Objective:To understand the cognition and training status of basic life support among medical staff in Linfen, Shanxi Province, and to provide reference for the development of targeted training strategies and programs.Methods:A questionnaire survey was conducted among medical staff in 12 county hospitals in Linfen, Shanxi Province by convenience sampling method. The survey included the general characteristics of departments and medical staff, previous basic life support training assessment and cognitive status.Results:A total of 839 medical staff were included, 756 (90.1%) completed the survey, 183 (24.2%) were doctors and 573 (75.8%) were nurses. Most personnel lacked awareness of environmental safety, emergency response system start-up, adequate compression, airway management, and electrical defibrillation.Conclusions:The cognitive status of basic life support of medical staff in Linfen county is not optimistic. It is necessary to construct an applicable precision training course and retraining assessment system to improve the cognitive level and practical operation ability.

目的 了解急诊医生心脏骤停患者脑保护的认知和实践情况.方法 通过问卷调查的方式进行,在全国范围内随机选取75家医院,参研医院所有的急诊科医生均参与调查研究.结果 共有1473名受访者参与研究,应答率为92.1％.89.4％受访者认为目标温度管理(target temperature management,TTM)有助于改善心脏骤停患者的神经功能,但仅有15.5％的急诊科及27.8％的受访者在临床实践中实施过TTM.对于理论上有脑保护作用,但目前缺乏相关证据支持的药物和措施,绝大多数受访者认为有脑保护作用并应用于临床实践中,应用最为普遍的三磷酸腺苷(85.9％)、减轻脑水肿的药物(73.5％)、自由基清除剂(70.8％)、营养神经药物(66.4％)、高压氧治疗(60.0％)及线粒体保护剂(45.6％).结论 急诊医生对TTM认知程度有很大改观,但实践情况仍然不理想,临床上更多选择理论上有保护作用但目前尚无确切证据的措施.

临床上常见混合药物中毒，地高辛为常见的中毒药物之一。地高辛用途广泛、容易获得，因此容易被滥用于自杀或谋杀 [1]。地高辛中毒,可影响消化系统、神经系统及心脏传导系统，严重者可导致心脏骤停（cardiac arrest，CA），即使在充分复苏的条件下过量的地高辛仍阻碍自主循环的恢复，但这是一种可逆病因，强化的药物清除能够有效降低地高辛药物浓度，但该过程需要花费时间。体外心肺复苏（extracorporeal cardiopulmonary resuscitation，ECPR）技术可以作为药物清除期间有效的心肺支持技术。本文报道1例以地高辛中毒为主要表现的混合药物中毒所致难治性CA的患者，使用ECPR、目标温度管理（Targeted temperature management，TTM）及血液净化技术，最终恢复神经功能。

心脏骤停复苏后昏迷患者的神经功能评估至关重要,不仅有助于避免有脑复苏可能的患者过早地撤除生命支持手段,导致不必要的死亡,而且有助于早期识别没有脑复苏希望的患者,优化医疗资源利用.早期神经功能评估是目前心肺复苏领域的难点,由于没有任何单一方法可直接评估神经功能预后,因此推荐综合临床、脑部影像学、血清学标志物、电生理检查等方面进行多模态神经功能评估.北京大学第三医院急诊科作为心肺脑复苏中心,综合国内外指南、研究进展及临床经验,制定了心脏骤停患者多模态神经功能评估规范,旨在为同行评估复苏后昏迷患者神经功能提供借鉴.

目的 调研使用不同调度系统的急救人员对电话指导心肺复苏(TCPR)的认知度和实施现状,探讨医疗优先调度系统(MPDS)对TCPR认知和实施的影响.方法 采用多中心的横断面调查研究,以方便抽样的方法从中国六大地理分区中分别抽取共计20个急救中心,通过匿名在线电子问卷的方法调查使用不同调度系统的急救人员对TCPR的认知及实施情况.结果 共1191人填写问卷,TCPR的知晓率为80.94％.960人知晓TCPR且问卷填写完整纳入研究.根据使用的调度系统分为MPDS组(438人)和对照组(522人).①MPDS组对无呼吸(48.63％vs.39.66％,P=0.005)的判定标准能够正确认知的比例,对TCPR流程中指导人工呼吸(78.31％vs.71.84％,P=0.021)、安抚旁观者情绪(48.40％vs.41.95％,P=0.045)和监测心肺复苏(CPR)质量(40.87％vs.33.14％,P=0.013)三个环节的认知度均高于对照组.②MPDS组中总是(25.57％vs.14.56％,P<0.001)和经常(24.20％vs.16.48％,P=0.003)电话判断心脏骤停率,总是(40.05％vs.20.39％,P<0.001)实施TCPR率,总是(18.90％vs.6.00％,P<0.001)、经常(14.52％vs.6.00％,P<0.001)和有时(18.08％vs.12.00％,P=0.023)指导AED使用率均高于对照组,而单纯按压的指导率低于对照组(23.01％vs.36.86％,P<0.001).③对MPDS的满意率(非常满意和比较满意)为80.36％,不满意的主要原因依次为指导CPR效率低(43.06％)、需要使用大量时间解释问题(41.67％)和容易使旁观者产生不耐烦情绪(33.33％).结论 中国急救人员对TCPR的认知度高,但TCPR的实际实施率低.使用MPDS有利于提高TCPR的实施率和实施质量.MPDS中的标准化问题、固定预案和实施流程,有利于准确识别心脏骤停、TCPR的启动、CPR的实施和质量控制、自动体外除颤器(AED)的使用.

目标温度管理是心脏骤停复苏后昏迷患者的重要治疗手段,能够减轻神经系统损伤,改善神经功能预后.我国心脏骤停后的目标温度管理起步较晚,临床医师对其认识不充分,尚未形成规范化的治疗方案.北京大学第三医院急诊科是国内率先开展目标温度管理的单位之一,制定了标准化的实施规范和针对常见并发症的应对策略.本实施规范是本单位多年来的临床经验,分享规范旨在为同行开展目标温度管理提供借鉴.

Objective:To investigate the current situation of telephone cardiopulmonary resuscitation (T-CPR) in China, and analyze the reasons for the low implementation rate of T-CPR.Methods:This was a multicenter cross-sectional survey. Twenty cities were selected from six geographical regions of China by convenient sampling method. Anonymous online electronic questionnaires were sent to emergency medical service staffs in each city. All respondents were divided into the routine T-CPR group and control group. Student's t test and Chi-square test were used to analyze the difference between groups. Multivariate logistic regression was used to analyze the influencing factors of T-CPR. Results:⑴A total of 1 191 questionnaires were collected. 80.94% of respondents knew T-CPR. Nine hundred and sixty respondents, who knew T-CPR and completed the questionnaires, were included in the study, and were divided into the routine T-CPR group ( n=401) and control group ( n=559). Nine hundred and thirty-nine (97.81%) responders believed that T-CPR should be implemented for cardiac arrest patients that could be confirmed by telephone.⑵Four hundred and one (41.77%) responders routinely implemented T-CPR. Among them, 237 (24.68%) responders always did and 164 (17.08%) responders often did. ⑶Multivariate logistic regression analysis showed that male ( OR=1.787, 95% CI: 1.235-2.587, P=0.002), age ( OR=1.025, 95% CI: 1.004-1.047, P=0.020), clinical medicine background ( OR=2.926, 95% CI: 1.387-6.171, P =0.005), dispatcher ( OR=5.305, 95% CI: 3.463-8.126, P<0.01), using medical priority dispatch system (MPDS) system ( OR=1.941, 95% CI: 1.418-2.656, P<0.01), and T-CPR policy or procedure ( OR=3.879, 95% CI: 2.652-5.674, P<0.01) were favorable factors for T-CPR. ⑷The top three reasons for implementing T-CPR in the routine T-CPR group were that they had received T-CPR training (67.08%), believed that T-CPR could improve survival rate (63.59%), and had standard T-CPR process (63.09%). The top three reasons for not implementing T-CPR in the control group were that worrying about bystander compliance (42.04%), worrying about the quality of bystander cardiopulmonary resuscitation (CPR) (38.28%), and worrying about medical dispute (36.14%). Conclusions:The awareness and implementation of T-CPR among emergency medical service staffs need to be improved. The implementation of T-CPR depend on telephone dispatchers with clinical medicine background, clear T-CPR policy, standardized operation procedure, and professional assistant tools. To improve the public's awareness of cardiac arrest and cardiopulmonary resuscitation, and to improve the supporting legal system are also conducive to the implementation of T-CPR.

Cardiopulmonary resuscitation is an important part of standardized residency training. There are certain flaws in the various commonly used training and assessment mode. In the exploration of the new mode, "step-by-step" training helps to learn skills step by step. "Low intensity and high frequency" training not only focuses on key points and difficulties, and lightens the burden of the teachers and residents, but also can improve the training effect through repeated reinforcement. Combining different training methods organically to establish a "diversified" training mode can make full use of the advantages of different methods and make up for each other's shortcomings. In addition, the "veto power" should be introduced into the assessment. Scenario simulation with role play may be an effective way to train teamwork ability, but it still needs further exploration.

China should establish an independent, complete and scientific cardiopulmonary resuscitation education and training system. This article summarized the experience of cardiopulmonary resuscitation training with the basic life support(BLS) course of American Heart Association since 2011. The advantages of BLS course included strict trainers' training and access system, standardized video and "practice while watching" mode, small class teaching mode, team training content and line-item veto in skill testing. The weaknesses of BLS course included the lack of education on the monitoring and prevention of cardiac arrest, the insufficient training on the reading of electrocardiogram waveforms during cardiac arrest, the use of automatic but not manual external defibrillator, and the lack of specific training for special patient groups. These weaknesses made BLS course not suitable for Chinese medical staffs. In the future, more researches were needed to build a new CPR training system with Chinese characteristics.

目的 通过对北京市急救中心人员进行调查,了解其对电话指导心肺复苏(telephone-assisted cardiopulmonary resuscitation,T-CPR)的知晓率及实施率,分析目前我国应用T-CPR存在的问题,为制定普及T-CPR的具体方案提供依据.方法 选择北京市12个120急救中心的急救人员共245人为调查对象,通过在线问卷调查方式统计其对T-CPR的知晓率和实施情况.结果 ①急救人员T-CPR的知晓率:北京市120急救人员T-CPR的知晓率为78.40％,其中调度员的知晓率为87.50％;②急救人员T-CPR实施率:在实际工作中,44.79％的急救人员经常或总是通过电话判断患者心脏骤停事件,43.75％的急救人员经常或总是指导旁观者心肺复苏(CPR);③旁观者CPR实施率:33.76％的急救人员认为经电话指导的旁观者CPR实施率＜5％,38.22％的急救人员认为旁观者持续胸外按压到急救人员到达现场的比率＜5％;④急救人员实施T-CPR的困难环节:急救人员认为安抚呼救者情绪(45.86％)、解除旁观者对CPR的顾虑(43.31％)、鼓励持续按压(39.49％)是T-CPR过程中难度最大的三个环节.结论 北京市急救人员实施T-CPR过程中存在多个问题,急救人员T-CPR知晓率较低、T-CPR实施率低,旁观者CPR实施率低,实施存在多个困难环节,因此,需要针对各个环节寻找改善方式,普及和规范T-CPR在实践中的应用,以期提高心脏骤停患者的生存率.

心脏骤停是导致人群死亡的重要原因,尽早开始心肺复苏对于改善患者预后至关重要.电话指导的心肺复苏是指急救中心人员接到旁观者求救电话后,判断患者发生心脏骤停,向施救的旁观者发布心肺复苏指令,指导旁观者进行的心肺复苏.电话指导的心肺复苏通过提高旁观者心肺复苏实施率,从而提高院外心脏骤停患者的存活率.现对近些年电话指导的心肺复苏的研究进展进行综述,为未来国内推广电话指导的心肺复苏提供一定依据.

Objectives To investigate the cognition of dispatcher-initiated telephone cardiopulmonary resuscitation (TCPR) among emergency medical system(EMS) personnel and compare the cognition of TCPR among EMS personnel in different economic status,and to understand the current situation of TCPR cognition of EMS personnel in China.Methods This study is a multicenter crosssectional survey.The method of multi-level convenient sampling was adopted,and the test reliability and split half reliability of the questionnaire was tested.Questionnaire survey and data collection were conducted from December 2018 to June 2019.The ethical approval number is M2018264.SPSS 20.0 was used for analysis.x2 test was used to analyze the differences between groups.Results A total of 1191 electronic questionnaires were collected.Of them,80.94％ respondents knew TCPR,97.82％ respondents thought that TCPR should be implemented in cardiac arrest,36.62％ respondents thought that bystander cardiopulmonary resuscitation quality monitoring was needed in TCPR,and TCPR training courses were set up in the emergency department which recruited 25.83％ respondents.Emergency personnel in developed areas had a better understanding of the criteria for judging patients' breathlessness (11.69％ vs 7.89％,P=0.048),of TCPR need ncluding guidance of chest compression (92.45％ vs 87.49％,P=0.012) and of bystander cardiopulmonary resuscitation (BCPR) quality monitoring including the frequency of artificial respiration (84.42％ vs 74.87％,P=0.029) than those in underdeveloped areas,but there was no significant difference in other indicators (P＞0.05).Conclusions TCPR knowledge of EMS personnel in China is unsatisfactory.Further training is needed to improve their understanding of the criteria for judging cardiac arrest in out-of-hospital cardiac arrest patients via telephone,TCPR content and bystander cardiopulmonary resuscitation quality monitoring.There is difference in TCPR knowledge between the EMS personnel in developed and undeveloped areas in China.

The emergency management training for general practitioners during job-transfer training is an important part of clinical teaching.At present,there are many problems in emergency management teaching,such as teaching contents are extensive but the class hours are limited,traditional teaching cannot meet students' needs for studying and lack of practice for emergency management skills,leading to poor teaching effects.In the teaching of emergency management of general practitioners during job-transfer training,we cultivated emergency management ability by elaborating teaching content,strengthening their clinical thinking of emergency management,carrying out a variety of training models,enhancing skill training,and stressing the evaluation of performance and so on.

目的 探讨急诊危重患者死亡分布特征,指导急诊资源合理分布及应用.方法 收集2013-2017年北京大学第三医院急诊科危重患者的临床资料,分析所有死亡患者的年龄、性别构成及死亡时间,应用帕累托图分析死因的构成情况.结果 (1)老年患者(≥60岁)占总死亡人数81.0％,年龄差异具有统计学意义(P＜0.05).(2)帕累托图分析显示,危重症患者的直接死因以呼吸系统疾病、猝死和(或)心脏骤停、休克、神经系统疾病为主.(3)在呼吸系统疾病、心血管系统疾病、休克患者中老年患者较非老年患者明显增多,而在神经系统疾病、猝死和(或)心脏骤停、创伤死亡患者中结果则相反(P＜0.05).在猝死和(或)心脏骤停、创伤疾病死亡患者中男性比女性常见,而在呼吸系统疾病中结果则相反(P＜0.05).(4)50.8％的死亡病例发生在患者入院后24h以内,其中猝死和(或)心脏骤停患者发病到死亡的中位数时间最短(1h),其次是休克(24h).而因恶性肿瘤死亡的患者发病到死亡的中位数时间可长达5040 h.结论 急诊科死亡患者以老年人为主,呼吸、猝死和(或)心脏骤停、休克、神经系统疾病为常见死因,大部分患者死于就诊早期,因此,需根据实际情况合理分配急诊医疗资源.

Objective To compare the time consumed for the procedure done,satisfaction and safety of the establishment of intraosseous (IO) access and central intravenous line placement (CVL) in critically ill patients using a randomized controlled trial.Methods The patients were randomly divided into the IO access group versus CVL group according to the inclusion criteria.The IO access and CVL were established,respectively for medicine or fluid administration.The success rates at the first attempt,time required for procedure completed,satisfaction and complications were recorded.Results During the study period,24 patients were enrolled,and divided equally and randomly into IO group (n=12) and CVL group (n=12).There were no significant differences in age,gender,BMI between the two groups.The patients with shock and cardiac arrest accounted for 83.3 ％ in IO group and 58.3 ％ in CVL group,respectively.The success rates at the first attempt was 91.7 ％ in IO access group versus 66.7 ％ in CVL group (P=0.158).the time required for procedure done was significantly shorter in IO access group (74.9 ±43.7)s compared with CVL group (944.0 s±491.5 s) (P＜0.01).The satisfaction of operators at the instruments used was 8.0±1.1 for IO access group versus 7.2±0.8 for CVL group (P==0.053).The overall satisfaction of the operators at the entire course of procedure was 3.7 + 0.7 in IO access group versus 3.9±0.3 in CVL group (P=0.377).Complications were not observed during the study period in the two groups.Conclusions The success rate at the first attempt was significantly higher in IO access group compared with CVL grouThe mean time consumed for procedure completed in IO group was much shorter than that in CVL group,and the operation was simple and practicable.During the emergency care of critical patients,if the peripheral intravenous line placement was difficult to establish,and IO access could be a choice of alternative used as a bridging procedure to rapidly establish the vascular access and win the rescue opportunity.

Objective To evaluate the status of implementation of the chain of survival and the gap between the guideline's recommendations and clinical practice as well as to analyze the factors influencing the prognosis of cardiac arrest (CA) patients.Methods A retrospective analysis of CA in adult patients admitted to Emergency Department of Peking University Third Hospital from January 2012 to December 2013 was carried out.The epidemiology,clinical features,implementations of the chain of survival and outcome were compared between out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) patients,with regard to the analysis of the predictors for survival and neurological outcome.Results A total of 414 patients with 69.8％ male and average age of (61.7 ± 18.0) years were divided into two groups,OHCA group (n =190) and IHCA group (n =224).Cardiogenic cause was found in 30％ of CA patients.There were 27.5％ patients with restoration of spontaneous circulation (ROSC),8.2％ patients discharged in survival and 3.1％ patients with good neurologic outcome (CPC =1 and 2).There were higher proportion of medical responders arriving to CA patients within 5 minutes after onset (99.1％ vs.10.5％,P ＜0.01),bystander carrying out cardiopulmonary resuscitation (100％ vs.15.3％,P ＜0.01),CPR initiated in 5 minutes (98.7％ vs.11.1％,P ＜ 0.01),defibrillation performed in 5 minutes (87.5％ vs.12.5％,P ＜ 0.01) in IHCA group compared with OHCA.There were no statistical differences in epinephrine administration and epinephrine dose,and targeted temperature management between two groups.There were higher proportion of ROSC (37.1％ vs.16.3％,P ＜ 0.05),higher percentage of survivals discharged (31.0％ vs.22.6％,P =0.002) and good neurologic outcome with CPC =1 or 2 (48.1％ vs.0.0％,P =0.029) in IHCA group compared with OHCA.Location of CA occurred and initial arrhythmia rectifiable with defibrillation treatment after ROSC were the favorable predictors for assessing the percentages of ROSC and survivals discharged.In contrast,male and age over 65 years were the unfavorable predictors of ROSC.Conclusions Improvement in outcome of victims with CA is required in every link of the chain of survival,especially in prehospital rescue act,bystander carrying out CPR,defibrillation,and therapeutic hypothermia in unconscious patients after resuscitation.The effective implementation of chain of survival concept can improve the prognosis of CA patients.

Therapeutic hypothermia is an important treatment for cerebral resuscitation in patients after cardiac arrest. But it is rarely used for comatose survivor post-cardiac arrest in China. The patient was the first case who was in coma post cardiac arrest caused by acute myocardial infarction and given hypothermia therapy in our hospital. After coronary reperfusion and therapeutic hypothermia, the patient's sneurologic function was recovered to normal. The paper discussed the indications, contraindications, cooling methods and complications of therapeutic hypothermia.

亚低温治疗是一项重要的体温管理技术,由于其能够改善危重症患者神经系统功能的预后,近年来被广泛应用于心脏骤停复苏后治疗、脑卒中及颅脑损伤等领域〔1-2〕。根据诱导体温下降的方式不同,亚低温治疗主要分为:体表降温、静脉输注冰盐水和血管内降温。其他包括药物降温、体腔灌洗、体外循环降温、选择性脑部降温等方法,由于种种

目的 比较分析老年和非老年急性肺栓塞(acute pulmonary embolism,APE)的临床特点.方法 对我院近8年来141例APE患者进行回顾性分析,根据年龄把141例患者分为两组,即老年 (年龄≥60岁) 组86例和非老年(年龄＜60岁)组55例,对两组患者的高危因素、临床特点、诊断及治疗等进行分析及比较.结果 ①老年APE 71%,明显高于非老年组(29%).②非老年组78.2%有明确的高危因素,而老年组仅有53.5%有明确的高危因素,两组比较差异有统计学意义(P<0.01),两组常见高危因素包括外科手术、深静脉血栓、恶性肿瘤、慢性静脉机能不全、骨折及心力衰竭、脑卒中等.③两组临床表现均以呼吸困难最常见,与老年组相比,非老年组胸痛、咯血、晕厥、发热、下肢深静脉血栓体征更常见(P<0.05).④非老年组静脉溶栓治疗32.7%,明显多于老年组(15.1%),两组住院期间病死率比较差异无统计学意义.结论 老年APE比非老年APE发生率更高,高龄是APE的独立危险因素;非老年APE患者大多数不仅有明确的高危因素,也有典型的临床表现,而老年APE则不同,所以临床医师对表现为呼吸困难的老年患者应警惕APE,以减少漏诊率.

In patients with ALI/ARDS,mechanical ventilation with lung protective ventilation strategies results in decreased mortality and enhances the number of days without ventilator use.While guidelines now strongly advise using lung protective ventilation in ALI/ARDS patients,there are presently no widely agreed-upon guidelines for the use of ventilation with lung protective ventilation strategies in patients who with non-ALI/ARDS conditions.Literatures concerning animal and clinical studies on lung protective mechanical ventilation in patients with non-ALI/ARDS conditions were searched out,and aspects including post ventilation oxygenation indices,cytokine levels,and lung histology were reviewed.The inconsistent results from different trials,however,do not definitely support the use of lung protective mechanical ventilation.Nevertheless,more prospective studies are needed to establish the optimal ventilator management strategies for patients with non-ALI/ARDS conditions.