Asian Case Reports in Emergency Medicine
Vol.05 No.01(2017), Article ID:20129,4 pages
10.12677/ACREM.2017.51001

Clinical Significance of Early Phase Endotracheal Intubation for Patients with Asphyxia Rescued through Cardiopulmonary Resuscitation

Yugang Guo1, Yang Wang2

1Emergency Department, Shanghai Jiangwan Hospital, Shanghai

2Emergency Department, Harbin Second Hospital, Harbin Heilongjiang

Received: Mar. 9th, 2017; accepted: Mar. 28th, 2017; published: Mar. 31st, 2017

ABSTRACT

Objective: To investigate the success rate of cardiopulmonary resuscitation by early endotracheal intubation for patients with asphyxia in emergency treatment. Methods: Retrospective analysis of clinical data from 86 cardiac arrest patients caused by asphyxia rescued in emergency room in two hospitals during the course from February 2008 to February 2015. Among these patients, 48 patients were treated with endotracheal intubation within 5 minutes of chest compression after heart arrest and 38 patients were given the same treatment after 5 minutes of chest compression. All patients were offered chest compressions, intravenous epinephrine, cardioversion and other life support treatments within indications. Results: 32 of 48 patients were successfully rescued with endotracheal intubation within 5 minutes (67% of successful rate) and 43 of 48 patients were responded by the same treatment (90% of response rate). In contrast, 3 of 38 patients were successfully rescued with endotracheal intubation after 5 minutes (8% of successful rate) and 20 of 38 patients were responded by the same treatment (53% of response rate). Conclusion: Early phase endotracheal intubation combined with regular cardiopulmonary resuscitation increased the success rate of cardiopulmonary resuscitation for cardiac arrest patients caused by asphyxia.

Keywords:Endotracheal Intubation, Chest Compression, Cardiopulmonary Resuscitation (CPR)

早期气管插管对心肺复苏抢救窒息病人的 临床意义

郭玉刚1,汪 洋2

1上海市江湾医院急诊科,上海

2哈尔滨市第二医院急诊科,黑龙江 哈尔滨

收稿日期:2017年3月9日;录用日期:2017年3月28日;发布日期:2017年3月31日

摘 要

目的:探讨早气管插管对提高急诊窒息病人心肺复苏(CPR)成功率的影响。方法:回顾性分析2008年2月到2015年2月两所医院急诊救治的86例因窒息导致心脏骤停患者。其中心脏骤停后胸外按压5分钟内给予气管插管术48例,超过5分钟以上时间给予气管插管术38例。所有病例均施与人工胸外心脏按压,肾上腺素静注,以及在适应症范围内电击复律等抢救措施。结果:因窒息导致的心脏骤停5分钟内给予气管插管术的48例中,32例复苏成功,成功率67%,有效43例(90%);超过5分钟以上时间给予气管插管术的38例中,抢救成功3例(8%),有效20例(53%)。结论:因窒息导致心脏骤停的病人早期进行气管插管术配合常规心肺复苏处理提高了心肺复苏的成功率。

关键词 :气管插管,胸外心脏按压术,心肺复苏(Cardiopulmonary Resuscitation, CPR)

Copyright © 2017 by authors and Hans Publishers Inc.

This work is licensed under the Creative Commons Attribution International License (CC BY).

http://creativecommons.org/licenses/by/4.0/

1. 引言

回顾两所医院2008年2月到2015年2月期间86例符合气管插管适应症并且无禁忌症的窒息所致心脏骤停患者急诊抢救的临床资料,根据所有病例中实施气管插管术的时间因素分析其对心肺复苏的抢救成功率的影响进行评估。现报告如下。

2. 临床资料和方法

2.1. 临床资料

男52例,女34例,年龄45~82岁,平均年龄78岁,脑梗塞后遗症进食不当窒息患者56例,肺部感染痰液阻塞所致窒息者24例,呕吐后出现窒息者3例,溺水1例,有机磷农药中毒1例,触电1例。所有病例资料均显示可排除气管插管术的禁忌症,其中,心脏骤停后胸外按压5分钟内给予气管插管术48例,超过5分钟以上时间给予气管插管术38例。

2.2. 诊断标准 [1]

意识突然丧失,伴有或不伴有全身性抽搐,呼吸断续或呼吸停止,大动脉搏动消失,血压测不出,心音消失,皮肤黏膜苍白或紫绀,瞳孔散大。心电图表现心室颤动或呈一直线。

2.3. 方法 [2] [3]

1) 常规人工胸外按压;2) 气管插管开放气道呼吸机辅助呼吸或面罩吸氧(严格按照气管插管的操作流程);3) 电除颤;4) 同时建立静脉通道,肾上腺素1 mg每3分钟一次连续三次静注,并以肾上腺素1 mg加入250 ml生理盐水中缓慢静点,维持循环,起搏心脏。辅以碳酸氢钠注射液1 mmol/kg静点,相当于5%碳酸氢钠注射液100 ml;5) 辅以保护脑肾功能。

3. 结果

呼吸心跳停止5分钟内给予气管插管的48例中,32例复苏成功,成功率67%,有效43例(90%);超过5分钟以上时间给予气管插管的38例中,抢救成功3例(8%),有效20例(53%)。

4. 讨论

1) 随着我国的老龄化进展,长期卧床的病人尤其是脑卒中所致卧床病人的增加,误吸引起的窒息的现象越来越多,即使是目前对吞咽功能的评估(洼田饮水实验 [4] )要求此类病人应以经鼻饲(经鼻胃管)来代替常规经口进食,但由于患者本人意愿以及舒适度情况,经鼻胃管饮食仍未能完全普及应用,由于误吸因素的存在,导致老年卧床病人的肺部感染风险性较前者有所增加,且痰液阻塞气道的发生率较以往研究相比明显增加 [5] 。另外一种情况就是胃内容物反流咽部阻塞气道。这种情况的发生比较少见,但由于老年病人的呼吸功能欠佳,仍能导致严重后果。

2) 基于上面讨论的情况,对于CPR抢救的因窒息导致心脏骤停患者,应争取早期插管,与此同时观察呼吸的情况及血氧饱和度。因脑血流中断10秒钟即出现可逆性脑损害,中断5分钟脑组织储备的糖原、ATP即将耗尽,能量代谢完全停止,神经细胞发生不可逆性损害,甚至导致不可避免性死亡,因有研究显示“黄金五分钟”内抢救成功率较高,故应及早进行抢救,提高心脏骤停患者成功率及生存率 [6] 。同时,我们通过观测呼吸状态及血氧饱和度检查来判定心肺复苏的效果。就气管插管在CPR中的时机和效果而言,有研究发现,在初期CPR中,简易面罩给氧足够,气管插管并非必须 [7] ,但不同原因引起心跳骤停的病人应需分别对待,尤其液体阻塞气道,气管插管不仅可保障其氧合功能也可同时吸出气道内异物,同时,对患者呼吸及有效循环的恢复也有着重要帮助。

3) 对因窒息导致心脏骤停患者实施CPR抢救,除有效的胸外心脏按压和电击除颤外,复苏成功之关键在于快速有效的人工通气。医院内紧急建立人工气道的首选方法是行气管插管机械通气。气管插管有利于气道内分泌物清除,通畅呼吸道,改善通气换气功能。同时通过气管内给药,快速吸收发挥作用;另一方面采用人工呼吸机保证足够的通气换气量,使机体有足够的氧供 [8] [9] 。有研究显示即使最有效的心脏按压也只能使心、肺、大脑和中枢神经系统的血液和氧供给维持较低水平,随心肺复苏时间延长,这种低水平血氧代偿功能也随之消失。因此,只有及时的气管插管供氧才能提高复苏成功率。本观察结果显示,胸外心脏按压5分钟内气管插管控制机械通气组的心肺复苏成功率明显高于5分钟后插管通气成功组。

急诊科病人多病情危重,随时会有呼吸心脏骤停的可能性,气管插管是保持机体通气及气道通畅的主要措施。急诊科医生要及早判断和掌握气管插管的时机、指征以及相关处理。在胸外按压时,如闻气道哈气声,可确认为有气流通过且呼吸道通畅,未闻及哈气声当考虑呼吸道梗阻,会严重影响心肺复苏的成功率。对于因窒息而发作的心脏骤停病人首先要摆正体位,使口腔,咽,气管呈一条直线,保持畅通气道,随时用手,吸引器或注射器清除口腔,咽、气管内异物、分泌物以及呕吐物。在抢救同时,迅速通知其他急救成员,尽早气管插管,连接简易呼吸器或呼吸机,恢复通气,防止呕吐物及胃内容物反流进入气道,以提高心肺复苏成功率。

文章引用

郭玉刚,汪 洋. 早期气管插管对心肺复苏抢救窒息病人的临床意义
Clinical Significance of Early Phase Endotracheal Intubation for Patients with Asphyxia Rescued through Cardiopulmonary Resuscitation[J]. 亚洲急诊医学病例研究, 2017, 05(01): 1-4. http://dx.doi.org/10.12677/ACREM.2017.51001

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