高级急救技能.ppt
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参见附件(2664KB)。
Advanced Skills
高级急救技能
Dr. Baxter Larmon, MICP
Professor
UCLA School of Medicine
Dr. Atilla üner, MD, MPH
Assistant Professor
UCLA School of Medicine
Airway Skills
呼吸道技能
Initial approach
初步步骤
* Assess breathing评估呼吸: Look 看, listen 听, feel 感觉.
(< 10 sec.)Absent 无呼吸? Inadequate 呼吸不恰当?
* If no spontaneous respirations, position victim 如没有自主呼吸，给予患者适当体位.
* Head-tilt chin-lift or jaw-thrust 头颈提高，下巴抬起， .
* Reassess breathing: If not adequate, begin ventilations 重新评估呼吸，如仍没有适当呼吸，开始协助换气.
Dangers of ventilation
辅助呼吸的危险
* The thorax has a compliance curve 胸部有顺应的弧线.
* The thorax is more pliable at lower volumes, and stiffens when inflated to higher volumes 胸部在低容量时较容易扩张，在高容量时较紧张.
* Too vigorous ventilation inflates the thorax, making it harder to ventilate 太用力的换气会扩充胸部导致较难换气.
* Now you're squeezing even harder, producing more inflation 如用力过渡会产生更多的充气.
Dangers of ventilation
辅助呼吸的危险
* An inflated thorax has a higher intrathoracic pressure 充气的胸部有较高的胸腔内压力.
* Higher intrathoracic pressure compresses the vena cava, causing decreased blood return to the heart 高的胸腔内压压迫腔静脉导致回心脏的血液下降.
* The heart is a pump: Less goes in, less comes out 心脏是一个泵，进来少，出去少.
* Blood pressure decreases 血压下降.
Not good.
Dangers of ventilation
辅助呼吸的危险
* Vigorous ventilation leads to pressure exceeding the lower esophageal sphincter tone 用力的换气导致对食道扩约肌肌张力有过多的压力.
* Gastric inflation 胃部膨胀.
* Regurgitation and aspiration 反流及吸入.
* Patients with hiatal hernia, obese, full stomach are at increased risk 病人如有肥胖、胃充满则会增加危险.
* Dead people have decreased sphincter tone死者有扩约肌张力下降.
Dangers of ventilation
辅助呼吸的危险
* Gastric inflation leads to elevated abdominal pressure 胃部的膨胀导致腹压上升.
* Elevated abdominal pressure inhibits diaphragm movement腹压上升抑制横膈的活动.
* Decreased diaphragm movement makes it more difficult to bag降低的横膈的活动使使用呼吸皮囊更加困难.
* Now you're ventilating even harder, producing more gastric inflation 换气更用力将导致更多的胃部膨胀.
Dangers of ventilation
辅助呼吸的危险
* Hyperventilation leads to alkalosis 过渡换气导致碱中毒.
* Alkalosis leads to cerebral vasospasm 碱中毒导致脑血管痉挛.
* Cerebral vasospasm leads to decreased blood flow to the brain脑血管痉挛导致流到脑部的血流减少.
* This can't be good 这是不好的现象.
* You and I breathe at a tidal volume of about 500 cc 10-12 times per minute 您与我所呼吸的潮气量是500 西西 约 10-12次每分钟.
Dangers of ventilation
辅助呼吸的危险
* For an 80 kg person, that's 500:80 = 6.25 cc/kg一位80 公斤的人，约6.25 西西/公斤.
* That's way less than 10-15 cc/kg 少于10-15西西/公斤
* An Ambu-bag has 1600 cc volume
一个充气皮囊有 1600 西西的容量.
* A good squeeze will produce 800-1000 cc or more. 一个好的压缩会产生 800-1000西西或更多
* Let's relax, and stop hyperventilating our patients 放松!停止我们对病人的过度换气
Bag-Valve-Mask
皮囊-阀门-面罩
* This is your most important airway skill 这是您最重要的呼吸技能!
* Best a two or three rescuer procedure 最好在2 或3 人的急救过程
* Position patient 为病人摆体位
* Airway adjunct if tolerated 如能承受给予口腔导气管
* Apply mask to bridge of nose 给予面罩包含鼻部
* "E technique" or two-hand grip 采用 E 技巧或使用两手抓握
* Cricoid pressure (Sellick maneuver)施压环状软骨
Bag-Valve-Mask
皮囊-阀门-面罩
BVM without oxygen source
无氧气来源的皮囊阀门面罩
* Deliver 10 cc/kg tidal volume over 2 seconds at 10-12 breaths per minute, or one breath every 4-6 seconds. 每分钟给予10-12次呼吸下(或每4-6秒一次呼吸情况下)可在2秒内给予每公斤体重10西西的潮气量
* 10 cc/kg results in clearly visible chest rise. 10西西/公斤可导致清楚可见的胸部起伏
* Slow and steady bag squeeze minimizes gastric inflation. 稳而慢的皮囊挤压可减少胃部的膨胀
* Common error: Too fast and too vigorous!常见的错误：太快及太用力
BVM with oxygen source
带氧气来源的皮囊阀门面罩
* Deliver 6-7 cc/kg tidal volume over 2 seconds at 10-12 breaths per minute, or one breath every 4-6 seconds.每分钟给予10-12次呼吸下(或每4-6秒一次呼吸情况下)可在2秒内给予每公斤体重6-7西西的潮气量
* 6 cc/kg results in visible chest rise. 6西西/公斤可导致清楚可见的胸部起伏
* Bag has 1600 cc volume, 6 cc/kg equals 400-600 cc for an average adult. 皮囊有1600西西的容量，对一为中等体重的成人而言，6西西/公斤等于400-600西西容量
* High-flow O2 is 8-12 L/min 高流量的氧气是每分钟8-12升/分
BVM with oxygen source
带氧气来源的皮囊阀门面罩
* Slow and steady bag squeeze minimizes gastric inflation.稳而慢的皮囊挤压可减少胃部的膨胀
* Common error: Too fast and too vigorous!常见的错误：太快及太用力
* Cricoid pressure by third rescuer. 由第三位给予环状软骨施压
* Locate cricoid. 找到环状软骨
* Apply only moderate pressure.施与中度的压力
* You can do this for hours if you take turns! 请轮流做
Troubleshooting 问题解决
If you can't properly ventilate:如不能适当的换气：
* Reposition your patient, try again. 在重新摆位后，再试一遍
* Check mask seal, correct, and try again.检查面罩的紧密性，正确、并再试一遍
* Insert oral or nasal airway, and try again.插入口或鼻的气道辅助器，并再试一遍
* Look for foreign body, remove by finger-sweep or Magill-forceps, and try again.检查有无异物，以手或 Magill 夹去除异物，并再试一遍
* Consider unrecognized injury or epiglottitis.考虑是否出现没被发现的外伤或喉炎
Advantages of intubation
插管的优点
* Sealed airway, eliminating gastric inflation and aspiration.紧密的呼吸辅助减少胃部膨胀及吸入
* Decreased dead-space, permitting more reliable and accurate ventilation.降低死腔可允许更可靠及正确的换气
* Eliminating need for mask-seal, permitting or improving mobility of the patient and permitting extrication and other maneuvers.同时减少过度的控制面罩的紧密性以允许或改善病人的活动性或其它的操作
* Ability to ventilate with ventilator.能以呼吸器辅助病人换气
Dangers of intubation插管缺点
* If you ventilate the stomach and don't realize it, you will kill your patient.如果您导致胃部的换气而不知道，有可能导致病人死亡
* Unrecognized hypoxemia due to prolonged efforts at a complex procedure, leading to poorer, not better, outcome. 长期复杂的操作所导致不被认知的低血氧症会导致较差的结果
* Induction of vomiting.引发呕吐
* Trauma to teeth, mouth, airway, C-spine.牙齿、口腔、呼吸道或颈椎外伤
Dangers of intubation插管的危险
* An intubated patient is even easier to hyperventilate, as there is no "mask seal safety valve".插管病人较容易过度换气因为没有"面罩紧密安全阀门"
* Barotrauma in asthmatics, children, COPD.气喘、儿童、慢性肺阻塞病人气压伤......（后略) ......
Advanced Skills
高级急救技能
Dr. Baxter Larmon, MICP
Professor
UCLA School of Medicine
Dr. Atilla üner, MD, MPH
Assistant Professor
UCLA School of Medicine
Airway Skills
呼吸道技能
Initial approach
初步步骤
* Assess breathing评估呼吸: Look 看, listen 听, feel 感觉.
(< 10 sec.)Absent 无呼吸? Inadequate 呼吸不恰当?
* If no spontaneous respirations, position victim 如没有自主呼吸，给予患者适当体位.
* Head-tilt chin-lift or jaw-thrust 头颈提高，下巴抬起， .
* Reassess breathing: If not adequate, begin ventilations 重新评估呼吸，如仍没有适当呼吸，开始协助换气.
Dangers of ventilation
辅助呼吸的危险
* The thorax has a compliance curve 胸部有顺应的弧线.
* The thorax is more pliable at lower volumes, and stiffens when inflated to higher volumes 胸部在低容量时较容易扩张，在高容量时较紧张.
* Too vigorous ventilation inflates the thorax, making it harder to ventilate 太用力的换气会扩充胸部导致较难换气.
* Now you're squeezing even harder, producing more inflation 如用力过渡会产生更多的充气.
Dangers of ventilation
辅助呼吸的危险
* An inflated thorax has a higher intrathoracic pressure 充气的胸部有较高的胸腔内压力.
* Higher intrathoracic pressure compresses the vena cava, causing decreased blood return to the heart 高的胸腔内压压迫腔静脉导致回心脏的血液下降.
* The heart is a pump: Less goes in, less comes out 心脏是一个泵，进来少，出去少.
* Blood pressure decreases 血压下降.
Not good.
Dangers of ventilation
辅助呼吸的危险
* Vigorous ventilation leads to pressure exceeding the lower esophageal sphincter tone 用力的换气导致对食道扩约肌肌张力有过多的压力.
* Gastric inflation 胃部膨胀.
* Regurgitation and aspiration 反流及吸入.
* Patients with hiatal hernia, obese, full stomach are at increased risk 病人如有肥胖、胃充满则会增加危险.
* Dead people have decreased sphincter tone死者有扩约肌张力下降.
Dangers of ventilation
辅助呼吸的危险
* Gastric inflation leads to elevated abdominal pressure 胃部的膨胀导致腹压上升.
* Elevated abdominal pressure inhibits diaphragm movement腹压上升抑制横膈的活动.
* Decreased diaphragm movement makes it more difficult to bag降低的横膈的活动使使用呼吸皮囊更加困难.
* Now you're ventilating even harder, producing more gastric inflation 换气更用力将导致更多的胃部膨胀.
Dangers of ventilation
辅助呼吸的危险
* Hyperventilation leads to alkalosis 过渡换气导致碱中毒.
* Alkalosis leads to cerebral vasospasm 碱中毒导致脑血管痉挛.
* Cerebral vasospasm leads to decreased blood flow to the brain脑血管痉挛导致流到脑部的血流减少.
* This can't be good 这是不好的现象.
* You and I breathe at a tidal volume of about 500 cc 10-12 times per minute 您与我所呼吸的潮气量是500 西西 约 10-12次每分钟.
Dangers of ventilation
辅助呼吸的危险
* For an 80 kg person, that's 500:80 = 6.25 cc/kg一位80 公斤的人，约6.25 西西/公斤.
* That's way less than 10-15 cc/kg 少于10-15西西/公斤
* An Ambu-bag has 1600 cc volume
一个充气皮囊有 1600 西西的容量.
* A good squeeze will produce 800-1000 cc or more. 一个好的压缩会产生 800-1000西西或更多
* Let's relax, and stop hyperventilating our patients 放松!停止我们对病人的过度换气
Bag-Valve-Mask
皮囊-阀门-面罩
* This is your most important airway skill 这是您最重要的呼吸技能!
* Best a two or three rescuer procedure 最好在2 或3 人的急救过程
* Position patient 为病人摆体位
* Airway adjunct if tolerated 如能承受给予口腔导气管
* Apply mask to bridge of nose 给予面罩包含鼻部
* "E technique" or two-hand grip 采用 E 技巧或使用两手抓握
* Cricoid pressure (Sellick maneuver)施压环状软骨
Bag-Valve-Mask
皮囊-阀门-面罩
BVM without oxygen source
无氧气来源的皮囊阀门面罩
* Deliver 10 cc/kg tidal volume over 2 seconds at 10-12 breaths per minute, or one breath every 4-6 seconds. 每分钟给予10-12次呼吸下(或每4-6秒一次呼吸情况下)可在2秒内给予每公斤体重10西西的潮气量
* 10 cc/kg results in clearly visible chest rise. 10西西/公斤可导致清楚可见的胸部起伏
* Slow and steady bag squeeze minimizes gastric inflation. 稳而慢的皮囊挤压可减少胃部的膨胀
* Common error: Too fast and too vigorous!常见的错误：太快及太用力
BVM with oxygen source
带氧气来源的皮囊阀门面罩
* Deliver 6-7 cc/kg tidal volume over 2 seconds at 10-12 breaths per minute, or one breath every 4-6 seconds.每分钟给予10-12次呼吸下(或每4-6秒一次呼吸情况下)可在2秒内给予每公斤体重6-7西西的潮气量
* 6 cc/kg results in visible chest rise. 6西西/公斤可导致清楚可见的胸部起伏
* Bag has 1600 cc volume, 6 cc/kg equals 400-600 cc for an average adult. 皮囊有1600西西的容量，对一为中等体重的成人而言，6西西/公斤等于400-600西西容量
* High-flow O2 is 8-12 L/min 高流量的氧气是每分钟8-12升/分
BVM with oxygen source
带氧气来源的皮囊阀门面罩
* Slow and steady bag squeeze minimizes gastric inflation.稳而慢的皮囊挤压可减少胃部的膨胀
* Common error: Too fast and too vigorous!常见的错误：太快及太用力
* Cricoid pressure by third rescuer. 由第三位给予环状软骨施压
* Locate cricoid. 找到环状软骨
* Apply only moderate pressure.施与中度的压力
* You can do this for hours if you take turns! 请轮流做
Troubleshooting 问题解决
If you can't properly ventilate:如不能适当的换气：
* Reposition your patient, try again. 在重新摆位后，再试一遍
* Check mask seal, correct, and try again.检查面罩的紧密性，正确、并再试一遍
* Insert oral or nasal airway, and try again.插入口或鼻的气道辅助器，并再试一遍
* Look for foreign body, remove by finger-sweep or Magill-forceps, and try again.检查有无异物，以手或 Magill 夹去除异物，并再试一遍
* Consider unrecognized injury or epiglottitis.考虑是否出现没被发现的外伤或喉炎
Advantages of intubation
插管的优点
* Sealed airway, eliminating gastric inflation and aspiration.紧密的呼吸辅助减少胃部膨胀及吸入
* Decreased dead-space, permitting more reliable and accurate ventilation.降低死腔可允许更可靠及正确的换气
* Eliminating need for mask-seal, permitting or improving mobility of the patient and permitting extrication and other maneuvers.同时减少过度的控制面罩的紧密性以允许或改善病人的活动性或其它的操作
* Ability to ventilate with ventilator.能以呼吸器辅助病人换气
Dangers of intubation插管缺点
* If you ventilate the stomach and don't realize it, you will kill your patient.如果您导致胃部的换气而不知道，有可能导致病人死亡
* Unrecognized hypoxemia due to prolonged efforts at a complex procedure, leading to poorer, not better, outcome. 长期复杂的操作所导致不被认知的低血氧症会导致较差的结果
* Induction of vomiting.引发呕吐
* Trauma to teeth, mouth, airway, C-spine.牙齿、口腔、呼吸道或颈椎外伤
Dangers of intubation插管的危险
* An intubated patient is even easier to hyperventilate, as there is no "mask seal safety valve".插管病人较容易过度换气因为没有"面罩紧密安全阀门"
* Barotrauma in asthmatics, children, COPD.气喘、儿童、慢性肺阻塞病人气压伤......（后略) ......
附件资料：
相关资料1：
- 急救图解.pdf
- 《自助急救手册》高清扫描版.pdf
- 254-急救良方.txt
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- 《灾害危机干预与心理急救手册》.邓明昱.文字版.pdf
- 019.急救良方-(明)张时彻辑; 康维点校（1987）.pdf
- 暴发性心肌炎的诊断与紧急救治.pdf
- 《临床急救 》高清晰PDF图片电子图书
- 《公民现场急救指南》扫描版.pdf
- 《157-常见中毒与实用急救措施》.杨立佩.扫描版.pdf
- 常见中毒急救手册.pdf
- 《图解应急救治》.于大鹏.扫描版.pdf
- 《常见有毒化学品应急救援手册》.伍郁静.何健民.扫描版.pdf
- 2005年美国心脏学会心肺复苏和心血管急救指南.pdf
- 《爱情急救手册》.陆琪.扫描版.pdf