SPECIAL RESUSCITATION SITUATIONS 特殊情況下的復甦術

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1 SPECIAL RESUSCITATION SITUATIONS 特殊情況下的復甦術
致命的電解質異常 Special resuscitation(特殊情況下的復甦術 )範圍廣，一小時的主題教學通常無法完全涵蓋，可依學員程度及其需要選擇適當主題進行教學或將部分內容融入於小組情境教學中。

2 40歲女性 Sudden collapse 經心臟電擊術後

3 40歲女性 12導程心電圖

4 40歲女性 血中鉀離子濃度過高 (K=7.0meq/L)

5 致命的電解質異常 造成心臟停止或降低急救成效 在檢驗數值出來前即採取急救措施 以高血鉀最易致命
致命的電解質異常可能造成心臟停止或降低急救成效，有時必須在檢驗數值未出來時即採取急救措施。

6 高血鉀 血鉀 > 5.0 mEq/L pH  0.1 U  serum K+  0.3 mEq/L
酸血症時鉀離子會由細胞內跑到細胞外，造成血鉀上升。一般情況下pH下降0.1則血鉀上升0.3mEq/L，故在酸中毒時，血鉀偏高，在給予鹼化治療時應提防血鉀偏低。

7 高血鉀原因 Drugs (K+-sparing diuretics, ACEI, NSAIDs, K supplements) ESRD Muscle breakdown (rhabdomyolysis) Metabolic acidosis Pseudohyperkalemia Hemolysis Tumor lysis syndrome Diet (rarely sole cause) Hypoaldosteronism (Addison disease, hyporeninemia) Type 4 renal tubular acidosis Other: hyperkalemic periodic paralysis 酸血症時鉀離子會由細胞內跑到細胞外，造成血鉀上升。一般情況下pH下降0.1則血鉀上升0.3mEq/L，故在酸中毒時，血鉀偏高，在給予鹼化治療時應提防血鉀偏低。 造成高血鉀症的原因很多，大部分與腎臟排出不良有關，較常引起心臟急症的原因為腎衰竭及藥物 (如K+-sparing利尿劑, ACE inhibitors, NSAIDs, potassium supplements) 所致。

8 高血鉀 S波變深 idioventricular rhythm sine waves VF、心跳停止 T波變高 P波變平 PR延長
症狀:全身無力(由下肢往上漸進式發生) ，呼吸衰竭 心電圖變化 T波變高 P波變平 PR延長 QRS波變寬 S波變深 idioventricular rhythm sine waves VF、心跳停止 高血鉀症常見的症狀為全身無力，通常由下肢往上漸進式發生，甚至造成呼吸衰竭。 其心電圖變化由T波變高、P波變平、PR interval延長至QRS波變寬、S波變深，甚至變成 idioventricular rhythm、sine waves及VF。故在可能有高血鉀症或病況不穩定病患應放置心電圖監視器，以便及早發現而採取必要急救措施。

9 Hyperkalemia Etiology – renal failure, transcellular shifts, cell death, drugs, pseudohyperkalemia Manifestations – cardiac, neuromuscular

10 高血鉀症的症狀

11 Hyperkalemia Treatment Stop potassium ! Get an ECG
Hyperkalemia with ECG changes is a medical emergency

12 Hyperkalemia Treatment
First phase is emergency treatment to counteract the effects of hyperkalemia IV Calcium Temporizing treatment to drive the potassium into the cells glucose plus insulin Beta2 agonist NaHCO3 Therapy directed at actual removal of potassium from the body sodium polystyrene sulfonate (Kayexalate) dialysis Determine and correct the underlying cause

13 低血鉀 血鉀 < 3.5 mEq/L 原因 攝取減少 流失過多(腸胃道及腎臟為主) 由細胞外移至細胞內
造成低血鉀症的原因不外乎鉀離子攝取減少、流失過多及由細胞外移至細胞內所致。而流失之路逕以腸胃道及腎臟為主。

14 低血鉀 症狀: 無力、疲累、麻痺 呼吸困難 便秘、麻痺性腸阻塞 小腿痙攣 肌肉崩解

15 低血鉀 心電圖變化 U波 T波變平 ST改變 心律不整(服用digoxin者尤甚) PEA or Asystole

16 低血鉀症的症狀 Atrial or ventricular tachyarrhythmia
Decreased amplitude of P wave U wave. Conjoined T-U wave: "camel's hump" note the "apparently" prolonged QT interval which is due to the fact that the T wave is actually a U wave with a flattened T wave merging into the following U wave

17 處置 2 mEq/min  10 mEq /5-10 min 減少流失及補充鉀 心律不整或 K+ <2.5  IV K +
最大量10-20 mEq/h + ECG 心跳停止(VF/VT): 2 mEq/min  10 mEq /5-10 min 血鉀1mEq須補充 mEq cardiac arrest from hypokalemia (ie, malignant ventricular arrhythmias): 2 mEq/min, followed by another 10 mEq IV over 5 to 10’ total body deficit: 150 to 400 mEq for every 1mEq  serum K+

18 高血鈉 血鈉 > 145 mEq/L 症狀: 口渴、意識不清、無力、躁動、 局部神經症狀、抽搐、昏迷

19 處置 減少水份流失、補水 低血容:補生理食鹽水
缺水量 =體重 x 0.5 x (血鈉 - 140) /140 ♂ 體重 x 0.4 x (血鈉 - 140) /140 ♀ 70公斤男性，血鈉160，缺水量 ? L 血鈉  mEq/h (< 12 / 24 hrs) Daily supply: Water deficit x 10 / (血鈉 - 140) Rate: Daily supply/24 + ongoing demand

20 低血鈉 血鈉 < 135 mEq/L 症狀:急性或 <120 才有症狀 噁心、嘔吐、頭痛、躁動、疲累、 抽搐、昏迷或死亡

21 處置 補鈉排水 SIADH: 限水 ( % ) Na+ deficit= (desired [Na+] - current [Na+]) x 0.5 x body wt (kg) (* 0.5 for men, 0.4 for women.) 3% saline = 513 mEq Na+/L  Na /hr (max /24h) 補充太快  pontine myelinolysis

22 鎂 Na, K, Ca之移動所必需 低血鎂細胞內鉀無法補齊 穩定細胞膜作用: 可治療心律不整

23 高血鎂 血鎂 > 2.2 mEq/L 最常見原因: 腎衰竭 其它原因: 攝取過多 內臟破裂仍持續進食

24 高血鎂 神經症狀 : 肌無力、麻痺、運動失調、 嗜睡、意識混亂 腸胃症狀:噁心、嘔吐 心血管症狀:血管擴張、緩脈、換氣不 足、心肺停止

25 高血鎂 心電圖變化 PR、 QT 延長 QRS 變寬 P波電位變小 T波變高 Complete AV block、Asystole

26 處置 補鈣離子 移除血鎂 減少攝取 CaCl2 ( 5 to 10 mEq IV ) 可避免致命性心律不整 血液透析 腎及心血管功能正常
IV N /S + furosemide 減少攝取

27 低血鎂 血鎂 < 1.3 mEq/L 比高血鎂症常見 吸收減少、流失增加所致 PTH或某些藥物
(eg, pentamidine, diuretics, alcohol) 補乳婦女:高危險

28 低血鎂 - 原因 GI loss: bowel resection, pancreatitis, diarrhea
Renal disease Starvation Drugs: diuretics, pentamidine, gentamicin, digoxin Alcohol Hypothermia Hypercalcemia Diabetic ketoacidosis Hyperthyroidism/hypothyroidism Phosphate deficiency Burns Sepsis Lactation

29 低血鎂 - 症狀 肌肉震顫、束顫或強直 眼球震顫 意識改變、運動失調、眩暈、抽搐、吞 嚥困難 低血鈣、低血鉀

30 低血鎂 - 心電圖變化 QT延長 末段T波倒置 Heart blocks VF

31 處置 1 to 2 g IV MgSO4 over 15’ 2 g of MgSO4 over 1 - 2’
Severe or symptomatic hypoMg 1 to 2 g IV MgSO4 over 15’ Torsades de pointes 2 g of MgSO4 over 1 - 2’ Seizures 2 g IV MgSO4 over 10’ Calcium gluconate (1 g) 大部分有 hypoCa 腎功能不全者小心補

32 鈣 1/2 Ca in the ECF: bound to alb
Alkalosis: Ca-alb binding   Ca2+ Acidosis  Ca2+ serum alb  1 g/dL  total serum Ca  0.8 mg/dL (Ca = Serum Ca * (4 - Albumin)) In hypoalb., Ca2+ may be normal Ca antagonizes K and Mg at the cell mem. Ca regulated by PTH and vit. D

33 高血鈣 serum Ca > 10.5 mEq/L or Ca2+ > 4.8 mg/dL
Primary hyperparathyroidism and malignancy account for >90% cases.

34 高血鈣 -症狀 Total serum Ca ≧12 to 15 mg/dL Neuro. S/S:
depression, weakness, fatigue, ,confusion (at lower levels) hallucination, disorientation, hypotonicity, coma (at higher levels) Renal concentration of urine

35 高血鈣 -症狀 CV S/S: variable < 15 to 20 : myocardial contractility 
> 15 to 20 : myocardial depression Automaticity and ventricular systole is shortened Arrhythmias ( refractory period  ) Digitalis toxicity is worsened Hypertension Many patients with hyperCa develop hypoK

36 高血鈣 -症狀 GI S/S: Renal S/S: ability to concentrate urine  dysphagia
constipation peptic ulcers pancreatitis Renal S/S: ability to concentrate urine  dehydration diuresis (loss of Na, K, Mg, and P vicious circle of Ca reabsorption)

37 高血鈣 -心電圖變化 QT變短 PR and QRS 延長 QRS voltage 變大 T-wave變平、變寬
Notching of QRS AV block

38 處置 Symptomatic or >15 mg/dL NS at 300 to 500 mL/h
After adequate rehydration: NS at 100 to 200 mL/h Closely monitor K & Mg Heart F. or Renal I.: hemodialysis Extreme conditions: chelating agents PO4 50 mmol/8-12 h or EDTA 10 to 50 mg/kg/4 h

39 處置(II) controversial heart failure: required
Lasix (1 mg/kg IV) controversial heart failure: required  reuptake of Ca from bone Reduce bone resorption calcitonin Glucocorticoids (prednisolone 20~40 mg/day) Increased calcitriol production can occur in patients with chronic granulomatous diseases (eg, sarcoidosis) and in occasional patients with lymphoma: give glucocorticoid

40 低血鈣 toxic shock syndrome abnormalities in Mg tumor lysis syndrome
serum Ca < 8.5 mEq/L or Ca2+ < 4.2 mg/dL Causes: toxic shock syndrome abnormalities in Mg tumor lysis syndrome rapid cell turnover hyperK, hyperP, and hypoCa

41 低血鈣 - 症狀 Occur when Ca2+ < 2.5 mg/dL Paraesthesia
Muscle cramps, carpopedal spasm Stridor Tetany Seizures Hyperreflexia Chvostek and Trousseau signs Cardiac contractility, heart failure

42 處置 急性，有症狀 10% Ca gluconate IV 10’ IV drip 0.5 to 2.0 mg/kg/hr in D5W
檢測血鈣 Q4-6H 維持血鈣 7-9 mg/dL 矯正 Mg, K, and pH

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