長崎救急医学会 - 長崎大学病院第27回 長崎救急医学会 第27回 長崎救急医学会学術集会 プログラム・抄録集 “超高齢時代の救急医療”
急救之重點dohc.tmu.edu.tw/downloads/急救與後送20090517.pdf · loses its ability to...
Transcript of 急救之重點dohc.tmu.edu.tw/downloads/急救與後送20090517.pdf · loses its ability to...
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:6090180
6090180
4 - 6
--
(%)
5 %19 %26 %4 8
ACLS (min)CPR (min)
> 168 16< 8
10 %19 %43 %0 4
0 %6 %-8 12
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VT Vf
pulseless arrhythmia irregular and chaotic electrical activity loses its ability to function as a pump. Sudden loss of cardiac output with subsequent tissue hypoperfusion creates global tissue ischemia;
VF is the primary cause of sudden cardiac death (SCD).
Irregular, choatic.* Loss of cardiac output. Pulse-less.
brain and myocardium are most susceptible.
Vf, pulseless VT
Primary ABCD. CPR. + defibrillation. (360J)Vf, VT : on endo, IV, monitoring. CPR. DDx.Bosmin 35 minutes/ 1 Amp IV. Vasopressin 40IU, .
VF or not
A
B
C
D
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Oropharyngeal Airway
Nasopharyngeal Airway
The Oropharyngeal Airway
Nasopharyngeal Airway
1) 2) . Air hunger. 3) CO2 4) .
Laryngeal-Mask AirwayThe LMA was invented by Dr. Archie Brain at the London Hospital, Whitechapel in 1981The LMA consists of two parts: mask and tubeThe LMA has proven to be very effective in the management of airway crisis
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Laryngeal-Mask Airway
The LMA design: Provides an oval seal around the laryngeal inlet once the LMA is inserted and the cuff inflated.
Once inserted, it lies at the crossroads of the digestive and respiratory tracts.
Defibrillation
Curved Blade Laryngoscope Inserted Against Epiglottis Visualization of Vocal Cords
Glotticopening
Arytenoidcartilage
Tongue
EpiglottisVallecula
Vocalcord
AnatomyAnatomy
Esophageal Tracheal COMBITUBE
Esophageal Tracheal Airway (Combitube), 140ml syringe, 20ml syringe, fluid deflector attachment
Insertion ProceduresPosition the patients neck in a neutral position.Lubricate the tube with sterile, water soluble lubricantLift the tongue and lower jaw upward to open the oropharynx
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Insertion ProceduresAdvance tube until the patients teeth are between the two black lines
Esophageal PlacementIf the Combitube is placed in the esophagus, the distal balloon will occlude the esophagus.Ventilations are provided through perforations in the side of the pharyngeal tube.Stomach contents can be safely expelled via the hole in the end of the tube.
Tracheal PlacementIf placed in the trachea, it functions as an endotrachealtube, with the distal balloon preventing aspiration.Ventilations are provided via the hole in the end of the tube.Stomach contents can be safely expelled via perforations in the side of the pharyngeal tube.
Anaphylaxis
A severe allergic reaction that is rapid in onset and may cause death. [E (IgE), , histamine].(30)
Symptoms
Anaphylactic reactions almost always involve the skin or mucous membranes.
More than 90% of patients have some combination of urticaria, erythema, pruritus, or angioedema.
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Symptoms--?
The upper respiratory tract commonly is involved, with complaints of nasal congestion, sneezingCough, hoarseness, or a sensation of tightness in the throat may presage significant airway obstruction.
Symptoms--,
Eyes may itch and tearing may be noted. Conjunctival injection may occur.
Dyspnea is present when patients have bronchospasm or upper airway edema.
Symptoms--
Hypoxia and hypotension may cause weakness, dizziness, or syncope. Chest pain may occur due to bronchospasm or myocardial ischemia (secondary to hypotension and hypoxia).
Airway patency
May be preferable to defer intubationattempts, and instead ventilate with a bag/valve/mask apparatus while awaiting medications to take effect. In extreme circumstances, cricothyrotomy or catheter jet ventilation may be lifesaving. Inhaled beta-agonists are used to counteract bronchospasm and should be administered to patients who are wheezing.
Bosmin, AntihistamineAdminister epinephrine to patients with systemic manifestations of anaphylaxis. With mild cutaneous reactions, an antihistaminealone may be sufficient, thus the potential adverse effects of epinephrine can be avoided. Patients on beta-blocker medications may not respond to epinephrine. In these cases, glucagonmay be useful. Antihistamines (eg, H1 blockers), such as diphenhydramine (Benadryl) are important and should be administered for all patients with anaphylaxis or generalized urticaria.
Steroid
Corticosteroids may not influence the acute course of the disease; therefore, they have a lower priority than epinephrine and antihistamines.
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!!
Fast sugar testEyetoneFinger stick.
History taking ()
: DM history Hypoglycemia();
Coma cocktail
Coma cock tail50% G/W for hypoglycemic coma. Naloxone for Morphine intoxication. Thiamine for Wernickeencephalopathy.
Anexate (Flumazenil) for BZD overdose.
A,E,I,O,U,T,I,P,P,S
(1) Alcohol.(2) Epilepsy, Electrolyte imbalance. (3) Insulin-induced.- Hypoglycemia.(4) Opiate.5Uremia.6Trauma.7Infection.8 Poison.(TCA, BZD,.)9 psychi-()10Stroke, shock.chief complaint, present illness, history taking
asthma
, :
CAD/IHD, AMI, ACS)
(COPD, Asthma)(hyperventilation syndrome)
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Asthma : etiology,
1., ..2...3.Cold air.4.5.6.
7. , . Allergy or -adrenergicPropranolol
Predisposing factor ,
mite
Wheezing 4(wheezing):
silent.
COPD nasal cannula 2 L/min.ACS (Acute coronary syndrome) nasal cannula 4L/min.Respiratory distress mask. Respiratory failure BVM, on endotrachealtube.
Hyperventilation syndrome
Make sure pulseoxymeter: well.Make sure normal breathing sound. history of emotional influence. Stress.Young, female. Occasionally elderly, male.Use plastic bag.
(ACS)
. (ACS).
:.
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1.:,,, . 2..3.. 4.. 5.,,,,.
Call for help 119,,
,()NTG,,,,. AED ()12 lead ECG.
4()843
101710
Stroke
.7075%
2530%
?
Facial droop Arm Drift. Abnormal speech..Any 1 of 3, stroke rate: 72%.
Cincinnati Prehospital Stroke Scale.Acad Emerg Med. 1997;4:986-990
time is brain . ,oxygen, pulse oximetry.. K.V.O. ,
, , (aspiration).. If MAP > 130 mmHg. Head up 30 degrees.
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Position ,
Head up 30 degrees. 30.
(tPA)
1). 18 y/o2). (Infraction) type.3). .
. tPAICH. , AVM, aneurysm, tumor.
, SBP> 185mmHg. DBP> 110mmHg.seizure attack.
< 10, 48 hoursheparin. INR >1.7 or PT> 15 sec wafrain
tPA
lumbar puncture, UGIB.
< 50 or > 400 mg/dL.
Victims from cardiac arrest are benefit from ECMO during CPR, when this arrest occurs from reversible conditions such as massive pulmonary embolism or CAD.
Acad Emerg Med 1999; 6:700707
The 2005 AHA guidelines for CPR and emergency cardiovascular care : ECMO during CPR should be considered for in-hospital cardiac arrest (IHCA) patients when the no-flow is brief and the condition is reversible(Class IIb)
Circulation 2005; 112(Suppl. I):IV-47IV-50
ECMO support can extend theduration of CPR
Review of consecutive adult in-hospital CPR patients without return of spontaneous circulation (ROSC) in 10 mins and with ECMO rescue, and analysis of the relationship between outcome and CRP duration and possible etiologies.
Patients: An observational cohort study in 135 consecutive adult in-hospital CPR patients without ROSC who received ECMO during CPR.
Crit Care Med 2008 Vol. 36, No. 9
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Exclusion Criteria of ECPR. CPR with traumatic origin unless bleeding was under controlPrevious severe brain damageTerminal status of malignancyAn age 75 yrs.(80yrs)
The outcome of in-hospital CPR is quite varied and major studies have reported a survival-to-discharge of 10% to 20%.A large series of adult in-hospital CPR patients with only 18% survival had a median CPR duration of 18 mins in all patients combined, which was even shorter in survivors.
ECMO support can extend theduration of CRP
Main Results: The average CPR duration was 55.7 27.0 mins and 56.3% of patients received subsequent interventions to treat underlying etiologies.The successful weaning rate was 58.5%The survival-to-discharge rate was 34.1%. The majority of survivors (89%) had an acceptable neurologic status on discharge. Risk factors for hospital mortality included longer CPR duration, etiology of ACS, a higher organ dysfunction score in the first 24 hrs. Crit Care Med 2008 Vol. 36, No. 9
ECMO () 2002.12.1 2008
Bridge
(Myocarditis )
(Pulmonary embolism)
1. (Meconium aspiration syndrome) 2. (Hyaline membrane disease)3. (Congenital diaphragm hernia) 4. (Persistent pulmonary hypertension of
neonate)
5.
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1. 2. 3. (Airway surgery)4. 5. (30)
Contraindications> 80 ()
ECMO
Trendelenburg's position
Head-down body tiltAnti-shock position
More likely to be effective during volume overloaded, not volume depletion.
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()
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ECG /SpO2 monitorsET-CO2,BP monitor, defibrillator
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endo suction ET-CO2Hypoxia
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/ EndoCVP catheterA-linesChest tubesNGFoley
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Priority!!
CT scans
Emergent laparotomy, thoracotomy,pericardial window, craniotomy
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E.g. SpO2 BP PR GCS Prognosis
/
on-line medical direction
BLSALS
NG
(COPD)
()()():
Cardiac EnzymesBrain CT
Critical patients
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SOP
Bypass
ABCDEs
benzodiazepines, fentanyl, propofol, ketamine,
Midazolam EtomidateThiopentalCitosol
Ketamine
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