Bài giảng Hồi sinh tim phổi nâng cao - Hoàng Bùi Hải

1 
HỒI SINH TIM PHỔI NÂNG CAO 
BS. Hoàng Bùi Hải 
BM HSCC- ĐHY Hà Nội 
 HSTP Nâng Cao 
ACLS 2010 Guideline 
 HSTP cơ bản 
 Ngừng tim 
 Nhịp nhanh 
 Nhịp chậm 
CPR Changes Emphasise 
“Push hard, push fast, 
minimise interruptions; allow 
full chest recoil, and don’t 
hyperventilate” 
Mất ý thức, ngừng thở hoặc thở ngáp 
Hoạt hóa hệ thống cấp cứu 
Ép tim 
(nhanh, mạnh, thả hết: ép 
> 100 l/ph, lún ngực 5 cm) 
Lấy máy 
sốc điện 
Cardiopulmonary Resuscitation and Emergency Cardiovascular CareAdult Basic Life 
Support: 2010 American Heart Association Guidelines 
2 phút 
Kiểm tra 
nhịp 
Dành cho người 
chưa được đào tạo 
Có mạch 
Không có mạch 
Mất ý thức, ngừng thở hoặc thở ngáp 
Bắt mạch cảnh 10s 
Thổi 
ngạt 
1 
lần/m
ỗi 5-
6s 
Khai thông đường thở 
Gọi cấp cứu 
Ép tim (nhanh, mạnh, giãn tối đa); Ép 100 l/ph 
Ép-Thổi 
5 chu kỳ 
Sốc điện 
Máy khử rung tự động (AED)/Máy sốc điện đến 
Sốc 1 lần Không Có 
Cardiopulmonary Resuscitation and 
Emergency Cardiovascular CareAdult 
Basic Life Support: 2010 American Heart 
Association Guidelines 
Thổi ngạt 2 lần 
2 phút 
Dành cho nhân viên y tế 
Nguyên lý cơ bản HSTPNC 
• To provide critical blood flow to the vital organs with high 
quality chest compressions 
• Defibrillation as soon as possible provides the best 
chance of survival in victims with VF or pulseless VT (cf. 
CPR prior to defib) 
• Return of spontaneous circulation as rapidly as possible 
• Intensive care support aimed to achieve the best 
outcomes 
HSTPNC – KEY I 
• High quality chest compressions with minimal 
interruptions; continuing compressions during defibrillator 
charging 
• Single (non-stacked) shocks, but stacked shocks may be 
considered for HPC witnessed arrest*, during cardiac 
catheterisation or after cardiac surgery 
• Precordial thump is de-emphasised 
• IV or IO drug administration (ETT de-emphasised) 
*Where a monitor / defibrillator is connected at the time 
• Adrenaline 1mg for VF/VT after the second shock once 
chest compressions have restarted and then every 3-5 
min (alternate blocks of CPR) 
• Amiodarone 300mg after third shock 
• Atropine no longer recommended for routine use in 
asystole or PEA 
• Less emphasis on early intubation 
• Capnography to confirm and continually monitor tracheal 
tube placement, quality of CPR, and to provide early 
indication of ROSC 
HSTPNC – KEY II 
HỒI SỨC SAU NTH 
• Recognition that a “post resuscitation care’ protocol may 
improve survival following ROSC 
• Avoid hyperoxaemia – oxygen titration to Sa02 94-98% 
• Primary PCI in appropriate patients with sustained ROSC 
• Normoglycaemic glucose control (BSL >10 mmol/l should 
be treated but hypoglycaemia avoided) 
• Therapeutic hypothermia to include comotose survivors 
of cardiac arrest of any rhythm 
Single Shock Defibrillation Strategy 
• Single shock strategy continues to be recommended to 
improve outcome by reducing interruption of chest 
compressions 
– Monophasic 360J / Biphasic 200 J (Adult) 
– Monophasic / Biphasic 4J/kg (Paed) 
• Exception is health professional witnessed VF/VT. 
– Salvo of three stacked shocks (Mono 360J / Biphasic 200J; with 
rhythm checks between shocks) 
– Followed by CPR and single shock strategy if unsuccessful 
NGỪNG TIM 
ĐƯỜNG TRUYỀN TĨNH MẠCH 
 “provision of high-quality CPR and rapid 
defibrillation are of primary importance and 
drug administration is of secondary 
importance” 
 20ml Bolus after drug 
ĐƯỜNG TRUYỀN QUA XƯƠNG 
• Reasonable to establish access if IV access 
is not readily available 
MASK THANH QUẢN 
• CPR more important than airway initially 
• Put in a supraglottic if intubation is going 
to be “hard” 
• LMA 
• King LT 
ĐO CO2 KHÍ THỞ RA 
• 100% sensitive and specific for tracheal 
intubation 
• Helps count 8-10 breaths minute 
• Predictor of outcome 
KHÔNG Atropin: VÔ TÂM THU 
VÀ HĐ ĐIỆN VÔ MẠCH 
• “Available evidence suggests that the 
routine use of atropine during PEA or 
asystole is unlikely to have a therapeutic 
benefit” 
Thuốc = Máy tạo nhịp 
• It hurts! 
• No better than drugs 
• Ok to go from drugs to TV pacing 
• NOT ROUTINE in arrest 
TÌM NGUYÊN NHÂN CÓ THỂ 
ĐIỀU TRỊ 
• 5Hs 
• Hypoxia 
• Hypovolemia 
• Hyperacidosis 
• Hyperkalemia 
• Hypothemia 
• 5Ts 
• Thrombus (MI) 
• Thrombus (PE) 
• Tension PTX 
• Toxins 
• Tamponade 
THUỐC CO MẠCH 
• VF continues after epi and CPR - 
vasopressor 
• Amiodarone is first line 
• Not proven to result in long term outcome 
• Lidocaine is useless also 
 Epinephrine 
• Never any evidence that it works! 
• A Randomized placebo controlled trial of adrenaline in 
cardiac arrest- the PACA trial 
• Conclusion: The use of adrenaline in cardiac arrest was 
associated w significant increase in the proportion of pts 
achieving ROSC however this improvement did not extend 
to survival to hospital discharge. 
Tóm lại- với Ngừng tim 
• Atropine OUT for PEA/Asystole 
• CPR first and fast 
• Airway- supraglottic emerges 
• Still have amiodarone even though it don’t work 
• Hope lies in a reversible cause 
NHỊP NHANH 
1. Pearl 1: Don’t cardiovert to sinus rhythm 
2. Pearl 2: Rates<150 don’t usually cause instability in 
normal healthy hearts 
3. Pearl 3: Many arrhythmias caused by hypoxia- Fix 
that first 
4. Pearl 4: If unstable use electricity- except narrow 
complex when adenosine may be ok 
5. Pearl 5: IF THEY ARE PRETTY STABLE - GET A 12 
LEAD ECG 
Nhịp nhanh – 5 nguyên tắc 
Adenosine 
• “ More rapid and less severe side effects 
than calcium blockers” 
• “recent evidence suggests that adenosine is 
relatively safe for both treatment and 
diagnosis” in Wide Complex Tachycardia 
Adenosine 
• May be considered in the initial diagnosis of 
stable, undifferentiated, regular, 
monomorphic, wide-complex tachycardia. 
Not to be used if the pattern is irregular. 
• New evidence of safety and potential 
efficacy. Help diagnose and treat SVT with 
aberrant conduction. 
BÀN CÃI 
• Not for irregular or polymorphic 
• SVT should slow or convert 
• VT usually will not 
Lựa chọn khác cho 
Nhịp nhanh QRS giãn rộng, đều – Bệnh 
nhân ổn định 
• Cardioversion, Procainamide, Amiodarone, 
Sotalol 
• Generally only try one! 
• Procaine 20-50mg/hour (17mg/kg or QRS 
50% narrowed, or hypotension) 
QRS giãn rộng, đều: 
Amiodarone 
• An option- better than lidocaine 
• 150 mg IV over 10 minutes Can repeat 
2.2 g IV total in 24 hours 
QRS giãn rộng – Không đều 
• Atrial fibrillation 
• Atrial fib - accessory pathway 
• Polymorphic VT 
Nhịp nhanh thất đa hình thái 
• Defibrillation 
3 kiểu NNT đa hình thái 
1. Prolonged QT : Magnesium 
2. Familial : IV Magnesium Pacing Beta-
blockers No Isoprel 
3. Ischemic: Amiodarone, BB, revascularization 
NHỊP NHANH 
Morphin 
• Morphine should be given with caution to 
pts with unstable angina. 
• Morphine is indicated in STEMI when CP 
unresponsive to nitrates. 
• Morphine found to be associated with an 
increase mortality with angina and unstable 
angina large registry. 
NHỊP CHẬM 
Atropin 
• Atropine is not recommended for 
PEA/Asystole. 
• Use of atropine unlikely to have a 
therapeutic benefit 
• First Dose-->0.5mg bolus 
• Repeat every 3-5 minutes 
• Max Dose 3mg 
NẾU ATROPIN THẤT BẠI 
• Transcutaneous Pacing 
• or 
• Dopamine 2-10 mcg per minute 
• Epinephrine 2-10mcg per minute 
Không dùng Atropine khi nào 
• Cardiac Transplant- ineffective 
• or brady Wide complex Type 2 or 3 blocks 
Chronotropic Drugs 
• For symptomatic or unstable bradycardia, 
chronotropic drug infusion are 
recommended as an alternative to pacing. 
• Epi, Dopamine acceptable alternative to 
external transcutaneous pacing when 
atropine is ineffective. 
5 nguyên nhân có thể chữa được 
của Hoạt động điện vô mạch 
• Hypoxia 
• Tension PTX 
• Hypovolemia 
• Cardiac Tamponade 
• Toxic-Metabolic 
5 Xử trí tại khoa Cấp cứu 
• Oxygenate and Ventilate 
• Secure IV Access 
• Look for 3 Causes (ECG, Temp, Vol status) 
• Epinephrine (1mg q 3mins) 
• Review all 5 causes 
5 Nguyên nhân có thể tìm nhờ 
Siêu âm 
• Tamponde 
• Hypovolemia 
• Massive PE 
• Cardiogenic Shock 
• Normal->Lung view 
Hoạt động điện vô mạch – 
Siêu âm 4 buồng tim 
• Pericardial Effusion + RV 
Strain=Tamponade 
• RV Strain=LV Strain=Hypovolemia 
• RV dil + RA dil vs LV Strain=PE 
• Poor contractility= Cardiogenic Shock 
• Nl = Lung view 
TÓM LẠI 
1. HSTP cơ bản tối ưu 
2. Sốc điện được hay không? 
3. Nhịp nhanh hay chậm 
4. Tìm nguyên nhân có thể điều trị 
5. Chăm sóc sau ngừng tuần hoàn 
48 
2010 American Heart Association Guidelines for 
Cardiopulmonary Resuscitation and Emergency 
Cardiovascular Care, Circulation. 2010;122:S729-S767