INVITED REVIEW online ML Comm J Neurocrit Care 2010;3 Suppl 2:S67-S74 ISSN 년미국심장협회심폐소생술및응급심혈관치료지침의주요내용 : 성인소생술을중심으로 가톨릭대학교의과대학응급의학교실 김영민

INVITED REVIEW online ML Comm J Neurocrit Care 2010;3 Suppl 2:S67-S74 ISSN 2005-0348 2010년미국심장협회심폐소생술및응급심혈관치료지침의주요내용 : 성인소생술을중심으로 가톨릭대학교의과대학응급의학교실 김영민 Brief Summary of Highlights in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: Focused on Adult Cardiopulmonary Resuscitation Young Min Kim, MD, PhD Department of Emergency Medicine, School of Medicine, The Catholic University of Korea, Seoul, Korea The recommendations in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care confirm the safety and effectiveness of many approaches, acknowledge ineffectiveness of others, and introduce new treatments based on intensive evidence evaluation and consensus of experts. In this review, the most significant developments in resuscitation science since 2005 are briefly discussed and the key issues and changes of adult cardiopulmonary resuscitation in the guidelines are summarized for healthcare providers. J Neurocrit Care 2010;3 Suppl 2:S67-S74 KEY WORDS: Cardiopulmonary resuscitation Guidelines. 서론 2010년은체외흉부압박에의한심정지환자의생존이처음으로문헌에보고된지 50주년이되는뜻깊은해이다. 지난 10월 18일 International Liaison Committee on Resuscitation(ILCOR) 는과학적근거를바탕으로한심폐소생술및응급심장치료에대한국제적치료권고합의문을발표하였고, 1 또한 American Heart Association(AHA) 및 European Resuscitation Council(ERC) 는각각새로운지침을발표하였다. 2,3 이번지침의개정작업은 2005년과비교해보다더근거중심의학적인방법으로진행되었다고볼수있는데, 277개의질문들에대해전세계 29개국가의 356명의저자들이작성한 411개의문헌고찰워크시트를전문가들 이검토하여완성한후 30개국의소생의학전문가들이모여합의회의를통해최종합의문이도출되었고, 이를바탕으로두소생술단체에서새로운지침들을만들어발표하게되었다. 우리나라도대한심폐소생협회를중심으로전문가개발회의및공개토론회를거쳐 2011년 2월에우리나라실정에맞는심폐소생술지침이개정, 발표될예정이다. 본글에서는먼저 2010년지침의변화에결정적인영향을준지난 5년동안의소생의학분야의가장중요한발전들을간략히알아보고, 이어 2010년 AHA 지침가운데의료인들이알고있어야할성인소생술에서의주요개정및재강조내용들과그에대한과학적근거들을요약, 정리해보도록하겠다. Address for correspondence: Young Min Kim, MD, PhD Department of Emergency Medicine, School of Medicine, The Catholic University of Korea, 505 Banpo-dong, Seocho-gu, Seoul 137-701, Korea Tel: +82-2-2258-6302, Fax: +82-2-2258-1997 E-mail: emart@catholic.ac.kr Copyright 2010 The Korean Neurocritical Care Society S67

J Neurocrit Care 2010;3 Suppl 2:S67-S74 2010 년지침의변화에결정적인영향을준지난 5 년동안의소생의학의중요한발전들 목격자소생술의효과의재확인및수행에영향을주는요인들에대한인식지난 5년동안심폐소생술의단순화와양질의기본소생술의중요성이지속적으로강조되어왔는데, 최근아시아국가의연구자들이보고한대규모관찰연구들 4-7 을비롯한몇몇연구들 8,9 은목격자심폐소생술이병원외심정지환자의생존율을향상시킬수있음을다시한번깨닫게해주었다. 또한성인심정지의경우흉부압박만을시행하는것이기존의방법 ( 구조호흡과흉부압박을병행하는 ) 과유사한결과를얻을수있을것으로인식되게되었다. 하지만소아의경우는기존의심폐소생술방법이여전히우월한것으로알려졌다. 4 심폐소생술질 (Quality) 의중요성재확인 2005년지침개정직전발표된병원외, 그리고병원내심폐소생술의낮은질에대한보고들 10,11 이후기본소생술의질을강조하고흉부압박의중단을줄이며한번의제세동만을시행하는전략이제세동의성공가능성을증가시키고, 환자의생존율을향상시킬수있었다는연구결과들이보고되었다. 12-14 또한소생술동안심폐소생술의질을인지하여되먹임해주는제세동기로부터얻어진자료들을이용해소생술팀이소생술후디브리핑 (debriefing) 을시행할경우병원내소생술의질이향상될수있다는보고로전문소생술훈련에서팀훈련과디브리핑의중요성이강조되게되었다. 15 병원내심정지및심폐소생술레지스트리의유용성인식비록관찰연구의한계점이있으나몇몇대규모병원내심정지및심폐소생술레지스트리자료를분석해보고된다양한연구결과들은병원내심정지의역학이나결과를파악하는데유용한정보들을제공해주었다. 16-22 소생술장비들이나전문소생술약물들에대한추가적인연구의필요성인식소생술장비들에대한몇몇연구보고들을통해그들의사용을권장하거나금지할근거가불충분함이인식되었고, 23-25 한무작위배정대조임상연구에서전문소생술약물들이자발순환회복은향상시키나장기적인심정지의예후에는영향을주지못함이보고되어전문소생술약물들에대한유용성이제고되고그를바탕으로잘설계된추가적인임상연구가 필요함이인식되었다. 26 심정지후집중치료의중요성및예후예측도구에관한추가적인연구필요성의인식저체온치료와함께혈역학적, 신경학적및대사기능을최적화하기위해여러전문영역이함께참여하는조직화된집중치료가심정지후자발순환을회복한혼수환자들의생존퇴원율을향상시킬수있음이보고되었다. 27-29 비록개별적인치료들의효과가아직까지명확히밝혀지지는않았지만자발순환회복후주요치료들을함께적용하는것이예후를향상시킬수있음을알게되었다. 특히저체온치료의경우한무작위배정대조시험 30 과준무작위배정대조시험 31 에서경도저체온치료가초기리듬이심실세동이나무맥성심실빈맥인혈역학적으로안정된병원외심정지후혼수환자들의퇴원및 6개월째신경학적예후를개선할수있음이증명된이후과거대조군을이용한두개의코흐트연구들 32,33 에서도저체온치료를받은심실세동에의한심정지환자들의신경학적예후가좋았던것으로나타나이러한환자들에대한 12~24시간의경도저체온치료의유용성을더욱지지해주었다. 또한동시대조군을이용한비무작위배정임상연구들 34,35 과과거대조군을이용한비무작위배정연구들 27,36-40 의결과를통해병원내및병원외모든심정지리듬환자들에게도저체온치료가도움이될수도있음이보고되었다. 한편저산소-허혈성뇌병증을동반한신생아들에서 72시간의경도저체온이안전하고좋은생존율이나신경학적예후와관련이있음이보고되었다. 41-44 소아심정지의경우는비록한후향적연구 45 에서저체온이도움이증명되지는못했지만현재전향적인다기관연구가진행중이어서그결과가기다려지는상황이다. 한편많은연구보고들을통해소생술후의미있는신경학적회복을보이지않는환자들에대한예후예측방법들이제시되어왔다. 46 하지만최근몇몇연구보고들 47-49 을통해저체온치료를적용받는환자들의경우는저체온치료를받지않았던환자들로부터얻어진기존의예후예측도구들이부정확할수있음이알려지면서추가적인연구의필요성이인식되었다. 교육의중요성인식기본소생술이나전문소생술에관한지식과술기능력이 3~6개월부터저하될수있음이알려지면서교육의질과재교육의중요성이강조되고, 몇몇보고들 50-55 을통해전문소생술교육에있어서팀워크나리더십기술을훈련하는것이중요함이인식되었다. S68

Summary of the 2010 AHA Adult CPR Guidelines YM Kim 2010 년 AHA 지침가운데성인소생술에서의주요개정및재강조내용 2010 년 AHA 심폐소생술및응급심장치료지침가운데 의료인이알고있어야할성인소생술의주요내용은각세부분야별몇가지변화된내용들과 2005년지침의권고사항이지속적으로강조되고있는내용으로요약해볼수있다. 기본소생술 (Basic life support) 기본소생술알고리듬이더욱단순화되었고, 호흡상태 확인 ( 보고, 듣고, 그리고느끼고 ) 과정은구조자마다다양하게적용되거나시간이소요될가능성이높아알고리듬에서제외되었다. 의료인은호흡이정지되었거나비정상적인호흡 (gasping) 상태의환자를발견할경우즉각적으로응급구조체계를가동하고자동제세동기를준비해야한다 ( 또는다른사람에게준비하도록요청한다 )(Class I). 몇가지연구들 56,57 에서의료인들도심정지환자에게서맥박을확인하는데어려움이있고시간이많이소요되는것으로보고되어, 의료인은맥박을확인하는데 10초이상걸려서는안되며 10초이내에맥박을확인하지못하면바로심폐소생술을시행하거나준비된자동제세동기를사용하는것이계속해서강조되었다 (Class IIa). 인공호흡을하기전에먼저흉부압박을시행하도록하였다 (A-B-C 순서에서 C-A-B 순서로바뀜 ). 물론인공호흡 2회보다흉부압박 30회를먼저시행하는것이더좋은결과를가져온다는근거는아직없지만, 흉부압박을시행하는것은심장이나뇌로혈류를공급할수있으며병원전성인심정지환자에대한연구들 5-7,58 에서목격자가심폐소생술을시행한경우시행하지않은경우보다생존율이더높았음을확인할수있었다. 한편동물연구들 59-61 과한임상연구 13 에서흉부압박시행이지체되거나중단될경우자발순환회복이나생존율이감소함을밝혀진후심폐소생술시행동안가능한지체나중단이발생하지않도록해야한다는것이 2005년이후지속적으로강조되고있는데흉부압박은거의즉각적으로시행될수있는반면기도개방이나구강인공호흡또는백마스크인공호흡과정은모두시간이소요될수있다. 따라서심정지초기가장중요한흉부압박시행의지체를줄이기위해인공호흡 2회에앞서흉부압박 30회를시행하도록하였다 (Class IIb). 정확한흉부압박시행 ( 충분한속도및깊이로압박하고, 압박간완전한흉부반동을시행하며, 흉부압박의중단을최소화하고, 과도한인공호흡을피함 ) 의중요성이더욱강조되었다. 흉부압박속도는분당약 100회에서분당최소한 100회로변경되었다 (Class IIa). 심폐소생술동안분당시행되는흉부압박수는자발순환회복및신경학적기능이유지된생존을결정하는중요한요소이다. 분당시행되는실제흉부압박수는흉부압박속도및흉부압박중단횟수와기간 ( 예 : 기도개방, 구조호흡시행또는자동제세동기분석 ) 에의해결정된다. 몇몇연구들 14,62 에서심폐소생술동안흉부압박시행횟수가많을수록생존율이높았고흉부압박시행횟수가적을수록생존율도감소하였다. 불충분한흉부압박속도또는자주발생하는중단 ( 또는둘모두 ) 은분당시행되는흉부압박수를감소시킨다. 따라서적절하게흉부압박을시행하기위해서는충분한흉부압박속도뿐만아니라흉부압박과정에서발생하는중단을최소화하는것모두가다시한번강조되었다. 성인의경우흉부압박깊이는기존 4~5 cm(1.5~2 inch) 에서최소한 5 cm(2 inch) 로약간변경되었다 (Class IIa). 깊이를범위로권장할경우혼란이생길우려가있으므로하나의흉부압박깊이를권장하게되었다. 기존지침에서흉부를힘껏누르도록권장되었지만구조자들은종종흉부를충분히압박하지않는것으로알려졌고, 63 또한흉부 CT를분석한한연구 64 에서 4~5 cm은성인흉부전후직경의약 1/5 만을누르게된다고보고되었다. 한편제세동기에기록된자료들을분석한한연구 65 에서는 5 cm 이상의깊이로압박한경우가그이하로압박한것보다제세동에의한자발순환회복가능성이높았던것으로보고되었고, 병원내소생술에디브리핑을적용한한연구 15 에서흉부압박의깊이를평균 5 cm으로교정한경우가교정전에비해자발순환회복율이높았던것으로나타났다. 이러한이유로이번지침에서는성인흉부압박깊이를하나로지정하였고기존지침보다더깊은흉부압박을권고하게되었다. 마지막흉부압박과전기충격간의시간, 전기충격전달간의시간및전기충격전달후즉각적인흉부압박재개까지의시간을최소화하는것이계속해서강조되었다 (Class IIb). 팀단위소생술이보다강조되었다. 소생술상황에따라단일구조자가도움을요청하는것으로시작하는경우도있지만여러명의구조자에의해함께시행되는경우가많다. 여러명의구조자가있을경우팀리더를선정함으로써팀을구성하는데중점을두어야한다. 추가인력이도착하면보통적은수의구조자가차례로시행해야하는임무가각팀원에게배분되어동시에시행될수있다. 예를들어, 한팀원이응급구조체계를가동하는동안다른팀원은흉부압박을시행하고, 세번째팀원은인공호흡을시행하거나인공호흡을위한백마스크를준비하며, 네번째팀원은자동제 S69

J Neurocrit Care 2010;3 Suppl 2:S67-S74 세동기를찾아준비한다. 따라서의료인들을위한소생술교육에는개별적인구조활동에대한훈련뿐만아니라효율적인팀단위훈련이반드시포함되어야한다 (Class I). 심정지상태에서인공호흡동안윤상연골을압박하는방법은권장되지않았다. 윤상연골압박은위확장을방지하며백마스크인공호흡동안역류및흡인의위험을감소시키는목적으로시행되지만인공호흡을방해하기도한다. 무작위배정연구결과들 66,67 에따르면윤상연골압박은전문기도확보를지체시키거나방해할수있으며시행하더라도흡인이발생할수있다. 또한구조자를적절하게교육시키기도쉽지않다. 68,69 따라서심정지상태에서윤상연골압박은더이상권장되지않는다 (Class III). 전문소생술 (Advanced life support) 정량적인파형이산화탄소측정기 (capnography) 가기관내관위치확인 (Class I) 및심폐소생술정확도의확인및감시 (Class IIa) 를위해권장되었다. 지속적인파형이산화탄소측정기는기관지내삽관의정확한위치를확인하고감시할수있는가장신뢰할수있는방법으로여러연구들을통해알려졌다. 70,71 기관지내삽관위치를확인할수있는다른방법들이있지만지속적인파형이산화탄소측정기보다는신뢰성이떨어진다. 특히이송도중에는기관내관의위치가변화될수있으므로구조자는삽관의정확한위치를확인하고감시하기위해지속적인파형을관찰해야한다. 이산화탄소가배출되고측정되려면폐순환이이루어져야하므로정량적인파형이산화탄소측정기는흉부압박의정확도및자발순환회복을인지하는생리학적탐지기로이용될수도있다. 환자특성이나구조자심폐소생술시행능력으로인한부적절한흉부압박은낮은 PETCO 2 를초래하게된다. 72 반대로자발순환회복은 PETCO 2 의급격한증가를야기할수있으며또한자발순환이회복된환자에서심박출량이떨어지거나다시심정지가발생되면또한 PETCO 2 가감소하게된다. 73,74 전문소생술알고리듬도보다단순화되었고, 정확한심폐소생술의중요성이계속해서강조되었다. 아트로핀을무맥성심율동 (PEA)/ 무수측 (asystole) 치료에통상적으로사용하는것을더이상권장하지않았다. 세개의연구들 75-77 에서심정지에서아트로핀의사용이소생가능성과는관련이없는것으로보고된바있고, 추가로진행된몇몇연구들에서는아트로핀의사용이나쁜생존율과관련이있는것으로보고되어, 78,79 이번지침에는그사용이제한되게되었다 (Class IIb). 한무작위배정대조임상연구에서장기적인예후에차이가없었고, 80 아트로핀에반응하지않는환자들에서도파민과경피심박조율을비교한연구에서도생존퇴원에차이가없어, 81 불안정한서맥에서아트로핀의효과가없는경우경피적심박조율의대안으로심박수를증가시킬수있는약물들 ( 도파민혹은에피네프린 ) 의사용이권장되었다 (Class IIb). 300명이상의환자가포함된다섯개의연구들 82-86 에서아데노신이이경우에안전하게사용되었던것을바탕으로미분화규칙적이고안정된넓은 QRS 빈맥 (undifferentiated regular stable wide-qrs tachycardia) 의초기치료및진단을위해안전하고효과적인방법으로아데노신의사용이권장되었다 (Class IIb). 심정지후집중치료 (Post-cardiac arrest care) 2010년 AHA 심폐소생술및응급심장치료지침에서는심정지후집중치료가심정지환자의생존율을높이고신경학적예후를향상시키는매우중요한과정으로인식되어, 소생의고리 (chain of survival) 의새로운다섯번째고리로지정되었고, 지침에서독립된장 (part) 으로분리되어기술되었다. 심정지후집중치료의목표를구체화하였다. 순환회복직후에는 1) 심폐기능과활력징후를정상화하여주요기관으로의관류를정상화하고, 2) 관상동맥중재술, 신경학적치료, 저체온치료, 목적-지향중환자치료 (goal-directed critical care) 를포함한포괄적인소생후치료가가능한병원또는시설로혹은병원내장소로환자를이송하여야하며, 3) 심정지의원인을찾아치료함으로써심정지의재발을막아야한다. 이어서즉시 1) 생존과신경학적회복을돕기위해체온조절을시작하고, 2) 급성관상동맥증후군을진단하고치료하며, 3) 최적화된기계호흡으로폐손상을최소화하고, 4) 다발성장기부전의발생을최소화하며필요한경우장기기능을유지시키며, 5) 신경학적예후를객관적으로평가하고, 6) 필요시생존자의재활치료를돕는다 심정지후집중치료시스템을갖출것을권고하였다. 심정지후집중치료는저체온치료, 혈역학적안정화와호흡치료, 즉각적인관상동맥중재술, 혈당조절, 신경학적진단및치료, 그리고예후평가등을포함하는포괄적이고체계적인다학제적치료시스템을필요로하는과정이다. 심정지환자를포괄적으로치료할수있는병원을지정하여심정지로부터소생된환자를전문적으로치료하거나병원내에서도체계화된프로토콜을사용하여치료할경우에심정지환자의생존율을높일수있는것으로알려졌다. 27-29 따라서이번지침에서는심정지로부터소생된환자를포괄적이고전 S70

Summary of the 2010 AHA Adult CPR Guidelines YM Kim 문적인집중치료가가능한병원으로이송하도록권장하며, 병원내에서는심정지후집중치료가가능한진료시스템을갖추도록권고하였다 (Class I). 저체온치료및체온조절의중요성이더욱강조되었다. 2005년지침에서와같이 2010년지침에서도심정지로부터소생된후의식이없는환자에서는 12~24시간동안 32~ 34 의저체온요법을하도록권장하였다. 심실세동에의한병원외심정지환자에서저체온요법의효과를보고한두개의무작위연구들 30,31 이후로심실세동과그외의심전도리듬이관찰된심정지환자나병원내심정지환자에서도저체온요법이예후에도움이될수있다는보고들 34-40 을바탕으로심실세동에의한병원외심정지는 Class I으로권고수준이상향조정되었고, 그외리듬에의한심정지나병원내심정지는계속적으로 Class IIb로권고되었다. 한편소생후발생한고열 (37.6 이상 ) 은신경학적예후에나쁜영향을주므로역시적극적으로치료할것을권고하였다 (Class I). 장기별평가와치료가구체적으로강조되었다. 급성관상동맥증후군은가장흔한심정지의원인이므로심정지로부터소생된모든환자는심전도와심장표지자 (cardiac biomarker) 검사를시행하여야한다 (Class I). 심정지로부터회복된초기한시간이내에는환자의신경학적예후를예측할수없으므로, 심전도상 ST분절상승이나좌각차단이관찰되는경우에는즉시경피관상동맥중재술을시행하여야한다. 심정지환자에서는급성관상동맥허혈의발생빈도가매우높기때문에 ST분절의상승이관찰되지않더라도경피관상동맥중재술을시행하는것이도움이될수있으며, 87,88 심근경색으로인한심정지후경피관상동맥중재술과저체온치료를동시에시행하는것도안전할수있다. 89-91 소생술후에폐의환기-관류장애로인하여저산소증이발생하는경우는흔치않다. 급성폐손상의발생여부는흉부방사선촬영, PaO 2/FIO 2 ratio를확인함으로써직, 간접적으로예측할수있다. 기계호흡은폐손상을최소화할수있도록 6~8 ml/kg의일회호흡량과흡기고원압 (inspiratory plateau pressure) 를 30 cm H 2O 이하로유지하도록한다. 92 정상뇌에서는동맥혈이산화탄소압이 1-mmHg 감소할때마다뇌혈류량이 2.5~4% 씩감소하는것으로알려졌으며, 소생술후상태에도동맥혈이산화탄소압의감소는뇌혈류량을감소시킨다. 93,94 따라서동맥혈이산화탄소압의감소는반드시피해야하며 (Class III), 동맥혈이산화탄소압은 40~45 mmhg범위내에서유지한다 (Class IIb). 동맥혈산소포화도가 100% 로유지될경우뇌손상을초래할수있다는연구결과들 95-100 이있으므로, 흡기산소의농도는동맥혈산소포화도를 94% 이상으로유지할수있도록조절 한다 (Class I). 자발순환회복후에는흔히혈역학적으로매우불안정한상태가발생하며, 일시적인심근기절 (myocardial stunning) 현상에의한심근수축력에장애가발생한다. 따라서혈역학적안정화를위하여수액및혈압상승제의투여를통하여혈압, 심박출량을정상화하고조직으로의관류를유지하여야한다 (Class I). 비록주요임상연구들 27,29 에서이상적인혈압이나산소포화도가확립되지는않았으나일반적으로평균동맥압은 65 mmhg 이상으로유지하고중심정맥혈산소포화도 (ScvO 2) 를 70% 이상으로유지하는것이권장된다. 자발순환회복후높은혈당은생존율과신경학적예후에나쁜영향을준다는보고들 101-103 이있지만, 소생후적절한혈당수준이나조절전략은아직까지밝혀지지않았다. 또한적극적으로정상수준의혈당을유지하는것이신경학적예후를호전시키는지에대한분명한증거는없으며, 정상수준의혈당을유지하는과정에저혈당의발생율이높아지는것으로알려졌다. 104 따라서이번지침에서는소생후혈당을 144~180 mmhg로유지하도록권장하고있으며 (Class IIb), 혈당을정상범위 (80~110 mmhg) 로조절을시도하는것은권장하지않는다 (Class III). 저체온치료에따른기존신경학적예후예측지침의적용을신중히할것이강조되었다. 운동반응및반사검사, 뇌파검사, 체감각신경유발전위검사 (somatosensory evoked potentials) 등은소생후신경학적예후를예측하는인자로활용되어왔다. 그러나심정지로부터소생된대부분의환자에서저체온치료가시행되면서기존에알려진신경학적예후의예측인자에의하여나쁜예후가예측되었으나, 혼수상태로부터신경학적으로회복된환자들의예가보고되고있다. 47-49 따라서저체온치료가시행된환자에서는나쁜예후를판단하는데있어자발순환회복후 72시간이상의관찰을통하여신경학적예후에대한예측을하도록권장되었다 (Class I). 결 추가된과학적근거들을바탕으로새로이개정된 2010년지침이많은구조자들과의료인들에게교육되고임상에적극적으로적용되어보다많은심정지환자들이생존할수있게되기를기대한다. REFERENCES 1. Hazinski MF, Nolan JP, Billi JE, Böttiger BW, Bossaert L, de Caen AR, et al. Part 1: executive summary: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular 론 S71

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