江 文 莒 醫 師 台大醫院急診醫學部 主治醫師 暨 臨床助理教授 台北花卉博覽會工作人員 緊急救護技術訓練課程 心肺復甦術及 自動體外去顫電擊器操作 江 文 莒 醫 師 台大醫院急診醫學部 主治醫師 暨 臨床助理教授

如果我在現場， 可以作什麼事 阻止這個病人的死亡?

病人救不活，問題在哪裏? 關於急救的幾個重要概念…

重要概念一：BLS和ACLS一樣重要 CPR開始時間(分) ACLS開始時間(分) <8 8~16 >16 <8 8~16 >16 0~4 43% 19% 10% 4~8 26% 18% 5% 8~12 6% 3% 0% 本表內容來自 ~ JAMA 1979; 241:1905

重要概念二：時間決定病人的預後 上帝從病人突然倒下去的那一秒開始計時… 如果沒有CPR，存活率每分鐘減少 7~10% ! 早期去顫電擊是VT與 VF 急救成功的關鍵；CPR可延長VF的時間，使存活率降低的速度減至每分鐘3 ~4% !

重要概念三：急救成功的關鍵 正確的CPR與及時的電擊 本來2000年是強調「早期的CPR與早期的電擊」，但現在的證據顯示這樣似乎較對。

猝死的四種心律 可電擊心律 不可電擊心律 Ventricular Tachycardia 心室撲動 Asystole 無心搏 Ventricular Fibrillation 心室顫動 PEA 無脈性心搏

正確的CPR 你(妳)的CPR做得好不好? 不好的 CPR: 研究顯示使動物或病患的存活率變差!! 壓得太少 (貼心電圖極、插管或放CVP…) 壓得太慢太淺 (只讓 N0 / R1壓到沒力…) 插管太久 (拿到「魔戒」就不肯放下…) 換氣太多 (每分鐘12下結果緊張給到30下…) 胸部沒有完全回彈 (累到手放在病人身上休息…) 不好的 CPR: 研究顯示使動物或病患的存活率變差!! 這兩年開始受到廣泛的討論的主題。 引用我的「台灣醫學會演講報告」。

品質良好的 CPR 2005 黃金標準 用力壓、快快壓、胸回彈、莫中斷! 用力壓 快快壓 (每分鐘100下) 鬆手時應使胸廓能完全擴張 胸外按壓儘量不要中斷 避免過度換氣

及時的電擊: 自動電擊器 AED 自動體外電擊器 (AED) AED area：步行1.5 分鐘 (可使病患在4分鐘內接受去顫術治療) 1997: 澳洲航空經驗 1999: Las Vegas 經驗 2000: Chicago 機場經驗 2004: 北美PAD臨床試驗 AED area：步行1.5 分鐘 (可使病患在4分鐘內接受去顫術治療) 2000 美國航空同上， 191個cardiac arrests更有40% 的存活率! (NEJM 2000) 1997 澳航報告裝在飛機上--> 46個 cardiac arrests 中有 91%急救成功並且 26%有長期存活 (Circulation 1997) 在1999年，在 Las Vegas 的賭場和飯店皆設置 AED area ，結果使當地猝死的存活率從 14% 遽昇至57%! 同樣自1999年6月起在全美最忙碌的Chicago Airport (每年約8千萬個旅客) 放置49台AED，機場內大部分的電視都播放AED的位置及使用法，10個月後統計，共有12個在機場 VF ATTACK 的旅客因此得救。第一個案例是一位剛下空橋的旅客collapse，兩分鐘內接受空服人員的電擊治療痊癒。 美國自 2000 年5月開始將在許多公共場所開始大量廣設 AED (柯林頓總統公開演講2000-5-20) PAD trial 在2004年8月發表在nejm 的結果：受訓過的 laypersons 能正確而安全的使用 AED，且能增加 OHCA 病人的出院存活率。 原出處： AHA Meeting Report 11/15/2000 Defibrillators offer safe landing for cardiac arrest NEW ORLEANS, Nov. 15 — Strategically placing automated external defibrillators (AEDs) one minute apart, and making them easy to spot, has helped prevent sudden cardiac deaths at Chicago's heavily trafficked O'Hare and Midway Airports, according to a study presented today at the American Heart Association's Scientific Sessions 2000. The City of Chicago Airport System's HeartSave Program placed 49 AEDs on walls throughout O'Hare and Midway airports in June 1999. Two more AEDs were placed in parking facilities. Approximately 80 million passengers each year travel through O'Hare and 20 million move through Midway. The devices were mounted in plain view. With easy-to-use audio and visual prompts, the devices helped minimize critical response times to emergency care. In the first ten months of operation, 14 sudden cardiac arrests occurred. Twelve of the 14 victims were in ventricular fibrillation — the often fatal, unsynchronized contraction of the heart's ventricles that permits little or no blood to be pumped from the heart. Nine of the victims were revived with an AED and sustained no neurological damage. In nine of the incidents, airport travelers successfully operated the devices, rather than on-site staff formally trained in the airport's HeartSave Program. In places without rapid response to these lethal heart rhythms, survival has averaged 4 percent. Survival is directly linked to the amount of time between the onset of sudden cardiac arrest and defibrillation. Chances of survival are reduced by 7-10 percent with every minute of delay. Few attempts at resuscitation are successful after 10 minutes. "Easy access and high visibility may be ingredients for success," says the study's lead author, Paula J. Willoughby, D.O., emergency medical services advisor for the Chicago Fire Department. "The real issue right now for these devices is where to put them." Willoughby is also an attending physician at West Suburban Hospital and Medical Center in Oak Park, Ill. AEDs have proven effective in rapidly correcting ventricular fibrillation. The device delivers an electrical charge that briefly stops the heart and allows it to resume a normal rhythm. Individuals who have ventricular fibrillation quickly collapse, and without an electrical shock to correct the abnormal rhythm, they will most likely die. "When these devices were first introduced, there was a lot of trepidation about where to put them and whether people would get shocked right and left if the lay public used them," Willoughby says. "Our data suggest that these devices can be simple to use and that the public can use them properly when given simple instructions. "The Chicago HeartSave Program is continually planning for strategic placement and further expansion of the program into work site locations. If the intent is to use them publicly, there needs to be very close access and people need to see right where they are," Willoughby says. She points out that while AEDs have been rapidly disseminated in emergency response vehicles, there has yet to be a national effort to strategically place them in public places around the nation. She believes that training the lay public in the use of AEDs will help avert many sudden cardiac deaths in people with life-threatening ventricular fibrillation. The American Heart Association recently updated and published "Guidelines 2000 for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)," which recommend placing more AEDs in public locations and training more lay rescuers in their use. According to these guidelines, AED programs have the potential to be the single greatest advance in the treatment of pre-hospital sudden cardiac arrest since the invention of CPR. "The association supports efforts to provide prompt defibrillation to victims of cardiac arrest, and AEDs are one of the most promising methods for achieving rapid defibrillation," says Rose Marie Robertson, M.D.; president of the American Heart Association. "The statistics are overwhelming — AEDs save lives and it takes little training to know how to use them." In addition to its traditional CPR training courses, the American Heart Association offers courses combining CPR and AED instruction for the lay public (toll free: 1-977-AHA-4CPR.) According to the latest data available, sudden cardiac arrest occurs more than 600 times per day in the United States — most of these are due to ventricular fibrillation. Early CPR and rapid defibrillation combined with early advanced care can result in long-term survival rates as high as 40 percent for witnessed sudden cardiac arrest. American Heart Association/ Co-author: Sherry Caffrey ---------------------------------------------------------------- N Engl J Med. 2004 Aug 12;351(7):637-46. Related Articles, Links Comment in: N Engl J Med. 2004 Aug 12;351(7):632-4.   Public-access defibrillation and survival after out-of-hospital cardiac arrest. Hallstrom AP, Ornato JP, Weisfeldt M, Travers A, Christenson J, McBurnie MA, Zalenski R, Becker LB, Schron EB, Proschan M; Public Access Defibrillation Trial Investigators. University of Washington, Seattle, USA. BACKGROUND: The rate of survival after out-of-hospital cardiac arrest is low. It is not known whether this rate will increase if laypersons are trained to attempt defibrillation with the use of automated external defibrillators (AEDs). METHODS: We conducted a prospective, community-based, multicenter clinical trial in which we randomly assigned community units (e.g., shopping malls and apartment complexes) to a structured and monitored emergency-response system involving lay volunteers trained in cardiopulmonary resuscitation (CPR) alone or in CPR and the use of AEDs. The primary outcome was survival to hospital discharge. RESULTS: More than 19,000 volunteer responders from 993 community units in 24 North American regions participated. The two study groups had similar unit and volunteer characteristics. Patients with treated out-of-hospital cardiac arrest in the two groups were similar in age (mean, 69.8 years), proportion of men (67 percent), rate of cardiac arrest in a public location (70 percent), and rate of witnessed cardiac arrest (72 percent). No inappropriate shocks were delivered. There were more survivors to hospital discharge in the units assigned to have volunteers trained in CPR plus the use of AEDs (30 survivors among 128 arrests) than there were in the units assigned to have volunteers trained only in CPR (15 among 107; P=0.03; relative risk, 2.0; 95 percent confidence interval, 1.07 to 3.77); there were only 2 survivors in residential complexes. Functional status at hospital discharge did not differ between the two groups. CONCLUSIONS: Training and equipping volunteers to attempt early defibrillation within a structured response system can increase the number of survivors to hospital discharge after out-of-hospital cardiac arrest in public locations. Trained laypersons can use AEDs safely and effectively. Copyright 2004 Massachusetts Medical Society

公共場所設置 AED

BLS: Public AED 公眾場所放置 AED 讓第一反應者在 CPR時應用，能增加 OHCA 的存活率! (Class-I) Airport, Casinos, Sport facilities, Shopping mall…

AED 的操作：四個通用步驟 1.打開開關 2. 『貼上電極、插入插頭』 3.分析心律 4.聽從『建議』 (按電擊鍵或CPR) 特殊狀況考量 狀況一、病患全身濕透怎麼辦? 在水中或大雨中使用AED 可能造成救援者的電傷或燙傷，並減少電流通過心臟的量而使電擊效果大大減低。 將病患移出水中/雨中，儘量擦乾再電擊 狀況二、病患是小孩子? 嬰兒須要CRP大部分是嬰兒猝死症候群、外傷或溺水引起。兒童須要CPR大部分是呼吸窘迫(如異物窒息)引起而非心臟的問題，大人則是心臟的問題為主。 8歲以下(體重約25公斤) 的兒童並沒有足夠的實證醫學證明有益處。之前仍不建議使用，但2005年ACLS 已允許1~8歲的兒童用 AED。 狀況三、病患有使用經皮吸收之藥物貼片 約四分之一名片大小的薄塑膠片 癌症病人止痛貼片、戒煙貼片等等。 大都貼在胸口或腹部。 會造成病患及膚局部電傷或燙傷，並減少電流通過心臟的量而使電擊效果大大減低。 要注意撕掉並將皮膚擦乾淨 狀況四、病患裝有心臟節律器 心臟節律器一般裝在左胸皮下；約50元硬幣大小的硬物。 目前建議將電擊片貼在距體內心臟節律器2.5公分(1吋)以上的地方進行電擊。 ========================================================= 每一次分析心律及電擊時：勿碰觸病人！ 聲音：對其他施救者警告— “我離開” “你離開” “大家都離開” “CLEAR” 看：是否“所有人都已離開” 身體：加上手勢 最後才按下電擊按鈕 The universal control steps are called universal because they are used to operate every AED. Because of the concept of “user-critical steps,” more of these universal steps are done automatically and not always by the operator. Ask providers to demonstrate use of the specific AED that they will use in their work setting. User-critical steps are any operational steps that must be performed by the operator; otherwise the device will fail. All AEDs require similar user-critical steps: Attach the defibrillator pads to the patient Attach the pads to the AED cables Attach the AED cables to the AED Power on the AED Analyze the patient signal for VF Charge the AED if VF is present Press the shock button to deliver the shock Notice how each step is critical. If any one step is omitted or done incorrectly, the person in VF will not be defibrillated. Any error here would mean the loss of a chance to save a person’s life. Some brands of AEDs perform these steps. The more an AED performs the user-critical steps, the lower the chance of error. For example, some AED models power up automatically when the AED lid is opened; in some the cables are preattached to the AED and the adhesive defibrillator pads. Some perform constant background analysis and will automatically “precharge” if VF is detected. One model has reduced the number of actions required of the operator to just 3: open the lid, attach the pads to the patient, and press the shock button.

摘自BLS for Healthcare Providers-AHA 體外自動電擊器 貼上電擊片 摘自BLS for Healthcare Providers-AHA

摘自BLS for Healthcare Providers-AHA 體外自動電擊器 電擊片位置 摘自BLS for Healthcare Providers-AHA

摘自BLS for Healthcare Providers-AHA 體外自動電擊器 打開開關 摘自BLS for Healthcare Providers-AHA

摘自BLS for Healthcare Providers-AHA 體外自動電擊器 分析節律 不 要 碰 觸 病 人 摘自BLS for Healthcare Providers-AHA

摘自BLS for Healthcare Providers-AHA 體外自動電擊器 電 擊 不要碰觸病人 摘自BLS for Healthcare Providers-AHA

AED 使用之特殊狀況 狀況一、病患全身濕透怎麼辦? 狀況二、病患是小孩子也可以用嗎? 狀況三、病患有使用經皮吸收之藥物貼片? 狀況四、病患裝有心臟節律器? 特殊狀況考量 狀況一、病患全身濕透怎麼辦? 在水中或大雨中使用AED 可能造成救援者的電傷或燙傷，並減少電流通過心臟的量而使電擊效果大大減低。 將病患移出水中/雨中，儘量擦乾再電擊 狀況二、病患是小孩子? 嬰兒須要CRP大部分是嬰兒猝死症候群、外傷或溺水引起。兒童須要CPR大部分是呼吸窘迫(如異物窒息)引起而非心臟的問題，大人則是心臟的問題為主。 8歲以下(體重約25公斤) 的兒童並沒有足夠的實證醫學證明有益處。之前仍不建議使用，但2005年ACLS 已允許1~8歲的兒童用 AED。 狀況三、病患有使用經皮吸收之藥物貼片 約四分之一名片大小的薄塑膠片 癌症病人止痛貼片、戒煙貼片等等。 大都貼在胸口或腹部。 會造成病患及膚局部電傷或燙傷，並減少電流通過心臟的量而使電擊效果大大減低。 要注意撕掉並將皮膚擦乾淨 狀況四、病患裝有心臟節律器 心臟節律器一般裝在左胸皮下；約50元硬幣大小的硬物。 目前建議將電擊片貼在距體內心臟節律器2.5公分(1吋)以上的地方進行電擊。

成人與兒童專用 AED 不同 1~8歲的兒童可使用 <1歲建議用手動，但若無法取得時可用

神的左右手：CPR + AED

CPR 2010 主要改變 流程圖簡化，移除「看、聽、感覺」評估 ，而以有無「意識」與「正常呼吸」決定是否 要開始急救。注意有時猝死初時可能以抽搐表現。 不熟練人工呼吸者，可使用 Hands-Only CPR CPR的順序改變 CAB (溺水除外) CPR 品質的重要與持續監測的方法 訓練有素的團隊，可以同時進行CABD…等處置 嬰兒急救若無法取得手動去顫器或專用去顫器 時，可使用成人 AED。

GASPING? ADAM-STOKE SEIUZURE? 瀕死喘息 及 瀕死抽搐 GASPING? ADAM-STOKE SEIUZURE?

BLS 2010：民眾 叫叫 CAB Hands-Only

BLS 2010 : 專業人員 (上)

BLS 2010 : 專業人員 (下)

情境案例 花博會上一個 65 歲的老先生因胸部不適冒冷汗來到救護站。妳是第一線的處理人員，怎麼辦? 他在座位上突然倒下，妳若正好在他身旁，該作何處理? 旁邊的一位同事立即幫他開始進行 CPR，當妳拿到 AED 趕到現場後該如何接手？

雙人急救 BLS (CPR+AED) 示範

復甦姿勢

總結：生命之鏈 ACLS 2010 新五環「生命之鏈」 死 生

謝謝參加。歡迎提問。