急诊科心肺复苏注册登记及复苏质量录像分析

Cardiopulmonary resuscitation registry and video records analysis of cardiopulmonary resuscitation performance in emergency department

目的：有效记录心肺复苏（CPR）全过程，分析比较医护人员的复苏表现，查找和发现存在的问题，为改进CPR工作提供依据，以提高CPR质量，改善患者存活率。方法采用Utstein模式注册登记和录像方法记录急诊科CPR过程，分析CPR10min内无胸外按压时间，安装机械装置、气管内插管和建立静脉通道需要时间，并对影响复苏效果的各因素进行多元回归分析。结果①2009年12月至2015年12月共注册登记376例心搏骤停（CA）患者，其中男性248例，女性128例；年龄68（53，78）岁；估计CA至开始复苏时间5.0（0.1，20.0）min，≤5min者189例；CA主要病因为急性心肌梗死（145例，占38.6%）。230例院外心搏骤停（OHCA）患者初始可电击心律16例（7.0%），其中心室纤颤（室颤）13例（5.7%），室性心动过速（室速）3例（1.3%）。146例院内心搏骤停（IHCA）患者初始可电击心律47例（32.2%），其中室颤40例（27.4%），室速7例（4.8%）。机械胸外按压219例（58.2%）。376例患者中自主循环恢复（ROSC）186例（49.5%），复苏成功（ROSC维持≥24h）110例（29.3%），住院治疗99例（26.3%），存活出院40例（10.6%）。146例IHCA患者中ROSC89例（61.0%），复苏成功63例（43.2%），住院治疗56例（38.4%），存活出院29例（19.9%）。230例OHCA患者中ROSC89例（38.7%），接受院前CPR65例（28.3%），复苏成功47例（20.4%），住院治疗43例（18.7%），存活出院11例（4.8%）。53例室颤患者中复苏成功37例（69.8%），存活出院25例（47.2%）。②可用于录像分析的有效病例77例，其中OHCA48例，IHCA29例。从患者就诊至安排到抢救床上延迟时间22（0，33）s，CPR10min内无胸外按压时间41（18，90）s，机械CPR安装时间43（31，69）s，气管插管时间59（35，109）s，建立静脉通道时间112（70，165）s。多元回归分析显示，CA时间、无胸外按压时间对复苏成功率（t1＝-3.452、t2＝-2.729）、存活出院率（t1＝-2.328、t2＝-2.736）有明显影响（均P＜0.05）；进一步分析显示，CA时间对OHCA患者复苏成功率有显著影响（t＝-2.409、P＝0.021），无胸外按压时间对IHCA患者复苏成功率、存活出院率有显著影响（t1＝-3.412、t2＝-2.536，均P＜0.05）。结论 CA至开始CPR时间和无胸外按压时间均是影响CA患者能否存活出院的关键因素。为减少无胸外按压时间，IHCA实施CPR时应推迟安装机械复苏装置。

Objective To effectually record cardiopulmonary resuscitation （CPR） procedure, analyze and compare the CPR performance of all medical and nursing staffs to find out the existed information for the improvement of the quality of CPR and its survival rate. Methods The medical data were collected according to the Utstein Criteria and CPR event was automatically recorded by a digital video-recording system, by which hands-off times within 10 minutes of CPR and times for installation of chest compression machine, establishment of endotracheal intubation and establishment of the venous channel were analyzed. Multiple regression analysis was conducted to analyze the factors affecting CPR effect. Results ① During the period from December 2009 to December 2015, a total of 376 patients with cardiac arrest （CA） was registered, including 248 males and 128 females, with a median age of 68 （53, 78） years. Estimated median time interval from CA to CPR initiation was 5.0 （0.1, 20.0） minutes and there were 189 cases less than or equal to 5 minutes. The acute myocardial infarction （AMI） with 145 cases （38.6%） was the main etiology of CA. Initial shockable rhythm was found in 16 patients （7.0%） out of 230 out-of-hospital cardiac arrest （OHCA） patients, of whom 13 underwent ventricular fibrillation （5.7%）, 3 underwent ventricular tachycardia （1.3%）. Initial shockable rhythm was found in 47 patients （32.2%） out of 146 in-hospital cardiac arrest （IHCA） patients, of whom 40 underwent ventricular fibrillation （27.4%）, and 7 underwent ventricular tachycardia （4.8%）. CPR by a mechanical device （Thumper） was performed in 219 patients （58.2%）. In 376 patients, 186 patients had return of spontaneous circulation （ROSC, 49.5%）, a successful CPR （ROSC ≥ 24 hours） was found in 110 patients （29.3%）, 99 patients was hospitalized alive （26.3%） and 40 patients were discharged alive （10.6%）. In 146 cases of IHCA, 89 patients had ROSC （61.0%）, a successful CPR was found in 63 patients （43.2%）, 56 patients were hospitalized alive （38.4%）, and 29 patients were discharged alive （19.9%）. In 230 patients of OHCA, 89 patients had ROSC （38.7%）, 65 patients received pre-hospital CPR （28.3%）, a successful CPR was found in 47 patients （20.4%）, 43 patients were hospitalized alive （18.7%）, and 11 patients were discharged alive （4.8%）. There were 37 patients had a successful CPR （69.8%）, and 25 patients were discharged alive （47.2%） in 53 patients with ventricular fibrillation. ② There were 77 patients with valid video information for analysis of CPR performance, with 48 patients of OHCA, and 29 patients of IHCA. Delay median time from the patients presence in the resuscitation room to be placed in rescue bed was 22 （0, 33） seconds. Hands-off median times during 10 minutes of CPR was 41 （18, 90） seconds. Thumper installment median times was 43 （31, 69） seconds. Median time for endotracheal intubation was 59 （35, 109） seconds. Median time of venous catheter placement was 112 （70, 165） seconds. It was shown by multivariate regression analysis that there was a significant correlation between estimated time interval from CA to CPR performed, hands-off time and success rate of CPR （t1 = -3.452, t2 = -2.729）, rate of discharge alive （t1 = -2.328, t2 = -2.736, all P 〈 0.05）. In 48 OHCA patients, success rate of CPR was significantly correlated with estimated time interval from collapse to CPR performed （t = -2.409, P = 0.021）. In 29 IHCA patients, success rate of CPR and rate of discharge alive was significantly correlated with hands-off times （t1 = -3.412, t2 = -2.536, both P 〈 0.05）. Conclusions Survival to hospital discharge following CA is significantly correlated with the time interval from collapse to CPR performed and hands-off times in CPR. Installment and usage of Thumper should be postponed in order to reduce hands-off times during CPR in IHCA.