pfupiso
European Resuscitation Council (ERC) neEuropean Society of Critical Care Medicine (ESICM) vakabatana kugadzira gwara iri rekuchengetedza vanhu vakuru mushure mekumutswa, zvichienderana ne2020 International Consensus on the Science and Treatment of CPR. Misoro inokurukurwa inosanganisira post-cardiac arrest syndrome, kuongororwa kwezvikonzero zvekumira kwemwoyo, kudzora oxygen nekufema, coronary infusion, kutarisa nekutarisira hemodynamic, kudzora pfari, kudzora tembiricha, manejimendi yekutarisira kwakanyanya, fungidziro, mhedzisiro yenguva refu, kugadziriswa, uye kupa nhengo.
Mashoko akakosha: Kusungwa kwemwoyo, kutarisirwa kwekumutswa mushure mekuvhiyiwa, kufanotaura, nhungamiro
Nhanganyaya uye chiyero
Muna 2015, European Resuscitation Council (ERC) neEuropean Society of Critical Care Medicine (ESICM) vakashanda pamwe chete kugadzira gwara rekutanga rekuchengetedza mushure mekumutswa, iro rakaburitswa muResuscitation and Critical Care Medicine. Gwara iri rekuchengetedza mushure mekumutswa rakagadziriswa zvakanyanya muna 2020 uye rinosanganisira sainzi yakaburitswa kubva muna 2015. Misoro yakafukidzwa inosanganisira post-cardiac arrest syndrome, oxygen and ventilation control, hemodynamic targets, coronary infusion, targeted temperature management, septic control, prognosis, rehabilitation, uye long-term results (Mufananidzo 1).
Pfupiso yekuchinja kukuru
Kutarisirwa kwekukurumidza mushure mekumutswa:
• Kurapwa mushure mekudzorerwa kweropa kunotanga pakarepo mushure meROSC (kupora kweropa rinotenderera netsaona), zvisinei nenzvimbo (Mufananidzo 1).
• Kana mwoyo wako wamira kunze kwechipatara, funga nezvekuenda kunzvimbo yekurapa mwoyo wako. Tsvaga chikonzero chekumira kwemoyo wako.
• Kana paine zviratidzo zvekiriniki (semuenzaniso, kusagadzikana kweropa) kana humbowo hweECG hwekuti mwoyo uri kudonha, coronary angiography ndiyo inotanga yaitwa. Kana coronary angiography isingaone chinokonzera chirwere, CT encepography uye/kana CT pulmonary angiography zvinoitwa.
• Kuziva nekukurumidza zvirwere zvekufema kana zvetsinga kunogona kuitwa nekuita CT scans yeuropi nechipfuva panguva yekuiswa muchipatara, coronary angiography isati yaitwa kana kuti yapera (ona Coronary Reperfusion).
• Ita CT yeuropi uye/kana angiography yemapapu kana paine zviratidzo zvinoratidza chikonzero chetsinga kana kufema usati wabatwa ne asystole (semuenzaniso, musoro, pfari, kana kusagadzikana kwetsinga, kufema kushoma, kana kushaya oksijeni kwakanyorwa muvarwere vane mamiriro ekufema anozivikanwa).
1. Nzira yekufema nekufema
Kutarisirwa kwenzira dzemhepo mushure mekutenderera kweropa kamwe kamwe kwagadziriswazve
• Kutsigirwa kwenzira dzekufema nedzekufema kunofanira kuenderera mberi mushure mekudzoreredza kutenderera kweropa (ROSC).
• Varwere vakambomira kushanda zvakanaka kwemoyo kwenguva pfupi, vakadzokera kukushanda zvakanaka kweuropi nekukurumidza, uye vakafema zvakanaka vangasada kuisirwa muchubhu, asi vanofanira kupihwa okisijeni kuburikidza nemasiki kana oxygen yavo muropa iri pasi pe94%.
• Kuisa machubhu emukati memudumbu kunofanira kuitwa kuvarwere vanoramba vari comatose mushure meROSC, kana kuvarwere vane zvimwe zviratidzo zvekunzwa kunyaradzwa uye kufefeterwa nemhepo, kana kusaisa machubhu emukati memudumbu panguva yeCPR.
• Kupinza machubhu emukati memudumbu kunofanira kuitwa nemunhu ane ruzivo rwepamusoro uye anobudirira zvakanyanya.
• Kuiswa kwechubhu ye endotracheal nemazvo kunofanirwa kusimbiswa ne waveform capnography.
• Kana pasina vanhu vane ruzivo rwekushandisa ma endotracheal intubators, zvine musoro kuisa supraglottic airway (SGA) kana kuchengetedza nzira yekufema uchishandisa nzira dzekare kusvika pawanikwa munhu ane hunyanzvi hwekushandisa ma intubator.
Kudzora okisijeni
• Mushure meROSC, 100% (kana kuti inowanikwa zvakanyanya) okisijeni inoshandiswa kusvika arterial oxygen saturation kana arterial partial pressure yeokisijeni yakwanisa kuyerwa nenzira yakavimbika.
• Kana oxygen yakakwana muropa yangogona kuyerwa nenzira yakavimbika kana kuti gasi reropa reropa rawanikwa, oxygen yakafemerwa inowedzerwa kuti iwane oxygen yakakwana muropa ye94-98% kana kuti arterial partial pressure yeoxygen (PaO2) ye10 kusvika 13 kPa kana 75 kusvika 100 mmHg (Mufananidzo 2).
• 避免ROSC后的低氧血症(PaO2 < 8 kPa或60 mmHg).
• Dzivisa hyperxemia mushure meROSC.
Kudzora mhepo inofefetera
• Wana magasi eropa mutsinga uye shandisa CO2 monitoring yekupedzisira kwemvura muvarwere vane michina inofefetera.
• Kune varwere vanoda kufefetedza nemechanical mushure meROSC, gadzirisa kufefetedza kuti uwane kumanikidzwa kwakajairika kwecarbon dioxide (PaCO2) muarterial (arterial partial pressure) ye4.5 kusvika 6.0 kPa kana 35 kusvika 45 mmHg.
• PaCO2 inowanzo tariswa muvarwere vanorapwa nehurongwa hwekutarisira tembiricha (TTM) nekuti hypocapnia inogona kuitika.
• Hunhu hwegasi reropa hunogara huchiyerwa uchishandisa nzira dzekugadzirisa tembiricha kana dzisiri tembiricha panguva yeTTM netembiricha yakaderera.
• Shandisa nzira yekudzivirira mapapu kuti uwane huremu hwemuviri hwe6 - 8 ml/kg hwakakwana.
2. Kutenderera kweropa mumoyo (coronary circulation)
Kusanganiswazve kweropa
• Varwere vakuru vane ROSC mushure mekufungirwa kuti mwoyo hauchagari zvakanaka uye ST-segment yakakwira paECG vanofanira kuongororwa nekukasika murabhoritari yekurapa chirwere chemwoyo (PCI inofanira kuitwa nekukasika kana zvataurwa).
• Kuongororwa kwekurabhoritari yekurapa cardiac catheterization nekukurumidza kunofanirwa kufungwa nezvako kuvarwere vane ROSC vane cardiac arrest out-of-hospital (OHCA) vasina ST-segment elevation paECG uye vanofungidzirwa kuti vane mukana mukuru wekuvharika kwetsinga dzemwoyo (semuenzaniso, varwere vane hemodynamic uye/kana vasina kugadzikana kwemagetsi).
Kutarisa nekugadzirisa kweHemodynamic
• Kuramba uchitarisa BP kuburikidza ne ductus arteriosus kunofanira kuitwa kuvarwere vese, uye kutarisa kubuda kweropa mumoyo kunonzwisisika kuvarwere vasina kugadzikana neropa.
• Ita echocardiogram nekukurumidza (nekukurumidza sezvinobvira) kuvarwere vese kuti vaone chero matambudziko emwoyo aripo uye kuti vaone huwandu hwekutadza kushanda zvakanaka kwemoyo.
• Dzivisai BP yakaderera (< 65 mmHg). Tarisai avhareji yeBP (MAP) kuti muwane weti yakakwana (> 0.5 mL/kg*h uye lactate yakajairika kana yakaderera (Mufananidzo 2).
• Bradycardia inogona kusarapwa panguva yeTTM pa33°C kana BP, lactate, ScvO2, kana SvO2 zvakakwana. Kana zvisina kudaro, funga nezvekuwedzera tembiricha yaunoda, asi kwete kupfuura 36°C.
• Kuchengetedza kufambiswa kweropa nemvura, norepinephrine, uye/kana dobutamine zvichienderana nekuti murwere anofanira kuwedzera sei ropa, kuvharwa kweropa, kana kuti kusungwa kwetsandanyama.
• Dzivisa hypokalemia, iyo inobatanidzwa ne ventricular arrhythmias.
• Kana kudzoreredza ropa kubva muropa, kudzikira kwetsandanyama, uye kurapwa kweropa zvisina kukwana, rutsigiro rwemagetsi (semuenzaniso, bharuni yemukati meaorta, mudziyo wekubatsira ventricular yeruboshwe, kana oxygenation yekunze kweropa) zvinogona kutariswa pakurapa kuvhunduka kwemwoyo kunoramba kuripo nekuda kwekutadza kushanda zvakanaka kweventricular yeruboshwe. Zvishandiso zvekubatsira ventricular yeruboshwe kana oxygenation yekunze kweropa zvinofanirawo kutariswa pavarwere vane haemodynamically unsustable acute coronary syndrome (ACS) uye recurrent ventricular tachycardia (VT) kana ventricular fibrillation (VF), pasinei nesarudzo dzakanakisisa dzekurapa.
3. Kushanda kwemuviri (kuvandudza kupora kwetsinga)
Dzora pfari
• Tinokurudzira kushandisa electroencephalogram (EEG) kuongorora electrospasms muvarwere vane pfari uye kutarisa mhinduro yekurapwa.
• Kuti tirape pfari mushure mekumira kwemoyo, tinokurudzira levetiracetam kana sodium valproate semishonga yekutanga yekurwisa pfari pamwe chete nemishonga yekunyaradza.
• Tinokurudzira kuti tisashandise nzira dzekudzivirira pfari nguva dzose kuvarwere mushure mekumira kwemoyo.
Kudzora tembiricha
• Kune vakuru vasingapindure kuOHCA kana kumisa kwemwoyo muchipatara (chero kurova kwemoyo kwekutanga), tinokurudzira kuti vatarisire tembiricha yavo (TTM).
• Chengeta tembiricha iri pakati pe32 ne36°C kwemaawa makumi maviri nemana.
• Kune varwere vanoramba vari pakoma, dzivisai fivha (> 37.7°C) kwemaawa angangoita 72 mushure meROSC.
• Usashandise mushonga wekudzikisa tembiricha yemuviri usati waenda kuchipatara. Kutarisirwa Kwekuchengetedzwa Kwakanyanya - Kushandisa mishonga yekunyaradza inoshanda kwenguva pfupi uye opioid.
• Kushandisa mishonga inovhara tsandanyama dzemutsinga nguva dzose hakubvumirwi kune varwere vane TTM, asi kunogona kufungwa nezvazvo kana paine dzihwa rakasimba panguva yeTTM.
• Kudzivirira maronda epfungwa kunowanzoitwa kuvarwere vane mwoyo yakamira.
• Kudzivirira thrombosis yetsinga yakadzika.
• 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).
• Tanga kudya kwemukati kwemhando yepasi (kudya kunovaka muviri) panguva yeTTM uye wedzera mushure mekudziyazve kana zvichidikanwa. Kana TTM ye36°C ikashandiswa sekupisa kunonangwa, mwero wekudyisa kwemukati wemuviri unogona kuwedzera kare panguva yeTTM.
• Hatikurudzire kushandisa mishonga inorwisa mabhakitiriya nguva dzose.
4. Kufanotaura kwakajairika
Gwaro remitemo
• Hatikurudzire mishonga inorwisa mabhakitiriya yekudzivirira chirwere ichi kuvarwere vasina chavanoziva mushure mekumutswa kubva pakumira kwemoyo, uye kufanotaura nezvechirwere ichi kunofanirwa kuitwa nekuongororwa kwekiriniki, electrophysiology, biomarkers, uye imaging, zvese kuzivisa hama dzemurwere uye kubatsira vanachiremba kuti vatarise kurapwa zvichienderana nemikana yemurwere yekuwana kupora kwetsinga (Mufananidzo 3).
• Hapana kana imwe chete inofanotaura chirwere ichi yakarurama zvizere. Saka, tinokurudzira nzira yekufanotaura neural nervous ine maitiro akasiyana-siyana.
• Pakufanotaura migumisiro yakaipa yetsinga dzeropa, kunyatsojeka uye kururama zvinodiwa kuti pasave nekufungidzira kwenhema kusina tariro.
• Kuongororwa kwetsinga dzemuviri kwakakosha kuti pave neruzivo rwekuti chirwere chichaitika riini. Kuti vadzivise kufanotaura kusina tariro, vanachiremba vanofanira kudzivirira kuvhiringidzika kwemhedzisiro yebvunzo inogona kukanganiswa nemishonga inonyaradza uye mimwe mishonga.
• Kuongororwa kwekiriniki zuva nezuva kunokurudzirwa kana varwere vachirapwa neTTM, asi kuongororwa kwekupedzisira kwekufanotaura kunofanirwa kuitwa mushure mekudzoserwa mvura.
• Vanachiremba vanofanira kuziva nezvenjodzi yekusatendeseka kwezviporofita, izvo zvinoitika kana mhinduro dzebvunzo dzinoratidza mhedzisiro yakaipa dzichishandiswa mukusarudza kurapwa, kunyanya maererano nekurapa kunochengetedza hupenyu.
• Chinangwa chebvunzo yeNeuroprognosis Index ndechekuongorora kuoma kwekukuvara kweuropi kunokonzerwa nekushaya oxygen. Neuroprognosis ndeimwe yezvinhu zvakawanda zvekufunga nezvazvo pakukurukura mukana wemunhu wekupora.
Kufanotaura kwemamodheru akawanda
• Tanga ongororo yekufanotaura nekuongorora kwakarurama kwekiriniki, kunoitwa chete mushure mekunge zvinhu zvikuru zvinokanganisa (semuenzaniso, kuraramisa, hypothermia) zvabviswa (Mufananidzo 4)
• Kana pasina zvinokonzera kuvhiringidzika, varwere vane comatose vane ROSC ≥ M≤3 mukati memaawa 72 vanogona kuva nemigumisiro yakaipa kana paine zviratidzo zviviri kana kupfuura zvinotevera: hapana pupillary corneal reflex pa ≥ maawa 72, kusavapo kweN20 SSEP ≥ maawa 24, high-grade EEG > maawa 24, specific neuronal enolase (NSE) > 60 μg/L kwemaawa 48 uye/kana 72, state myoclonus ≤ maawa 72, kana diffuse brain CT, MRI uye extreme hypoxic injury. Zvizhinji zvezviratidzo izvi zvinogona kunyorwa maawa 72 asati aitwa ROSC; Zvisinei, mhedzisiro yavo ichaongororwa chete panguva yekuongororwa kwekiriniki.
Kuongororwa kwekiriniki
• Kuongororwa kwekiriniki kunogona kukanganiswa nemishonga inonyaradza marwadzo, opioid, kana mishonga inozorodza tsandanyama. Kuvhiringidzika kunogona kuitika nekuraramisa kunofanira kugara kuchifungwa uye kuchibviswa.
• Kune varwere vanoramba vari mukoma maawa makumi manomwe nemaviri kana kuti gare gare mushure meROSC, bvunzo dzinotevera dzinogona kufanotaura fungidziro yakaipa yetsinga.
• Muvarwere vanoramba vari comatose maawa makumi manomwe nemaviri kana kuti gare gare mushure meROSC, bvunzo dzinotevera dzinogona kufanotaura mhedzisiro yakaipa yetsinga:
- Kusavapo kwemaitiro emuviri wemwana ari pakati nepakati (bilateral standard pupillary light reflexes)
- Kuyera kwevadzidzi (quantitative pupilometry)
- Kurasikirwa ne corneal reflex kumativi ese
– Myoclonus mukati memaawa makumi mapfumbamwe nematanhatu (96), kunyanya state myoclonus mukati memaawa makumi manomwe nemaviri (72)
Tinokurudzirawo kunyora EEG kana paine myoclonic tics kuti uone chero chiitiko che epileptiform kana kuona zviratidzo zveEEG, zvakaita sekupindura kwemashure kana kuenderera mberi, zvichiratidza mukana wekupora kwetsinga.
neurophysiology
• EEG (electroencephalogram) inoitwa kuvarwere vanorasikirwa nepfungwa mushure mekumira kwemoyo.
• Maitiro eEEG ane njodzi huru anosanganisira mamiriro ekudzvanywa kwemasero ane kana asina kubuda ropa nguva nenguva uye kudzvanywa kwemasero. Tinokurudzira kushandisa maitiro aya eEEG sechiratidzo chekufanotaura kwakashata mushure mekupera kweTTM uye mushure mekunyaradza.
• Kuvapo kwechirwere chepfari paEEG mumaawa makumi manomwe nemaviri ekutanga mushure meROSC chiratidzo chekuti chirwere hachina kunaka.
• Kusavapo kwemhinduro yeruzivo rweEEG chiratidzo chekuti chirwere chemwoyo hachina kunaka mushure mekumira kwemoyo.
• Kurasikirwa kwe cortical N20 potential nekuda kwekunzwa kwemajoini maviri kunoratidza kuti hapana fungidziro yakanaka mushure mekumira kwemoyo.
• Mhedzisiro yeEEG uye somatosensory evoked potentials (SSEP) inowanzo tariswa kana tichitarisa kuongororwa kwekiriniki nedzimwe bvunzo. Mishonga inovhara tsinga dzemutsinga inofanirwa kutariswa kana SSEP yaitwa.
Zviratidzo zvehupenyu
• Shandisa nzira dzakasiyana-siyana dzekuyera NSE pamwe chete nedzimwe nzira dzekufungidzira mhedzisiro mushure mekumira kwemoyo. Kuwanda kwakakwira pamaawa makumi maviri nemana kusvika makumi mana nemasere kana maawa makumi manomwe nemaviri, pamwe chete nekuwanda kwepamusoro pamaawa makumi mana nemasere kusvika makumi manomwe nemaviri, zvinoratidza kuti chirwere hachina kunaka.
Kufungidzira mifananidzo
• Shandisa zvidzidzo zvekufungidzira uropi kufanotaura migumisiro yakaipa yetsinga mushure mekumira kwemwoyo pamwe chete nezvimwe zvinofanotaura mafambiro echirwere munzvimbo dzine ruzivo rwakakodzera rwekutsvagisa.
• Kuvapo kwekuzvimba kweuropi kwakapararira, kunoratidzwa nekudzikira kukuru kwehuwandu hwebvudzi/chena paCT yeuropi, kana kuderera kukuru kwehuwandu hwema "diffusion" paMRI yeuropi, kunoratidza kufambira mberi kwetsinga mushure mekumira kwemoyo.
• Zvakawanikwa pakufungidzira zvinowanzo fungidzirwa pamwe chete nedzimwe nzira dzekufanotaura mafambiro ezvirwere zvetsinga.
5. Rega kurapwa kunochengetedza hupenyu
• Kukurukurirana kwakasiyana kwekuongorora kwekufanotaura kwekurega kushandisa mushonga uye kupora kwetsinga dzeropa pakurapa kunochengetedza hupenyu (WLST); Sarudzo yeWLST inofanira kufunga nezvezvimwe zvinhu kunze kwekukuvara kweuropi, zvakaita sezera, zvirwere zvinosangana nazvo, mashandiro enhengo dzemuviri, uye kusarudzwa kwemurwere.
Ipa nguva yakakwana yekutaurirana, fungidziro yenguva refu mushure mekumira kwemoyo
Kurapwa kuri muchikwata kunosarudza uye • kunoongorora mashandiro emuviri neasiri ehama nehama. Kuona nekukurumidza zvinodiwa pakugadziriswa kwemuviri usati wabuda muchipatara uye kupa rubatsiro rwekugadziriswa kwemuviri kana zvichidikanwa. (Mufananidzo 5).
• Kuronga kushanya kwekutevera kune vese vakapona chirwere chemwoyo mukati memwedzi mitatu yekubuda muchipatara, kusanganisira zvinotevera:
- 1. Kuongororwa kwezvinetso zvepfungwa.
2. Kuongororwa kwezvinetso zvemanzwiro uye kuneta.
3. Ipa ruzivo nerutsigiro kune vakapona nemhuri.
6. Kupa nhengo dzemuviri
• Zvisarudzo zvese zvine chekuita nekupa nhengo zvinofanira kutevedzera zvinodiwa nemutemo netsika dzemunharaunda.
• Kupa nhengo dzemuviri kunofanirwa kufungwa nezvako kune avo vanosangana neROSC uye vanosangana nezvinodiwa zverufu rwetsinga (Mufananidzo 6).
• Muvarwere vane kufema kwemuviri vasina kuzadzisa zvinodiwa kuti vafe netsinga, kupa nhengo dzemuviri kunofanirwa kufungwa nezvazvo panguva yekumira kweropa kana sarudzo yaitwa yekutanga kurapwa kwekupedzisira kwehupenyu uye kurega kutsigira hupenyu.
Nguva yekutumira: Chikunguru-26-2024