chidule
Bungwe la European Resuscitation Council (ERC) ndi European Society of Critical Care Medicine (ESICM) agwirizana kuti apange malangizo osamalira akuluakulu pambuyo pa kubwezeretsedwa, mogwirizana ndi 2020 International Consensus on the Science and Treatment of CPR. Mitu yomwe ikukambidwa ikuphatikizapo post-cardiac arrest syndrome, kuzindikira zomwe zimayambitsa kumangidwa kwa mtima, kuwongolera mpweya ndi mpweya wabwino, kulowetsedwa kwa mtima, kuyang'anira ndi kuyang'anira hemodynamic, kuwongolera khunyu, kuwongolera kutentha, kuwongolera chisamaliro chamankhwala champhamvu, kuneneratu za matenda, zotsatira za nthawi yayitali, kukonzanso, ndi kupereka ziwalo.
Mawu Ofunika: Kumangidwa kwa mtima, chisamaliro cha kutsitsimutsa munthu pambuyo pa opaleshoni, kuneneratu, malangizo
Chiyambi ndi kukula kwake
Mu 2015, European Resuscitation Council (ERC) ndi European Society of Critical Care Medicine (ESICM) adagwirizana kuti apange malangizo oyamba othandizira odwala omwe amabwera pambuyo pochira, omwe adasindikizidwa mu Resuscitation and Critical Care Medicine. Malangizo awa othandizira odwala omwe abwera pambuyo pochira adasinthidwa kwambiri mu 2020 ndipo adaphatikizapo sayansi yofalitsidwa kuyambira 2015. Mitu yomwe yaphunziridwa ikuphatikizapo post-cardiac arrest syndrome, oxygen and ventilation control, hemodynamic targets, coronary infusion, targeted temperature management, suction control, prognosis, rehabilitation, ndi zotsatira za nthawi yayitali (Chithunzi 1).
Chidule cha kusintha kwakukulu
Chisamaliro cha nthawi yomweyo pambuyo potsitsimutsidwa:
• Chithandizo chotsitsimutsa thupi chimayamba nthawi yomweyo pambuyo poti ROSC (kuchira kwa magazi ozungulira mwadzidzidzi) yayamba kugwira ntchito, mosasamala kanthu za malo (Chithunzi 1).
• Ngati muli ndi vuto la mtima lomwe simunalandire chithandizo, ganizirani kupita ku chipatala chothandizira odwala matenda a mtima. Dziwani chomwe chimayambitsa vuto la mtima.
• Ngati pali umboni wa matenda (monga kusakhazikika kwa magazi m'thupi) kapena ECG wosonyeza kuti mtima uli ndi ischemia, coronary angiography imayamba kuchitidwa kaye. Ngati coronary angiography siikuzindikira chomwe chimayambitsa matendawa, CT encepography ndi/kapena CT pulmonary angiography zimachitidwa.
• Kuzindikira msanga matenda opuma kapena amitsempha kungachitike pochita CT scans ya ubongo ndi chifuwa panthawi yogonekedwa m'chipatala, coronary angiography isanayambe kapena itatha (onani Coronary Reperfusion).
• Chitani CT ya ubongo ndi/kapena angiography ya mapapo ngati pali zizindikiro kapena zizindikiro zomwe zikusonyeza chifukwa cha mitsempha kapena kupuma asanayambe asystole (monga mutu, khunyu, kapena kusowa kwa mitsempha, kupuma movutikira, kapena kuchepa kwa mpweya komwe kwalembedwa mwa odwala omwe ali ndi matenda odziwika bwino opumira).
1. Njira yopumira mpweya ndi kupuma
Kuyang'anira njira zoyendetsera mpweya pambuyo poti magazi ayenda mwadzidzidzi kwabwezeretsedwa
• Chithandizo cha njira yopumira ndi mpweya chiyenera kupitilira pambuyo poti magazi ayambanso kuyenda bwino (ROSC).
• Odwala omwe adasiya kugwira ntchito bwino kwa ubongo, omwe adabwerera kuntchito bwino nthawi yomweyo, komanso omwe adapuma bwino sangafunike kulowetsedwa mu endotracheal intubation, koma ayenera kupatsidwa mpweya kudzera mu mask ngati kuchuluka kwa mpweya m'mitsempha yawo kuli kochepera 94%.
• Kulowetsa m'mimba mwa odwala omwe ali ndi comatose pambuyo pa ROSC kuyenera kuchitidwa kwa odwala omwe ali ndi vuto la kupuma movutikira komanso kupuma movutikira, ngati kulowetsa m'mimba mwa odwala sikunachitike panthawi ya CPR.
• Kulowetsa m'mimba mwa munthu wodziwa bwino ntchito yake kuyenera kuchitika ndi katswiri wodziwa bwino ntchito yake yemwe ali ndi chiwopsezo chachikulu.
• Malo oyenera a chubu cha endotracheal ayenera kutsimikiziridwa ndi waveform capnography.
• Ngati palibe ma intubator odziwa bwino ntchito, ndi bwino kuyika supraglottic airway (SGA) kapena kusunga njira yolowera mpweya pogwiritsa ntchito njira zoyambira mpaka katswiri wodziwa bwino ntchito atapezeka.
Kulamulira mpweya
• Pambuyo pa ROSC, mpweya wa 100% (kapena wopezeka mokwanira) umagwiritsidwa ntchito mpaka mpweya wokwanira wa m'mitsempha kapena kupanikizika pang'ono kwa mpweya m'mitsempha kungathe kuyezedwa moyenera.
• Mpweya wokwanira m'mitsempha yamagazi ukatha kuyezedwa moyenera kapena mpweya woipa m'magazi ukapezeka, mpweya wouziridwa umayikidwa kuti mpweya wokwanira m'mitsempha yamagazi ukhale 94-98% kapena mpweya wochepa wamagazi (PaO2) wa 10 mpaka 13 kPa kapena 75 mpaka 100 mmHg (Chithunzi 2).
• 避免ROSC后的低氧血症(PaO2 <8 kPa或60 mmHg).
• Pewani kukwera kwa magazi mutatha kumwa mankhwala a ROSC.
Kuwongolera mpweya wabwino
• Pezani mpweya wa m'magazi ndikugwiritsa ntchito njira yowunikira CO2 kumapeto kwa mafunde mwa odwala omwe ali ndi mpweya wokwanira.
• Kwa odwala omwe akufuna mpweya wabwino wa makina pambuyo pa ROSC, sinthani mpweya wabwino kuti ukhale ndi mphamvu ya carbon dioxide (PaCO2) ya 4.5 mpaka 6.0 kPa kapena 35 mpaka 45 mmHg.
• PaCO2 nthawi zambiri imayang'aniridwa mwa odwala omwe amalandira chithandizo cha kutentha koyenera (TTM) chifukwa hypocapnia ikhoza kuchitika.
• Mpweya wa m'magazi nthawi zonse umayesedwa pogwiritsa ntchito njira zowongolera kutentha kapena kusasintha kutentha panthawi ya TTM ndi kutentha kochepa.
• Gwiritsani ntchito njira yotetezera mpweya m'mapapo kuti mufike pamlingo woyenera wa 6 - 8 ml/kg wa kulemera kwa thupi.
2. Kuyenda kwa magazi m'mitsempha ya mtima
Kubwezeretsanso kwa madzi m'thupi
• Odwala akuluakulu omwe ali ndi ROSC pambuyo pokayikira kuti mtima waima komanso kuchuluka kwa ST-segment pa ECG ayenera kuyesedwa mwachangu mu labotale ya cardiac catheterization (PCI iyenera kuchitidwa nthawi yomweyo ngati yaperekedwa).
• Kuwunika mwachangu kwa labotale ya catheterization ya mtima kuyenera kuganiziridwa mwa odwala omwe ali ndi ROSC omwe ali ndi vuto la mtima losakhazikika (OHCA) omwe alibe ST-segment elevation pa ECG ndipo akuyerekezeredwa kuti ali ndi mwayi waukulu wotseka mitsempha ya mtima (monga odwala omwe ali ndi hemodynamic ndi/kapena omwe ali ndi vuto lamagetsi).
Kuyang'anira ndi kuyang'anira magazi m'thupi
• Kuyang'anira kuthamanga kwa magazi nthawi zonse kudzera mu ductus arteriosus kuyenera kuchitika mwa odwala onse, ndipo kuyang'anira kutulutsa kwa mtima ndikofunikira kwa odwala omwe ali ndi vuto la hemodynamic.
• Chitani echocardiogram mwamsanga (mwamsanga momwe mungathere) kwa odwala onse kuti mudziwe matenda aliwonse a mtima omwe ali m'thupi ndi kuyeza kuchuluka kwa vuto la mtima lomwe silikugwira ntchito bwino.
• Pewani kuthamanga kwa magazi (< 65 mmHg). Yesetsani kuti mukwaniritse kuchuluka kwa mkodzo wotuluka m'magazi (MAP) kuti mukwaniritse kuchuluka kwa mkodzo wotuluka (> 0.5 mL/kg*h ndi lactate wabwinobwino kapena wochepa (Chithunzi 2).
• Bradycardia ikhoza kusachiritsidwa panthawi ya TTM pa 33°C ngati kuthamanga kwa magazi, lactate, ScvO2, kapena SvO2 kuli kokwanira. Ngati sichoncho, ganizirani kuwonjezera kutentha komwe mukufuna, koma osapitirira 36°C.
• Kusunga madzi m'thupi pogwiritsa ntchito madzi, norepinephrine, ndi/kapena dobutamine kutengera kufunika kwa kuchuluka kwa mitsempha yamagazi, kutsekeka kwa mitsempha yamagazi, kapena kutsekeka kwa minofu mwa wodwala aliyense.
• Pewani hypokalemia, yomwe imagwirizana ndi ventricular arrhythmias.
• Ngati kubwezeretsa madzi m'thupi, kupindika kwa minofu, ndi chithandizo cha vasoactive sizikwanira, chithandizo cha makina oyendera magazi (monga, intra-aortic balloon pump, left ventricular assist device, kapena arteriovenous extracorporeal membrane oxygenation) chingaganizidwe pochiza kugwedezeka kosalekeza kwa mtima chifukwa cha kulephera kwa left ventricular. Zipangizo zothandizira za left ventricular kapena extracorporeal endovascular oxygenation ziyeneranso kuganiziridwa mwa odwala omwe ali ndi haemodynamically unstable acute coronary syndrome (ACS) ndi recurrent ventricular tachycardia (VT) kapena ventricular fibrillation (VF), ngakhale pali njira zabwino kwambiri zochizira.
3. Kugwira ntchito kwa minofu (kukonza kuchira kwa mitsempha)
Lamulirani khunyu
• Tikulangiza kugwiritsa ntchito electroencephalogram (EEG) pozindikira electrospasms mwa odwala omwe ali ndi khunyu komanso kuyang'anira momwe chithandizo chikuchitikira.
• Pofuna kuchiza khunyu pambuyo poti mtima wasiya kugwira ntchito, tikupangira levetiracetam kapena sodium valproate ngati mankhwala oyamba oletsa khunyu kuwonjezera pa mankhwala ochepetsa ululu.
• Tikukulimbikitsani kuti musagwiritse ntchito njira yodzitetezera ku khunyu mwa odwala omwe agwidwa ndi mtima.
Kulamulira kutentha
• Kwa akuluakulu omwe sachitapo kanthu pa OHCA kapena kulephera kwa mtima m'chipatala (kugunda kulikonse kwa mtima koyambirira), tikupangira kuyang'anira kutentha kwa mtima (TTM).
• Sungani kutentha kwa malo omwe mukufuna kukhala pakati pa 32 ndi 36 °C kwa maola osachepera 24.
• Kwa odwala omwe akukhalabe ndi chikomokere, pewani kutentha thupi (> 37.7°C) kwa maola osachepera 72 mutalandira chithandizo cha ROSC.
• Musagwiritse ntchito mankhwala ozizira musanapite kuchipatala kuti muchepetse kutentha kwa thupi. Kusamalira Chisamaliro Chachikulu - Kugwiritsa ntchito mankhwala ochepetsa kutentha thupi komanso opioid.
• Kugwiritsa ntchito mankhwala oletsa mitsempha nthawi zonse kumapewedwa kwa odwala omwe ali ndi TTM, koma kungaganizidwe ngati akuzizira kwambiri panthawi ya TTM.
• Chitetezo cha zilonda za m'mimba chimaperekedwa nthawi zonse kwa odwala omwe ali ndi vuto la mtima.
• Kupewa matenda a deep vein thrombosis.
• 如果需要，使用胰岛素输注将血糖定位為7.8-10 mmol/L（140- 180 mg/dL），避免低血糖 mmol（7mg）<4.0.
• Yambani kudya zakudya zopatsa thanzi zochepa (kudya zakudya zopatsa thanzi) panthawi ya TTM ndipo muwonjezere kutentha mukatha kutenthetsanso ngati pakufunika. Ngati TTM ya 36°C igwiritsidwa ntchito ngati kutentha komwe mukufuna, kuchuluka kwa chakudya chopatsa thanzi kungakwere msanga panthawi ya TTM.
• Sitikulimbikitsa kugwiritsa ntchito mankhwala ophera tizilombo toyambitsa matenda nthawi zonse.
4. Kuneneratu zamtsogolo
Malangizo onse
• Sitikulimbikitsa maantibayotiki oletsa matenda kwa odwala omwe ali ndi chikumbumtima atachira chifukwa cha kulephera kwa mtima, ndipo kudziwitsidwa kwa matenda a neuroprognosis kuyenera kuchitidwa pofufuza zachipatala, electrophysiology, biomarkers, ndi kujambula, kuti adziwitse achibale a wodwalayo komanso kuthandiza asing'anga kuti alandire chithandizo kutengera mwayi wa wodwalayo wochira bwino muubongo (Chithunzi 3).
• Palibe cholosera chimodzi chomwe chili cholondola 100%. Chifukwa chake, tikupangira njira yolosera za mitsempha yamitundu yosiyanasiyana.
• Poneneratu zotsatira zoyipa za mitsempha, kulunjika kwakukulu ndi kulondola ndikofunikira kuti tipewe kulosera zabodza zopanda chiyembekezo.
• Kuyezetsa ubongo ndikofunikira kwambiri kuti munthu adziwe ngati pali vuto la matenda. Pofuna kupewa kulosera molakwika kuti palibe chiyembekezo, madokotala ayenera kupewa kusokoneza zotsatira za mayeso zomwe zingasokonezedwe ndi mankhwala oletsa ululu ndi mankhwala ena.
• Kuyezetsa matenda tsiku ndi tsiku kumalimbikitsidwa odwala akalandira chithandizo cha TTM, koma kuwunika komaliza kwa matenda kuyenera kuchitika pambuyo polandira chithandizo.
• Madokotala ayenera kudziwa za chiopsezo cha kutengera ulosi wodzipangira okha, komwe kumachitika pamene zotsatira za mayeso owonetsa zotsatira zoyipa zimagwiritsidwa ntchito posankha chithandizo, makamaka pankhani ya mankhwala ochiritsira moyo.
• Cholinga cha mayeso a Neuroprognosis Index ndikuwunika kuopsa kwa kuvulala kwa ubongo komwe kumabwera chifukwa cha hypoxic-ischemic. Neuroprognosis ndi chimodzi mwa zinthu zingapo zomwe muyenera kuganizira pokambirana za kuthekera kwa munthu kuchira.
Kuneneratu za mitundu yambiri
• Yambani kuwunika momwe matenda angakhalire ndi kuyezetsa kolondola kwachipatala, komwe kumachitika pokhapokha zinthu zazikulu zomwe zimasokoneza (monga kuletsa kupuma, hypothermia) zitachotsedwa (Chithunzi 4)
• Ngati palibe zinthu zosokoneza, odwala omwe ali ndi comatose omwe ali ndi ROSC ≥ M≤3 mkati mwa maola 72 akhoza kukhala ndi zotsatira zoyipa ngati pali zinthu ziwiri kapena zingapo zotsatirazi: palibe pupillary corneal reflex pa ≥ maola 72, kusakhalapo kwa N20 SSEP ≥ maola 24, high-grade EEG > maola 24, specific neuronal enolase (NSE) > 60 μg/L kwa maola 48 ndi/kapena 72, state myoclonus ≤ maola 72, kapena diffuse brain CT, MRI ndi extreme hypoxic injury. Zizindikiro zambirizi zitha kulembedwa maola 72 asanafike ROSC; Komabe, zotsatira zawo zidzawunikidwa pokhapokha panthawi yowunika za matenda.
Kuyezetsa kuchipatala
• Kuyezetsa kuchipatala kungasokonezedwe ndi mankhwala ochepetsa ululu, opioid, kapena mankhwala ochepetsa ululu. Kusokoneza komwe kungachitike chifukwa cha mankhwala ochepetsa ululu kuyenera kuganiziridwa nthawi zonse ndikuchotsedwa.
• Kwa odwala omwe akhalabe ali mu chikomokere maola 72 kapena kupitirira pambuyo pa ROSC, mayeso otsatirawa anganene kuti matenda a mitsempha ndi oipa kwambiri.
• Kwa odwala omwe amakhalabe ndi chikomokere maola 72 kapena kupitirira pambuyo pa ROSC, mayeso otsatirawa anganeneretu zotsatira zoyipa za mitsempha:
- Kusakhala ndi ma reflexes a kuwala kwa ana aang'ono awiri
- Kuwerengera kwa ophunzira
- Kutaya kwa corneal reflex mbali zonse ziwiri
– Myoclonus mkati mwa maola 96, makamaka state myoclonus mkati mwa maola 72
Tikulimbikitsanso kulemba EEG pamaso pa matenda a myoclonic tics kuti tidziwe chilichonse chokhudzana ndi epileptiform kapena kuzindikira zizindikiro za EEG, monga momwe ubongo umayankhira kapena kupitiriza kwake, zomwe zikusonyeza kuti ubongo ukhoza kuchira.
neurophysiology
• EEG (electroencephalogram) imachitidwa kwa odwala omwe ataya chikumbumtima atasiya kugwira ntchito ya mtima.
• Ma EEG omwe ali ndi vuto lalikulu amaphatikizapo kutsekeka kwa malo okhudzidwa ndi kutuluka kapena kusakhala ndi kutuluka kwa magazi nthawi ndi nthawi komanso kutsekeka kwa magazi. Tikukulimbikitsani kugwiritsa ntchito ma EEG awa ngati chizindikiro cha matenda osachiritsika pambuyo pa kutha kwa TTM komanso pambuyo pogona.
• Kupezeka kwa khunyu pa EEG m'maola 72 oyambirira pambuyo pa ROSC ndi chizindikiro cha matenda osachiritsika.
• Kusayankha bwino pa EEG ndi chizindikiro cha matenda osachiritsika pambuyo poti mtima wasiya kugwira ntchito.
• Kutayika kwa mphamvu ya cortical N20 chifukwa cha masoma awiri chifukwa cha kufooka kwa mitsempha yamagazi ndi chizindikiro cha matenda a mtima omwe angachitike pambuyo poti mtima wasiya kugwira ntchito.
• Zotsatira za EEG ndi somatosensory evoked potentials (SSEP) nthawi zambiri zimaganiziridwa pofufuza zachipatala ndi mayeso ena. Mankhwala oletsa mitsempha ayenera kuganiziridwa akamachitidwa SSEP.
Zizindikiro za moyo
• Gwiritsani ntchito miyeso yosiyanasiyana ya NSE pamodzi ndi njira zina kuti mudziwiretu zotsatira za mtima ukasiya kugwira ntchito. Miyeso yokwera pa maola 24 mpaka 48 kapena maola 72, pamodzi ndi miyeso yapamwamba pa maola 48 mpaka 72, zikusonyeza kuti munthu sadzalandira chithandizo choyenera.
Kujambula
• Gwiritsani ntchito maphunziro owunikira ubongo kuti mulosere zotsatira zoyipa za mitsempha pambuyo pa kuima kwa mtima pamodzi ndi zinthu zina zodziwira matenda m'malo omwe ali ndi chidziwitso choyenera chofufuza.
• Kupezeka kwa kutupa kwa ubongo komwe kumachitika nthawi zambiri, komwe kumawonetsedwa ndi kuchepa kwakukulu kwa chiŵerengero cha imvi/yoyera pa CT ya ubongo, kapena kuchepa kwakukulu kwa kufalikira kwa magazi pa MRI ya ubongo, kumasonyeza kuti matenda a mitsempha sali bwino pambuyo poti mtima wasiya kugwira ntchito.
• Zomwe zapezeka m'mafayilo nthawi zambiri zimaganiziridwa pamodzi ndi njira zina zodziwira matenda amitsempha.
5. Siyani chithandizo chothandizira moyo
• Kukambirana kosiyana za kuwunika kwa nthawi yomwe munthu angasiye mankhwala ndi kuchira kwa mitsempha ya m'mitsempha ya chithandizo chothandizira moyo (WLST); Chisankho cha WLST chiyenera kuganizira zinthu zina kupatula kuvulala kwa ubongo, monga zaka, matenda ena, ntchito ya ziwalo za thupi, ndi kusankha wodwala.
Tengani nthawi yokwanira yolankhulirana, komanso nthawi yayitali yodziwira matenda a mtima mutasiya kugwira ntchito
Mlingo wa chithandizo mkati mwa gululo umatsimikiza ndi • kuchita mayeso a thupi ndi ntchito zina zomwe sizili za abale ndi achibale. Kuzindikira msanga zosowa za kukonzanso thupi la odwala omwe ali ndi vuto la thupi asanatulutsidwe m'chipatala ndikupereka chithandizo cha kukonzanso thupi ngati pakufunika kutero. (Chithunzi 5).
• Konzani maulendo otsatira a anthu onse opulumuka ku stroke mkati mwa miyezi itatu kuchokera pamene anatulutsidwa m'chipatala, kuphatikizapo zotsatirazi:
- 1. Kuwunika mavuto a maganizo.
2. Kuwunika ngati muli ndi vuto la maganizo ndi kutopa.
3. Perekani chidziwitso ndi chithandizo kwa opulumuka ndi mabanja.
6. Kupereka ziwalo za thupi
• Zisankho zonse zokhudzana ndi kupereka ziwalo ziyenera kutsatira malamulo ndi makhalidwe abwino am'deralo.
• Kupereka ziwalo kuyenera kuganiziridwa kwa iwo omwe akwaniritsa ROSC ndipo akwaniritsa zofunikira za imfa ya mitsempha (Chithunzi 6).
• Kwa odwala omwe ali ndi vuto la kupuma movutikira omwe sakwaniritsa zofunikira za imfa ya mitsempha, kupereka ziwalo kuyenera kuganiziridwa panthawi yotseka magazi ngati asankha kuyamba chithandizo cha kumapeto kwa moyo ndikusiya chithandizo cha moyo.
Nthawi yotumizira: Julayi-26-2024