A 27-year-old man falls off a fishing boat and is rescued by prehospital providers after being submerged for 25 minutes in 3°C (37.4 ̊F) water. He is pulseless and, after defibrillation with an automated external defibrillator, there is a transient return of spontaneous circulation (ROSC) and cardiopulmonary resuscitation is continued. At hospital admission, his core temperature is 18.2°C (64.8°F), pupils are fixed and dilated, and ventricular fibrillation is identified. Multiple defibrillation attempts, along with the administration of advanced cardiac life support protocol drugs are unsuccessful at establishing ROSC. Laboratory results are: arterial blood gases, pH 6.71, partial arterial carbon dioxide pressure 75, partial arterial oxygen pressure 70, base excess -22.1 mmol/L; sodium 142 mEq/L, potassium 5.9 mEq/L, chloride 108 mEq/L, bicarbonate 10 mEq/L, lactate 18 mmol/L.
Which of the following is the most appropriate next step in management ?
A. Administer procainamide before making a defibrillation attempt.
B. Initiate rewarming with forced air, lavage of warm saline in the stomach, and infusion of warm saline IV.
C. Initiate venoarteria lextracorporeal membrane oxygenation support.
D. Obtain brain CT to identify irreversable changes secondary to hypoxia.
答案解析:
在水中浸没后,受害者最初屏住呼吸,然后典型的是喉痉挛、缺氧和高碳酸血症,然后引起喉部松弛,允许吸水。随着体温下降,正常窦性心律转变为窦性心动过缓,继而出现房颤、心室颤动和心搏停止。持续的重度酸中毒和低氧血症导致心肌膜不稳定,妨碍恢复正常的窦性心律。
在这种情况下,静脉-动脉体外膜肺氧合(V-A ECMO)将有助于复温,在恶性室性心律失常和重度酸中毒的情况下提供血流动力学支持,并进行氧合。在非低温诱导的院外和院内心脏骤停的情况下,V-A ECMO与10%-30%的存活率相关。只有在循环稳定的低温患者中,使用强制空气、IV液体、温热湿化气体以及胃和膀胱灌洗进行复温才有效。
在患者充分复温(超过30 ℃[86℉])之前,持续的除颤尝试不太可能成功。在18 ℃(64.4°F)时,大脑可以耐受比37 ℃长十倍的循环停滞期。瞳孔扩大可由多种损伤引起,绝不能视为死亡迹象。据报道,心脏骤停后神经功能恢复良好,长期CPR浸入冷水后核心温度为13.7 ℃(56.66℉)。因此,在复温努力失败之前,不应将患者视为死亡。
正确答案:C
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