Ειδικη ΚΑΡΠΑ.pdf

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ΕΞΕΙΔΙΚΕΥΜΕΝΗ ΚΑΡΔΙΟΠΝΕΥΜΟΝΙΚΗ ΑΝΑΖΩΟΓΟΝΗΗ 16 o Δπηκέιεηα θεθαιαίνπ: Αιεμάλδξα Ξαπατσάλλνπ - Γηώξγνο Πηεθαλάθεο Ξεξηερόκελα 16.1 ΔΗΠΑΓΩΓΗΘΑ............................................................................................................... 498 16.2.1 ΝΟΗΠΚΝΗ ................................................................................................................ 498 16.3 ΘΑΡΔΘΛΡΖΟΗΔΠ ΝΓΖΓΗΔΠ ΒΑΠΗΘΖΠ ΘΑΟΞΑ ................................................... 499 16.3.1 ΒΑΠΗΘΖ ΞΝΠΡΖΟΗΜΖ ΡΖΠ ΕΥΖΠ ............................................................................ 500 16.4 ΔΜΔΗΓΗΘΔΚΔΛΖ YΞΝΠΡΖΟΗΜΖ ΡΖΠ ΕΩΖΠ ..................................................... 501 16.4.1 ΘΑΟΓΗΑΘΝΗ ΟΘΚΝΗ AΛΑΘΝΞΖΠ ............................................................................. 502 16.4.2 MONITORING ΖΘΓΟΑΦΖΚΑΡΝΠ ............................................................................. 504 16.4.3 ΑΞΗΛΗΓΥΠΖ ........................................................................................................... 504 16.4.4 ΞΟΝΘΑΟΓΗΑ ΞΙΖΜΖ ΟΝΘΗΑ)................................................................................ 506 16.4.5 ΔΠΥΡΔΟΗΘΔΠ ΘΑΟΓΗΑΘΔΠ ΚΑΙΑΜΔΗΠ ....................................................................... 507 16.5 ΑΙΓΝΟΗΘΚΝΗ ............................................................................................................. 507 16.5.1 ΝΗΘΝΚΔΛΗΘΝΠ ΑΙΓΝΟΗΘΚΝΠ ΑΛΡΗΚΔΡΥΞΗΠΖΠ ΡΖΠ ΑΛΑΘΝΞΖΠ............................ 507 16.5.2 ΑΛΡΗΚΔΡΥΞΗΠΖ ΑΞΗΛΗΓΥΠΗΚΥΛ ΟΘΚΥΛ.............................................................. 507 16.5.3 ΑΛΡΗΚΔΡΥΞΗΠΖ ΚΖ ΑΞΗΛΗΓΥΠΗΚΥΛ ΟΘΚΥΛ ........................................................ 511 16.4.4 ΘΑΡΑ ΡΖ ΓΗΑΟΘΔΗΑ ΡΖΠ ΘΑΟΞΑ..............................................................................512 16.4.5 ΑΔΟΑΓΥΓΝΠ, ΑΔΟΗΠΚΝΠ, ΝΜΓΝΛΥΠΖ .....................................................................513 16.4.6 ΔΛΓΝΑΓΓΔΗΑΘΖ ΞΟΝΠΒΑΠΖ.....................................................................................514 16.4.7 ΦΑΟΚΑΘΔΡΗΘΖ ΘΔΟΑΞΔΗΑ ..................................................................................... 515 16.4.8 ΑΛΑΠΡΟΔΤΗΚΑ ΑΗΡΗΑ ΘΑΟΓΗΑΘΖΠ ΑΛΑΘΝΞΖΠ...................................................... 517 16.4.9 ΠΖΚΔΗΑ ΕΥΖΠ ΘΑΡΑ ΡΖΛ ΘΑΟΞΑ ...........................................................................519 16.5 ΑΙΓΝΟΗΘΚΝΗ ΑΟΟΘΚΗΩΛ ΞΝ ΠΣΔΡΗΕΝΛΡΑΗ ΚΔ ΘΑΟΓΗΑΘΖ ΑΛΑΘΝΞΖ......519 16.5.1 ΔΘΡΗΚΖΠΖ ΡΝ ΑΠΘΔΛΝΠ - ΓΠΚΔΛΖ ΠΖΚΔΗΑ ΘΑΗ ΠΚΞΡΥΚΑΡΑ ........................ 520 16.5.2 ΔΘΡΗΚΖΠΖ ΡΝ ΟΘΚΝ .........................................................................................521 16.5.3 ΑΛΡΗΚΔΡΥΞΗΠΖ ΒΟΑΓΘΑΟΓΗΑΠ ΘΑΗ ΑΞΝΘΙΔΗΠΚΥΛ ................................................521 16.5.4 ANTIΚΔΡΥΞΗΠΖ ΡΑΣΑΟΟΘΚΗΥΛ.......................................................................... 523 16.5.5 ΠΓΣΟΝΛΗΠΚΔΛΖ ΖΙΔΘΡΟΗΘΖ ΑΛΑΡΑΜΖ................................................................ 524 16.6 ΞΝΠΡΖΟΗΜΖ ΕΩΡΗΘΩΛ ΙΔΗΡΝΟΓΗΩΛ ΚΔΡΑ ΡΖΛ ΘΑΟΞΑ .............................. 527 16.7 ΔΘΒΑΠΖ ΘΑΟΞΑ ........................................................................................................ 529 16.7.1 ΑΙΠΗΓΑ ΡΖΠ ΔΞΗΒΗΥΠΖΠ ....................................................................................... 529
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  • 16o

    :

    -

    16.1 ............................................................................................................... 498

    16.2.1 ................................................................................................................ 498

    16.3 ................................................... 499

    16.3.1 ............................................................................ 500

    16.4 Y ..................................................... 501

    16.4.1 A ............................................................................. 502 16.4.2 MONITORING ............................................................................. 504 16.4.3 ........................................................................................................... 504 16.4.4 () ................................................................................ 506 16.4.5 ....................................................................... 507

    16.5 ............................................................................................................. 507

    16.5.1 ............................ 507 16.5.2 .............................................................. 507 16.5.3 ........................................................ 511 16.4.4 .............................................................................. 512 16.4.5 , , ..................................................................... 513 16.4.6 ..................................................................................... 514 16.4.7 ..................................................................................... 515 16.4.8 ...................................................... 517 16.4.9 ........................................................................... 519

    16.5 ...... 519

    16.5.1 - ........................ 520 16.5.2 ......................................................................................... 521 16.5.3 ................................................ 521 16.5.4 ANTI .......................................................................... 523 16.5.5 ................................................................ 524

    16.6 .............................. 527

    16.7 ........................................................................................................ 529

    16.7.1 ....................................................................................... 529

  • 498

    16.7.2 ................................... 530

    16.8 .................................................................. 531

    16.9 .......................................................................................................... 533

    16.1 . ,

    .

    , ( ).

    , , .

    . , - , " " . 40 :

    1954, Elam --, , ( ),

    1957 Kouwenhoven

    1960, Kouwenhoven .

    , , , , , .

    , , .

    16.2.1

    (cardiac arrest) , .

    (Cardiopulmonary Resuscitation =

    /

  • 16

    499

    CPR) 1 .

    :

    ( ) .

    :

    2 .

    (Basic life Support = BLS) , .

    (Advanced Life Support = ALS) , .

    (Post - resuscitation care) , , , , .

    16.3 , , ,

    , . 2010. .

    - 2005

    1 1997

    (). 2

    Advanced, () . .

  • 500

    , .

    30 .

    ( )

    1 sec.

    2005 .

    : .

    : 100/min.

    : 5 cm.

    - : - 30:2 .

    : . , , ( ) 2 min, .

    : 2005, 2010, . , , . . ( ) .

    16.3.1

    , , . ( 16-1):

    ,

    , , .

    .

  • 16

    501

    16-1.

    - - ( West).

    (CPR) . 15-1. .

    . 16-1. .

    (166)

    30

    2

    16.4 Y

    , (LS)

    . ' , .

    :

    (. 16-1), , .

    &

  • 502

    (monitoring) 12- ,

    ,

    ()

    .

    :

    BLS 5 min

    AED BLS ALS

    ALS

    , ALS (

    BLS ).

    16.4.1 A

    :

    :

    : .

    () " , , > 150/min" ( 16-2).

    , .

    16-2. .

    () " , ( ) , " ( 16-3).

    1 % .

  • 16

    503

    16-3. .

    () " , " ( 16-4).

    16-4. .

    () () , ( 16-5).

    16-5. .

    .

    70% .

    , .

    .

    :

  • 504

    , , , ( ).

    , ,

    :

    , (Mobitz II).

    16.4.2 MONITORING

    monitoring , .

    : ( , ,

    , ), - (

    , 3 - ), , , ,

    , ( , , , 1 2 , ).

    Monitoring :

    , shock, .

    16.4.3 . .

    (DC) , (shock) .

    / 5 sec .

  • 16

    505

    , :

    ,

    ( 16-6),

    .

    16-6. (),

    ().

    A

    : ( 16-6 ).

    : ( 16-6 ).

    , , : /

    /

    < 200 Joules (150 J shock 360 J )

    .

    :

    (200 J shock, 360 J ),

    4 J/kg 5-20 J .

    (paddles):

    : ( 16-7)

    : .

  • 506

    16-7. (paddles) .

    (impedance) :

    :

    13 cm ,

    8 - 12 cm > 1 > 10 kg

    4.5 cm , < 10 kg ,

    gel gel (gel pads),

    8 kg , 5 kg 1-8 3 kg < 10 kg,

    shock, .

    16.4.4 ()

    10 sec ,

    ( 16-8).

    , . , . . .

    :

    ,

    .

  • 16

    507

    16-8. .

    16.4.5 , ( ).

    :

    -

    10-30 min .

    16.5

    16.5.1

    ( ) ( )

    15-2.

    16.5.2

    , (). (), , ,

    (SVT).

    , :

    ( )

  • 508

    . 16-2. .

    , , - 30:2 ( 15.2)

  • 16

    509

    (gel gel pads).

    (/) . 1: 1 :

    . shock 150-200 J (360 J ). - (30:2),

    2

    , 100/min 10/min monitor .

    2: / :

    2 (150-360 J 360 J )

    2 monitor .

    3: /:

    1 mg 3 (150-360 J 360 J

    ) 2 1 mg () 300

    mg monitor .

    4: / :

    300 mg 4 (150-360 J 360 J

    ) 2 monitor .

    5: 1 mg ( 3-5 , ).

    6: /:

    2 2 1 mg / 3 - 5

    ( ). monitor

    7: monitor

    , :

    ,

    .

    8: monitor :

    .

  • 510

    :

    10 sec

    .

    :

    , , ,

    , ,

    , ,

    , , .

    : - :

    3 ,

    3 5 , , /,

    ,

    ,

    3-5 .

    , , .

    ( ) :

    , ,

    2 , , ( , , ) (ROSC = Return of Spontaneous Circulation),

    , z

    (ROSC), ,

    (), .

    :

    ,

  • 16

    511

    placebo , ,

    / 150 mg 900 mg 24 ,

    100 mg ( 1 mg kg-1) , ,

    (2 gr bolus ) torsades de pointes (.. ).

    /:

    , (gel ).

    : ,

    , ,

    /.

    : , , , ,

    , ,

    , , , , .

    16.5.3

    15.4.3.1 ()

    () .

    ,

    . ( ). , .

    30:2 .

    () 100/min 10 /min.

    1 mg / .

  • 512

    monitor 2 . , / : / ,

    / (), ,

    2 , 1 mg 3 - 5 ( ).

    /: .

    : 2 ,

    1 mg 3 - 5 ( ).

    15.4.3.2

    . 2010 , .

    , P, . .

    30:2 .

    () 100/min 10 /min.

    , . 1 mg / . monitor 2 . :

    1 mg / 3 5 (

    ). monitor 2 .

    /: .

    16.4.4

    / / , (4 s and 4s / 4 4 , 15.5.4), .

    30:2: monitor

    .

  • 16

    513

    ( ): ,

    2 .

    :

    .

    , , 30:2 , . , 2 2 .

    16.4.5 , ,

    , .

    .

    10 sec, .

    : ,

    , ,

    .

    : , 100/min,

    , 10 /min, .

    . , . , :

    Combitube (LMA) ProSeal LMA ( ).

    , . , ( 30:2).

  • 514

    .

    :

    , , ,

    .

    (SaO2) . , SaO2 . , , , 94 98%.

    16.4.6

    , .

    .

    :

    , .

    , .

    20 ml bolus 10 20 , .

    , ( , ) . . .

    , .

    : , ,

    ( 16-9).

    : ,

    .

  • 16

    515

    16-9.

    .

    .

    16.4.7

    .

    :

    ,

    ,

    ,

    .

    15- 3 .

    15.4.7.1

    (Epinephrine) , - - .

    - .

    . , 1 , . . .

    :

    :

  • 516

    1 mg 3 - 5 min, , .

    (flush) 20 ml .

    15.4.7.2

    (Angoron) /, shock 300 mg 20 ml 5%. / 150 mg 900 mg 24 .

    , . , .

    (Lignocaine) 100 mg 1 mg x kg-1.

    , .

    15.4.7.3

    , , , Ca++ . 10 ml CaCl2 10% (Calcium Chloride) , 10 min, :

    , , , .

    15.4.7.4 -

    o (Sodium Bicarbonate) . , , - .

    . CO2 . . 20-25 min 50%.

  • 16

    517

    :

    : 1792 2000 msm/L, . .

    : , . :

    aHCO3 + H+ Na+ + H2 + C2

    NaHCO3 CO2. CO2 , ' pH. CO2 NaHCO3 .

    : 1990, Weil , 2000 mOsm/L ( ) . 2.5 mEq/kg 43 - 50% (60%). .

    : .

    :

    . 50 ml 8.4%: , , .

    16.4.8

    , . , ,

    .

    ():

    Hypoxia

    Hypovolaemia

    Hyperkalaemia, hypokalaemia, hypocalcaemia, acidaemia and other metabolic disorders , , , ,

    Hypothermia .

  • 518

    :

    Tension Pneumothorax

    Tamponade

    Toxic substances

    Thromboembolism (Pulmonary embolism or coronary thrombosis) , .

    15.4.8.1 H ()

    1. 100%. . , .

    2.

    . , . , .

    3.

    , , , , .. , . 12 . , , .

    4.

    .

    15.4.8.2 T

    1. . . , .

    2. , . . .

    3. , . , , .

    4.

  • 16

    519

    . , . , 60 90 .

    , , , , , , . , 10 .

    16.4.9

    ( , ) monitor (..

    , ), monitor. , . , / , . , .

    16.5

    , . , ,

    (ROSC), : , . , . , , . , , .

    , , , . , , . , , . , .

    :

    ;

    ;

  • 520

    16.5.1 - .

    :

    : .

    . ( >150/min) ( ) ( ), . , .

    , , ( ) .

    40/min. , . , , , .

    . , , , . (, , ). ( , , ).

    ( ) . ,

  • 16

    521

    , .

    16.5.2

    . , , , , ,

    , . monitor . , 12 . , . 12 . , .

    16.5.3

    (. 16-4) , : shock,, , , .

    :

    0,5 mg , ,

    .

    , (0,5 mg 3- 5 )

    3 mg

    . . , ,

    2 10 g/min.

    , , :

  • 522

    , Mbitz II, QRS, 3 .

    . 16-4.

    1. Shock

    2.

    3.

    4.

    0,5 mg iv

    ;

    ;

    Mbitz II

    QRS

    > 3 sec

    0,5 mg iv , 3 mg

    5 g x min-1

    2-10 g x min-1

    *

    ABCDE

    2 &

    monitor & 12 , , SpO2

    & (..

    )

    *

    ( - Ca2+)

  • 16

    523

    , . , , 2 10 g/min, .

    ORS , ( ORS) .

    , . , , - . , :

    , ,

    .

    16.5.4 ANTI

    : , .

    , . , (. 16-5) :

    .

    , .

    : Shock, , , & ,

    , , , . < 90 mmHg.

    , .

    , . , .

  • 524

    , , .

    , . ( ) / ( ).

    : (. ) QRS QRS ( 0.12 sec).

    : ,

    . ( , , , ) , , . , , .

    : shock

    .

    16.5.5

    .

    :

    shock R , shock T

    . R. shock , .

    : , (

    monitor ) (

    ) R.

    :

  • 16

    525

    (.. ...

    shock shock ( shock)

    shock, -, , .

    , , shock, , . , shock, . , .

    :

    shock 120-150 J 200 J

    , shock .

    :

    ,

    shock 70-120 J 100 J

    , shock .

    .. :

    , ...

    , / , ..:

    , .

  • 526

    . 16-5. .

    ; 5.

    6.

    7.

    8.

    *

    300mg iv 10-20 min shock 900mg 24

    ABCDE

    2 &

    monitor & 12 , , SpO2

    & (.. )

    QRS ; ( 48

    ;

    :

    12

    (. - )

  • 16

    527

    16.6

    (Post-resuscitatin Care) . (ROSC)

    . . , . . . , , , (.. (), ) .

    , . . , .

    /. . , , , . , , , , , . , 2-3 . / , , .

    15.6.1.1

    :

    (ROSC) , , 15-30 . , . , . (ROSC) .

    :

    24 (ROSC) . ( ).

  • 528

    , (.. , , ) .

    :

    / 5 - 15% (ROSC), 10 - 40% . . , , , , .

    :

    48 . 37C .

    . , , ( ).

    , VF , (ROSC). 32-34C 12-24 .

    32-34C. 12-24 .

    - , .

    . (0,25-0,5C h-1) .

    - , , , . , .

    , , , , .

    :

    . (4,5 6,1 mmol l-1) ,

  • 16

    529

    . . , , (4,5 6,1 mmol l-1), 10 mmol l-1 , 90 . 2010 10 mmol l-1 ( , 180 mg dl-1 ) .

    . 16-6. .

    -

    -

    16.7

    16.7.1

    . ' Utstein (Chain of Survival, 16-10), "" .

    :

    ,

    ,

    .

    Utstein Circulation ( 1991).

  • 530

    16-10. .

    22.105 , 9.974 (45%) 6.353 (30%) [ (ICNARC), , 1995 2004].

    16.7.2 , :

    . 5% .

    .

    , , . ' 25% -33%. ' .

    , , , .

    , . 100% .. .

    (ROSC). , 50% . ,

  • 16

    531

    , ( ) .

    S-100b . .

    24 , 100% . () 24-28 (ROSC). , .

    16.8

    . , , ,

    . , .

    :

    (BLS/ AED providers course).

    T . ( ), , , , ( , ) . .

    (Immediate Life Support- ILS)

    , (, , , , , , ).

  • 532

    . ILS ( 24) .

    (Advanced Life Support

    ALS)

    To . , , . ALS , , , .

    (European

    Paediatric Immediate Life Support EPILS)

    , , , ..

    (European

    Paediatric Life Support EPLS)

    EPLS , . .

    (Neonatal Life Support NLS)

    , , . 10 -20 min.

    , . :

    ,

    ( ) ,

    ( , , , , ) ,

    , ,

  • 16

    533

    , .

    16.9 # 1. Baskett PJF, Chamberlain D, Editorial. The ILCOR advisory statements. Resuscitation

    1997; 34: 97-98

    2. Bossaert L, Callanan V, Cummins RO. Early defibrillation: An Advisory Statement by the Advanced Life Support Working Group of the International Liaison Committee On Resuscitation, Resuscitation 1997; 34: 113-114

    3. Cummins RO, Ornato JP, hies WH, Pepe PE. Improving Survival from sudden Cardiac Arrest: "Chain of Survival" Concept. Circulation 1991, 83: 1832-1847.

    4. Cummins RO, Chamberlain DA, et al. Recommended Guidelines for Uniform Reporting of Data From Out-of-Hospital Cardiac Arrest: The Utstein Style. Circulation 1991; 84: 960-975

    5. Cummins RO, Ornato JP, hies WH, Pepe PE. Improving Survival from sudden Cardiac Arrest: "Chain of Survival" Concept. Circulation 1991, 83: 1832-1847

    6. Deakin CD, Nolan JP, Sunde K, Koster RW. European Resuscitation Council Guidelines for Resuscitation 2005. Section 3. Electrical therapies: Automated external defibrillators, defibrillation, and pacing. Resuscitation 2010;81:1293-1304

    7. Deakin CD, Nolan JP, Soar J, Sunde K, Koster RW, Smith GB, Perkins JD. European Resuscitation Council Guidelines for Resuscitation 2010. Section 4. Adult advanced life support. Resuscitation 2010;81:1305-1352

    8. Elam JO, Brown ES, Elder JD: Artificial respiration by mouth - to- mask method: A study of the respiratory gas exchange of paralyzed patients ventilated by operator's expired air. Engl J Med 1954; 250: 749

    9. Halperin HR, Guerci AD: Vasoconstrictors during CPR. Are they used optimally? Chest 1990; 98: 787-789

    10. Hodge D. Interosseous infusion: a review. Paediatric Emergency Care 1985; 1: 214-218 11. Jaffe AS: New and Old Paradoxes: Acidosis and Cardiopulmonary Resuscitation.

    Circulation 1989; 80: 1079-1083

    12. Kette F, Weil MH, von Planta M, Gazmuri RJ, Rackow EC. Buffer agents do not reverse intramyocardial acidosis during Cardiac Resuscitation. Circulation 1990; 81: 1660-1666

    13. Koster RW, Baubin MA, Bossaert LL, Caballero A, Cassan P, Castrn M, Granja C, Handley AJ, Monsieurs KG, Perkins GD, Rafflay V, Sandroni C. European Resuscitation Council Guidelines for Resuscitation 2005. Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation 2010;81:1277-1292

    14. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-Chest cardiac massage. JAMA, 1960; 173: 1064

    15. Krischer JK, Fine EG, Weisfeldt MZ, Guerci AD. Comparison of prehospital conventional and simultaneous ventilation cardiopulmonary resuscitation. Crit Care Med 1989; 17: 1263-1269

    16. Ornato JP: High-dose Epinephrine during resuscitation (Editorial). JAMA 1991; 265: 1160-1161

    17. Quinton DN, O'Byrne G, Aitkenhead AR. Comparison of endotracheal and Peripheral Intravenous Adrenaline in Cardiac Arrest. Lancet 1987; I: 828-829

    18. Report of the Royal College of Physicians. Resuscitation from cardiopulmonary arrest: training and organisation. J R Coll Phys 1987; 21: 3

    19. Soar J, Monsieurs K, Balance JHW, Barelli A, Biarent D, Greif R, Handley AJ, Lockey AS, Richmond S, Ringsted C, Wyllie JP, Nolan JP, Perkins GD. European Resuscitation

    # O .

  • 534

    Council Guidelines for Resuscitation 2005. Section 9. Principles of training in resuscitation. Resuscitation 2010;81:1434-1444

    20. Weisfeldt ML, Guerci AD. Sodium Bicarbonate in CPR (Editorial). JAMA 1991; 266: 2129-2130