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Electrical Therapies and BLS

Electrical Therapies and BLS. 台大醫院急診醫學部 袁昂醫師. Electrical Therapies. Defibrillation Automated external defibrillators (AEDs) Manual defibrillators Synchronized cardioversion Electrical pacing. VF and Defibrillation. VF: rhythm causing “ all ” sudden cardiac arrest

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Electrical Therapies and BLS

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  1. Electrical Therapies and BLS 台大醫院急診醫學部 袁昂醫師

  2. Electrical Therapies • Defibrillation • Automated external defibrillators (AEDs) • Manual defibrillators • Synchronized cardioversion • Electrical pacing

  3. VF and Defibrillation • VF: rhythm causing “all” sudden cardiac arrest • VF: useless quivering of heart  no blood flow • VF treatment: only one therapy works  defibrillation • Defibrillation success: chances drop every minute

  4. Defibrillation and Time • Approximately 50% survival after 5 minutes • Survival reduced by 7% to 10% per minute (if no CPR) • Rapid defibrillation is the key • CPR prolongs VF, slows deterioration Minutes: collapse to 1st shock

  5. VF and CPR • Bystander CPR provided, survival rate decreases 3% to 4%/min from collapse to defibrillation. • CPR and defibrillation within 5 min of collapse predicts good neurological outcomes. • CPR alone is unlikely to terminate VF.

  6. Probability of Survival Is Related to 2 Intervals: (1) Collapse to Defibrillation and (2) Collapse to CPR Collapse to start of CPR: 1, 5, 10, 15 (min) Probability of survival to hospital discharge Collapse to defibrillation interval (min)

  7. Chain of Survival 生命之鏈 Early Early Early Early Access CPR Defibrillation Advanced Care

  8. Shock First or CPR First? • Arrest in hospitals or place with AEDS • Shock immediately • Out-of-hospital cardiac arrest (OHCA), EMS call-to-arrival intervals > 4 min • CPR 5 cycles before shock (Class IIb)

  9. 1-Shock or 3-Shock Protocol? • 1 shock failed, subsequent shock usually failed. • Interrupt to CPR due to defibrillation • Deliver 1 shock and then immediately resume CPR (Class IIa). • May modify in ICU setting • Deliver another shock after 5 cycles of CPR (Class IIb).

  10. ON Operation of AEDs: 4 Universal Control Steps 1. POWER ON the AED 2. ATTACH pads 3. ANALYZE rhythm 4. SHOCK (if advised)

  11. Primary ABCD Survey Focus: Basic CPR and Defibrillation • Check responsiveness • Activate emergency response system • Call for defibrillator A = Airway: open the airway B = Breathing: check breathing, provide positive-pressure ventilations C = Circulation: check circulation, give chest compressions D = Defibrillation: assess for and shock VF/pulseless VT

  12. AED Safety • With every analysis and shock: no one touches patient! • Verbal: warning to bystanders— • “I’m clear” • “You’re clear” • “Everybody’s clear” • Visual: check “all clear” • Physical: add hand gestures • Only then press to shock

  13. Special Situations • Victim lying in water? • Pacemaker or implanted defibrillator: 1 inch away • ICD shock: wait 30-60 sec • Transdermal medication patches: removed the patches • Victim 1-8 years old: use adult AED if no choice. • Energy: 2 J/kg then 4 J/kg, but as high as 9 J/kg were used. • No infant recommendation

  14. Defibrillation Waveforms • Monophasic or biphasic waveforms • No specific waveforms is associated with a higher effectiveness. • Different energy levels • Optimal energy for biphasic waveforms? • Usually 150-200 J (< 200 J) for VF • Monophasic use 360 J for VF • Fixed or escalating energy?

  15. Synchronized Cardioversion • Avoid shock in the relative refractory period, which may induce VF. • Re-entry or automaticity • Monophasic energy levels • Af: 100-200 J • AF or SVT: 50-100 J • VT with pulse: 100-200-300-360 J • Optimal energy for biphasic waveforms?

  16. Ventricular Tachycardia

  17. Polymorphic VT

  18. 心肺復甦術介紹Cardiopulmonary resuscitation(CPR) 2005 美國心臟學會基本救命術指導原則 An update of CPR technique 台大醫院急診醫學部 林鍵皓醫師

  19. Basic life support (BLS) Introduction of CPR technique

  20. BLS Algorithm

  21. 基本口訣：叫-叫-A-B-C 叫：檢查意識、確認現場安全 叫：求救、擺正患者平躺姿勢 A(開)：打開呼吸道 B(吹)：評估呼吸、吹氣 C(壓)：評估循環、壓胸

  22. 步驟1、2

  23. 步驟1-叫（叫病人）

  24. 叫病人

  25. 步驟2-叫（求救）

  26. 及早求救 (呼叫119) • 當你打電話求救時，告訴救護員： —發生的地點、地址、街道名稱，或顯而易見的指標 —你打電話地點的電話號碼 —發生甚麼事：心臟病發作、車禍、摔傷等等 —多少人需要幫助 —患者情況 —做過什麼處置 • 不要先掛電話，讓對方先掛電話。在很多地區有受過專業訓練的緊急派遣員會指導你做下一步驟的急救

  27. 在醫院內 打9595 說你是誰 在哪裡

  28. 步驟3、4

  29. 步驟3-A（打開呼吸道）

  30. 壓額抬顎法

  31. A-打開呼吸道 (Airway) • 呼吸道是否暢通 • 注意有無頸椎受傷的可能 • 以適當的方法打開呼吸道 • 壓額抬顎法（一般民眾） • 下巴推擠法（醫護人員在有頸椎有受傷者）

  32. 下顎推前法（醫護人員在有頸椎有受傷者）

  33. 步驟4-B（評估呼吸及吹氣）

  34. B-評估呼吸及吹氣

  35. 瀕死式呼吸 • 呼氣漸漸變長 • 吸氣短而費力 • 呼吸漸漸不規則、變慢，成為喟嘆式呼吸 • 任何非正常呼吸型態，都視為沒有呼吸

  36. 步驟5

  37. 步驟5-C評估循環及壓胸

  38. C-檢查脈搏 (Circulation) 嘿! 不可超過10秒! • 一般民眾不用檢查脈搏! • 如果作完 叫-叫-A-B，病人仍無動作無反應，則立刻進行心臟按摩! • 醫護人員： • 以兩根手指感覺頸動脈的脈搏 • 如無脈搏則立刻進行心臟按摩!

  39. C-壓胸 胸骨下半段 （兩乳頭連線中點）

  40. 好的壓胸～～標準的壓胸動作 用力壓、快快壓、胸回彈、莫中斷!

  41. 步驟5-壓胸

  42. 步驟6 Attention! AED到達，給一次電擊就好! 電擊完立刻再 CPR!!

  43. 電擊器使用的時機與注意事項 • 時機 • 若病人目擊倒下或倒下時間在4-5分鐘內，優先考慮AED或電擊器的使用 • 若病人不知何時倒下，先進行五個循環或兩分鐘的CPR，再使用AED及電擊器 • 注意事項 • 電擊一次即可，不再「電電電」！ • 電擊完立即進行五個循環或兩分鐘的CPR，再檢查心律，不要立即檢查心律！

  44. AED的操作：四個通用步驟 ON 1. 打開開關 2. 貼上電極 3. 分析心律 4. 建議電擊

  45. BLS的操作精神與口訣 叫叫 AB-CPR 用力壓、快快壓、胸回彈、莫中斷 30比2 五循環 檢查節律並換手 電擊立刻五循環 檢查節律並換手 • 操作精神 • 評估→缺什麼補什麼 • 口訣

  46. CPR常見的錯誤 氣吹不進去 頭後仰不夠、嘴未蓋全、鼻子未捏緊 重新打開呼吸道 胸部按壓位置不對 答數方式不對

  47. 小孩與嬰兒 • 兒童 • 青春期前（1-8歲） • 單手掌根，胸壁厚度的1/3-1/2 • 嬰兒 • 小於1歲，大於一個月 • 兩手指，胸壁厚度的 1/3到1/2 • 壓吹比：30:2

  48. 歡迎討論

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