dǎo)致A-B-C-D流程救治效果不佳的重要原因[17]。

與D、D-C流程相比，C-A-B流程在救治心搏呼吸驟停方面發(fā)揮了最為顯著的效果，這一流程將患者自主循環(huán)恢復(fù)時(shí)間縮短至10 min以內(nèi)，且將患者復(fù)蘇成功率、復(fù)蘇存活率提升至19.61%、9.80%，其優(yōu)勢(shì)在于：多數(shù)心搏呼吸驟停患者具有可除顫心律，將胸外按壓置于心肺復(fù)蘇流程前置位，可使機(jī)體血液供應(yīng)迅速恢復(fù)，而在保證持續(xù)胸外按壓的同時(shí)，逐漸開放氣道、應(yīng)用救治藥物，能夠有效增加全身循環(huán)阻力，利于心搏、呼吸的及時(shí)恢復(fù)[18]。

綜上所述，C-A-B流程對(duì)心搏呼吸驟?；颊叩木戎涡Ч黠@優(yōu)于其他流程，可作為心肺復(fù)蘇的首選方案予以推廣，但在實(shí)際應(yīng)用中，不應(yīng)局限于C-A-B流程框架，需按照現(xiàn)場(chǎng)及患者實(shí)際情況靈活組合各類復(fù)蘇程序。

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Discussion on the selection of cardiopulmonary resuscitation processes in patients with breath and cardiac arrest

MA Chunmao, YANG Ying. （Department of Emergency, Pengzhou People’s Hospital,Pengzhou 611930 china）

Objective: The objective of this study was to observe the effect of different cardiopulmonary resuscitation processes on the success rate of resuscitation in patients with breath and cardiac arrest, and to provide references for the selection of cardiopulmonary resuscitation processes in patients with breath and cardiac arrest. Methods: A total sample of 192 cases with complete data of patients with breath and cardiac arrest rescued in our hospital between January 2015 and January 2017 were retrospectively analyzed. According to patients’ cardiopulmonary resuscitation process, patients receiving chest compressions-airway-breathing (C-A-B) were included in CAB group, patients receiving defibrillationresuscitation drugs (D) were included in D group, patients receiving defibrillation-resuscitation drugs-chest compressions(D-C) were included in DC group, patients receiving airway-breathing-chest compressions-resuscitation drugs were included in ABCD group. The success rate of resuscitation, the survival rate of resuscitation and the recovery time of spontaneous circulation in patients with successful resuscitation were compared among four groups, and the optimization of cardiopulmonary resuscitation process was also discussed. Results: The success rate and the survival rate of resuscitation of CAB group were both higher than those of the other three groups. The success rate and the survival rate of resuscitation of D group and DC group were all higher than that of ABCD group, and the differences were statistically significant (P＜0.05). The recovery time of spontaneous circulation of CAB group was shorter than that of the other three groups. The recovery time of spontaneous circulation of D group and DC group were also shorter than that of ABCD group, and the differences were statistically significant (P＜0.05). Conclusions: For patients with breath and cardiac arrest, the priority of chest compressions in cardiopulmonary resuscitation process is of great importance for improving the success rate and the survival rate of resuscitation, and shortening the recovery time of spontaneous circulation.

breath and cardiac arrest; cardiopulmonary resuscitation; process; success rate

R605

A

2095-5200(2017)06-020-03

10.11876/mimt201706008

馬春茂，本科，主治醫(yī)師，研究方向：急診臨床，Email：375654496@qq.com。