急性心肌梗死经创伤性心肺复苏后溶栓治疗的可行性探究

Study of thrombolytic therapy on acute myocardial infarction following traumatic cardiopulmonary resuscitation

目的 探究急性心肌梗死（AMI）患者经有创伤的心肺复苏（CPR）后溶栓治疗的临床可行性.方法 回顾性分析11例猝死后经CPR成功的AMI患者,复苏中所有患者接受胸外按压15～30 min及实施呼吸机通气,气管内插管6例,气管切开造瘘5例,锁骨下静脉穿刺置管9例,颈内静脉穿刺置管2例,经锁骨下或颈内静脉植入心脏临时起搏器10例,脑脊液穿刺检查6例,心包腔穿刺引流3例.溶栓采用重组人组织纤维蛋白溶酶原激活物（rt-PA）：50 mg静脉内泵入.观察经CPR后溶栓治疗的自主循环恢复（ROSC）率、呼吸功能改善率、出血发生率、心脏不良事件发生率和成活率等.结果 急性期死亡1例,后期（〉72 h）死亡2例,3例患者分别于两周均参与炎症因子分泌及调控,同时,在此通路中,Toll作用蛋白（Tollip）与热休克蛋白90（HSP90）等生物分子同样可以引起炎性因子分泌的变化[13,14],研究显示,重症脓毒症患者更加严重的免疫抑制现象存在一个复杂的调控机制,难以用单一的TLR4受体表达改变解释,仍需进一步加以研究.后接受择期PCI术,8例患者最终出院.结论 经创伤性CPR后的AMI患者给予静脉溶栓治疗,未发生与出血直接相关的临床死亡,溶栓后心脏不良事件发生少且易救治,可提高患者的生存质量.

Objective To explore the clinical feasibility of thrombolytic therapy of acute myocardial infarction （AMI） following the traumatic cardiopulmonary resuscitation （CPR）. Methods In this retrospective study, 11 cases of sudden death with AMI were performed external chest compression for 15 - 30 minutes and mechanical ventilation during resuscitation. Of them 6 cases accepted endotracheal intubation and 5 cases tracheotomy; 11 cases center venous catheter （9 cases via subclavicular vein, 2 eases via intrajugular vein）. 10 cases were implanted temporary cardiac pacemaker at bedside, 6 cases were drawn cerebral spinal fluid in lumber vertebra and 3 cases were carried out pericardiocentesis. Under the stable condition, all the patients received rt - PA 50 mg intravenously after resuscitation. The restoration of spontaneous circulation （ ROSC）, respiratory restoration, the incidence of bleeding and adverse cardiac events, the survival rate at the emergency stage were assessed. Results During follow up, one case died at the emergency stage, two cases died after 72 hours. 8 cases showed better clinical outcome and discharged from hospital （3 cases received PCI）. Conclusion The thrombolytic treatment of acute myocardial infarction following the traumatic cardiopulmonary resuscitation can improve the living quality and without any adverse result from thrombolytic therapy.