Minicase 부정맥(Arrhythmias)

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1 심폐소생술 Cardiopulmonary Resuscitation (CPR) 김준수 성균관대학교의과대학내과학교실 삼성서울병원심장. 혈관센터순환기내과

2 돌연심장사 ( 突然心臟死 ) 란? 심장원인에의해예기치않게의식을잃고 1시간이내갑자기사망하는경우 수면중사망한경우

4 돌연심장사의주된부정맥 Ventricular fibrillation (VF) Rapid ventricular tachycardia (VT) Pulseless electrical activity (PEA) Asystole

5 미국 돌연심장사의발생빈도 돌연심장사는사망의중요원인 매년천명당 1명 ~ 2 명 ( 연간 30 ~ 35 만명 ) 국내 정확한통계없음 심장질환이사망원인중 3위 (2002 년통계청자료 )

6 돌연심장사의위험질환 관상동맥질환 협심증, 심근경색증 - 가장흔함 비후성심근증 판막성심질환 심부전 부정맥 심실빈맥, 심실세동, 브루가다증후군 대동맥질환 약물

7 돌연심장심장사의발생건수 심근경색후심실빈맥 / 세동에서회복기환자 병원외심정지에서소생한환자 좌심실기능저하 <30%, 심부전환자 과거관상동맥질환병력환자 관상동맥질환고위험환자 건강한성인

8 사례 1 평소건강한고등학교여학생 학교에서 800m 달리기도중갑자기쓰러짐 다른동료들그냥지나쳐감 환자얼굴이시퍼렇게변하고, 사지경련후호흡멈춤 뒤늦게달려온구급요원이환자응급실로후송 심전도기록상이미심장멈춘상태 의사가심장마사지, 인공호흡시작, 전기쇽치료 심장박동다시회복되었으나혼수상태로중환자실입원 심한뇌허혈로뇌부종발생, 인공호흡기로호흡유지 폐혈증발생 사망

9 사례 2 평소건강한대학교남학생 친구와병원옆을지나가다가갑자기쓰러지면서사지경련 환자즉시병원응급실로데려감 심전도기록상치명적인심실세동진단 의사즉각적으로전기쇽치료및심폐소생술시행함 중환자실입원후 2일째의식회복, 기억력장애 돌연심장사방지위하여삽입형제세동기시술 퇴원후 3개월째갑자기의식잃고쓰러짐 삽입형제세동기에서전기쇽이나가환자의식회복

10 사례 3 평소건강한고등학교남학생 학교에서 4명한조로하는달리기도중갑자기쓰러짐 체육선생이바로달려와즉각적으로심폐소생술시행함 119 구급대도착후심폐소생술하면서응급실로데려감 심전도기록상치명적인심실세동진단 의사즉각적으로전기쇽치료및심폐소생술시행함 중환자실입원후 3일째의식회복, 기억력장애남음 돌연심장사방지위하여삽입형제세동기시술 퇴원후 2년째갑자기의식잃고쓰러짐 삽입형제세동기에서전기쇽이나가환자의식회복

11 사례 4 평소빨리걷거나계단오를시흉통을느끼는 60 대남자 골프장에서티샷후걸어나감 2번째샷을준비중갑자기가슴을움켜잡고앞으로쓰러짐 주위동료들특별한조치못하고우왕좌왕함 심폐소생술시행치않고카트에환자실고나감 119 구급대가응급실로후송하였으나이미사망함 급성심근경색증에의한치명적인심실빈맥으로사망 의사환자사체영안실로보냄

12 사례 5 비교적건강한 40 대남자 밤에자다가갑자기괴성을지르고눈돌아가고사지경직됨 얼굴이시퍼렇게변하면서호흡멈춤 같이자던부인이소리에일어나환자가슴을두드림 수분뒤에환자갑자기푸하고숨을쉬면서의식을회복함 119 구급대불러응급실도착 환자의형이젊은나이에갑자기사망함 돌연심장사의위험도가높은브루가다증후군으로진단됨 삽입형제세동기시술받고퇴원함 퇴원후 2달째밤에자다가과거증상발생 삽입형제세동기에서전기쇽이나가환자의식회복

13 사례 6 과거유방암으로치료병력있는 60 대여자 물건들고계단올라와서있다가순간적으로쓰러짐 금방의식회복하였으나머리외상입음 순환기내과외래진료 운동부하검사시매우빠른비지속성심실빈맥유발됨 심실빈맥유발시약간현기증느낌 심전기생리학적검사시심실세동유발됨 환자의식잃고사지경련발생 환자가슴에부착한패취로전기쇽나가정상심박동으로됨 특발성심실세동으로삽입형제세동기시술받고퇴원함 퇴원후 5달째물건들고귀가하다가갑자기쓰러짐 삽입형제세동기에서전기쇽이나가환자의식회복

14 사례 7 2년전급성심근경증앓은 70 세남자 심장기능저하로인한호흡곤란으로외래에서약물치료중 간헐적으로발생하는가슴두근거림증상으로홀터검사함 검사상증상없이수초정도지속되는심실빈맥관찰됨 입원후심전기생리학적검사시심한어지럼증증상발생 증상발생시매우빠른심실빈맥이유발되어멈추지않음 환자가슴에부착한패취로전기쇽나가정상심박동으로됨 삽입형제세동기시술받고퇴원함 퇴원후 6달째친구와심한언쟁후심한어지럼발생 삽입형제세동기에서전기쇽이나가자증상없어짐

15 환자사례들에서관찰된소견 돌연심장사는예측하기어렵다. 심정지시즉각적인심폐소생술이환자의생명을구하는데큰도움을준다. 전문적인치료를할수있는병원에얼마나빨리도착하느냐가환자의예후에큰영향을준다. 돌연심장사의가족력이있거나, 흉통, 어지럼증, 실신등의증상이있으면절대무시하지말고순환기내과의사진료를받아야한다. 과거심근경색을앓고심장기능이저하된경우에는심한자각증상이없어도향후발생할수있는돌연심장사의위험도를평가받아야한다.

16 돌연심장사단계 심폐소생술 전구증상 ( 인공호흡및흉부마사지, 전기쇽치료 ) 치명적상황의시작 심정지 생물학적사망 수일 ~ 수개월 1 시간이내수분 ~ 수주

17 심폐소생술의중요성 적절한조치를받지않은병원외심정지환자의생존율은매우낮다. 6.4 % 이하 목격자에의해즉각적인심폐소생술, automated external defibrillator (AED) 시행된환자의생존율은높다. 49%-74%

18 심폐소생술의성공요인 계획된프로그램에의한심폐소생술자교육 Basic Life Support (BLS) Advanced Cardiovascular Life Support (ACLS) 심정지의즉각적인인지 목격자에의한즉각적인심폐소생술시행 심정지후 5분이내에전기충격 ( 제세동 ) AED 사용

19 2005 AHA Guidelines for CPR 효과적인 chest compression 의강조 Compression-to to-ventilation ratio 변경 Rescue breath over 1 second Single shock -> > immediate CPR -> > rhythm check 성인외에 1세-8세소아에서도 automated external defibrillator (AED) 사용재확인

20 Chest Compression Push hard and push fast Rate: 100/min (except newborns) Depth: 4 to 5 cm Produce visible chest rise Allow the chest to recoil completely Equal compression and relaxation times Try to limit interruptions in chest compressions & prevent compressor fatigue Change or rotate the compressor role about every 2 minutes The switch as quickly as possible ( ideally in less than 5 seconds) Resume compressions without checking for a pulse

21 Effect of Interrupting Compression (1) (Berg RA, et al. Circulation. 2001;104: )

22 Effect of Interrupting Compression (2) (Yu T, et al. Circulation 2002;106:368-72)

23 Effect of Interrupting Compression (3) P R O S C Hand-off time (sec) (Eftestol T,Sunde K, et al. Circulation 2002;105(19): )

24 Compression-Ventilation Ratio 30 : 2 ratio 1-rescuer or 2-rescuer 2 CPR for adults All lay rescuer 15 : 2 ratio 2-rescuer CPR for infants and children Ventilation 8 to 10 breaths per minute Reduce hyperventilation

25 Ideal Compression-Ventilation Ratio Expert rescuer Breathing time<5s Lay rescuer Breathing time<16s (Babbs CF &, Kern KB. Resuscitation. 2002;54(2): )

26 Types of Waveforms A msec

27 Recommended Energy for Initial Shock 150 J to 200 J for a biphasic truncated exponential waveform 120 J for a rectilinear biphasic waveform 360 J for a monophasic waveform 2J/kg for monophasic or biphasic waveform In children

28 Effect of Defibrillation Mode (Clark CB, et al. Resuscitation 2002;54: 183-6)

29 1-Shock versus of 3-Shocks3 Modern biphasic defibrillators can convert VF with one shock more than 90% of the time. Interrupting CPR between each shock adversely effects the outcomes of CPR. After VF is terminated, many victims have a nonperfusing rhythm for several minutes. There is no evidence that indicates that a 3-shock 3 algorithm improves outcomes of CPR.

30 Adult BLS Healthcare Provider Algorithm No No movement movement or or response response Phone Phone emergency emergency number, number, Get Get AED AED Open Open AIRWAY, AIRWAY, check check BREATHING BREATHING 2 2 BREATHS BREATHS Check Check pulse pulse within within sec sec No pulse Definite pulse COMPRESSIONS COMPRESSIONS and and 2 2 BREATHS BREATHS 1 1 breath breath every every 5 5 to to 6 6 sec. sec. Recheck Recheck pulse pulse every every 2 2 min. min. AED/defibrillator AED/defibrillator ARRIVES ARRIVES Shockable Check Check rhythm/shockable rhythm/shockable rhythm? rhythm? Not Shockable 1 1 shock shock Resume Resume CPR CPR immediately immediately for for 5 5 cycles cycles Resume Resume CPR CPR immediately immediately for for 5 5 cycles cycles Check Check rhythm rhythm every every 5 5 cycles cycles

31 ACLS Pulseless Arrest Algorithm Pulseless Pulseless arrest BLS, arrest BLS, Oxygen, Oxygen, monitor/defibrillator monitor/defibrillator Shockable VF/VT VF/VT Check rhythm/shockable rhythm? Check rhythm/shockable rhythm? Not Shockable Asystole/PEA Asystole/PEA 5 cycles of CPR 1 1 shock Resume shock Resume CPR CPR immediately immediately Check Check rhythm Shockable rhythm Shockable rhythm? rhythm? Shockable 5 cycles of CPR 1 1 shock Resume shock Resume CPR CPR immediately immediately vasopressor vasopressor Check Check rhythm Shockable rhythm Shockable rhythm? rhythm? Shockable Not Shockable 5 cycles of CPR Not Shockable 1 1 shock Resume shock Resume CPR CPR immediately immediately antiarrhythmics antiarrhythmics (Amiodarone (Amiodarone or or lidocaine) lidocaine) Resume CPR immediately for 5 cycles Resume CPR immediately for 5 cycles vasopressor Consider vasopressor Consider atropine atropine Not Shockable Check Check rhythm Shockable rhythm Shockable rhythm? rhythm? Asystole/PEA:go Asystole/PEA:go to to algorithm If algorithm If pulse pulse present, present, begin postresuscitation begin postresuscitation care care 5 cycles of CPR Shockable Follow VF/VT Follow algorithm VF/VT algorithm During During CPR CPR Do Do correct correct CPR CPR Minimize Minimize interruption interruption Search Search for for and and treat treat possible possible contributing contributing factors: factors: 6H 6H and and 5T 5T

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<C0CEC5CFBCF6B7C3B1B3C0B0C1F6C4A7BCAD2D28C3D6C1BEC3E2B7C2C8AEC0CE292D312DC3D62E687770> 인턴 수련교육 및 진료 지침서 53 15. 심폐소생술 심폐소생술(Cardiopulmonary Resuscitation, CPR)이란 심장이 멎은 사람에게 인 공호흡과 인공순환을 유지하여 주요 장기에 산소를 공급하는 치료 술기이다. 심폐소생술에 관한 표준 가이드라인의 국제화를 위하여 1993년에 미국심장학 회(American Heart Association,