[大都市地区心脏急症管理实验模型中的院外心脏骤停]

[Out-of-hospital cardiac arrest in an experimental model of the management of cardiologic emergencies in a metropolitan area].

作者信息

Casaccia M, Bertello F, Sicuro M, De Bernardi A, Scacciatella P

机构信息

Divisione di Cardiologia, Ospedale Maggiore S. Giovanni Battista, Torino.

出版信息

G Ital Cardiol. 1995 Feb;25(2):127-37.

PMID:7642017

Abstract

Since March 1992, an emergency medical system--EMS--(Servizio Emergenze Cardiologiche Territoriale, SECT) operates in the metropolitan area of Turin (130, 16 Km2), for a population of 964,000 inhabitants. SECT is based on a mobile intensive care unit, staffed with a physician and a nurse, trained in advanced cardiopulmonary resuscitation (CPR) and equipped to treat all cardiac emergencies. According to the "Utstein Style" we report the demographic and clinical features of the patients (pts) suffering Cardiac Arrest (CA) and the impact of SECT on out-of-hospital CA. During 26 months of activity, SECT performed 3,648 missions (most important among these: 457 acute myocardial infarction, 723 angina, 523 arrhythmias, 270 acute heart failure, 154 cardiac arrest), and managed 207 confirmed CA (154 calls for CA, 53 CA occurred after team arrival because of other symptoms). Resuscitation was attempted in 135 pts, in 72 pts medical personnel accerted an irreversible death state. 86% of CA occurred at home. In all cases a cardiac etiology was presumed. All CA were witnessed: 53 by EMS personnel, 82 by lay bystander. In 53 EMS witnessed CA, ventricular tachycardia (VT) or ventricular fibrillation (VF) was showed in 47.2%, asystole in 43.4%, other rhythms (Oth) in 9.4%. Return of spontaneous circulation (ROSC) was obtained in 52.8% pts, 76% in VT/VF Group. 43.4% were admitted alive to intensive care unit (ICU), 68% in VT/VF Group. 37.7% were discharged alive, 64% in VT/VF Group. In 82 lay witnessed CA initial rhythm was VT/VF in 31.7%, asystole in 59.7%, Oth. In 8.6%. CPR was attempted by lay bystander in 28% of cases. ROSC was obtained in 18.3%. CPR was attempted by lay bystander in 28% of cases. ROSC was obtained in 18.3% pts, 42.3% in VT/VF Group. 15.8% were admitted alive to ICU, 34.6% in VT/VF Group. 9.7% pts were discharged alive, 23% in VT/VF Group. Discharged alive rate in lay attempted CPR cases was 17.4%. The collapse-EMS CPR interval was 16 +/- 6.13 min (range 4-29), with a collapse-call receipt interval of 8.57 +/- 5.75 min (range 1-23) and a call receipt-EMS CPR interval of 8.06 +/- 3.56 min (range 2-19). The same intervals are significantly longer in not attempted CPR cases: respectively 26.53 +/- 10.73 min (range 10-65) -p < 0.001-, 19.29 +/- 11.3 min (range 5-60) -p < 0.001- and 8.26 +/- 3.96 (range 3-25) -p = NS-. Although far from the international effectiveness standards, SECT seemed to improve the out-of-hospital CA prognosis. High rate of CA occurred at home, time delay in early access link, better trend in survival in lay bystander attempted CPR cases and lack in early defibrillation lead to strategies for system improvement through targeted CPR training as well as semiautomatic external defibrillators introduction.

摘要

自1992年3月起，一个紧急医疗系统——紧急医疗服务（Servizio Emergenze Cardiologiche Territoriale，SECT）在都灵市区（面积13016平方公里）运行，服务人口达96.4万。SECT以一个移动重症监护单元为基础，配备一名医生和一名护士，他们均接受过高级心肺复苏（CPR）培训，并具备治疗所有心脏急症的设备。根据“乌斯坦模式”，我们报告心脏骤停（CA）患者的人口统计学和临床特征以及SECT对院外CA的影响。在26个月的活动期间，SECT执行了3648次任务（其中最重要的有：457例急性心肌梗死、723例心绞痛、523例心律失常、270例急性心力衰竭、154例心脏骤停），并处理了207例确诊的CA（154次CA呼叫，53例CA在团队到达后因其他症状发生）。对135例患者尝试进行复苏，72例患者经医务人员确认处于不可逆死亡状态。86%的CA发生在家中。在所有病例中均推测为心脏病因。所有CA均有目击者：53例由紧急医疗服务人员目击,82例由普通旁观者目击。在紧急医疗服务人员目击的53例CA中，室性心动过速（VT）或室性颤动（VF）占47.2%，心搏停止占43.4%，其他心律（Oth）占9.4%。52.8%的患者实现自主循环恢复（ROSC），VT/VF组为76%。43.4%的患者存活入院进入重症监护病房（ICU），VT/VF组为68%。37.7%的患者存活出院，VT/VF组为64%。在82例由普通旁观者目击的CA中，初始心律为VT/VF的占31.7%，心搏停止的占59.7%，其他心律的占8.6%。28%的病例由普通旁观者尝试进行CPR。18.3%的患者实现ROSC。28%的病例由普通旁观者尝试进行CPR。18.3%的患者实现ROSC，VT/VF组为42.3%。15.8%的患者存活入院进入ICU，VT/VF组为34.6%。9.7%的患者存活出院，VT/VF组为23%。普通旁观者尝试进行CPR的病例中存活出院率为17.4%。心脏骤停至紧急医疗服务CPR的间隔时间为16±6.13分钟（范围4 - 29分钟），心脏骤停至呼叫接收的间隔时间为8.57±5.75分钟（范围1 - 23分钟），呼叫接收到紧急医疗服务CPR的间隔时间为8.06±3.56分钟（范围2 - 19分钟）。在未尝试进行CPR的病例中，相同的间隔时间明显更长：分别为26.53±10.73分钟（范围10 - 65分钟）-p < 0.001-，19.29±11.3分钟（范围5 - 60分钟）-p < 0.001-，以及8.26±3.96分钟（范围3 - 25分钟）-p =无显著性差异-。尽管远未达到国际有效性标准，但SECT似乎改善了院外CA的预后。CA在家中发生的比例很高，早期接入环节存在时间延迟，普通旁观者尝试进行CPR的病例中生存趋势较好以及缺乏早期除颤，这些情况促使通过有针对性的CPR培训以及引入半自动体外除颤器来改进系统策略。