【摘要】 目的 探讨人工关节置换术后C反应蛋白(CPR)、血沉(ESR)变化与感染的关系及对感染早期诊断的价值。方法 回顾总结84例行关节置换术患者术后3、6、9、14天采取空腹血检查CPR、ESR数值变化。结果 所有患者术后均出现不同程度的CPR增高、ESR增快，与术前相比差异有显著性，感染组患者术后ESR与CPR表现为持续的升高。结论 关节置换术后ESR与CPR持续的升高预示有感染可能，是早期诊断关节置换术后感染的一种简单、有效和经济的术后常规筛选检查指标、而且动态监测时间越长升高越快，诊断价值越大。
【关键词】 C反应蛋白;血沉;关节置换术;感染
人工关节置换手术越来越普及，为严重的骨关节炎、类风湿关节炎晚期、创伤性关节炎、股骨头缺血坏死提供了一种改善功能、减轻病痛的良好的治疗方法[1]。同时关节置换术后并发症的发生也是灾难性的，尤其是感染，特别是发生在老年人身上。所以预防术后感染，是关节置换工作的重中之重。一直以来把CPR、ESR作为观察术后感染或潜在感染的重要指标。但是由于CPR、ESR没有特异性，术后CPR、ESR数值普遍升高，如何参考CPR、ESR数值作为监测感染和观察疗效的敏感指标，文献没有相关报道。通过对本科84例人工关节置换术后所检测的CPR、ESR变化作以总结，以希了解在人工关节置换术后非感染患者与感染患者CPR、ESR变化的规律，能对术后感染早期诊断提供帮助。
1 资料与方法
1.1 一般资料 2005年1月-2009年12月5年时间本院行人工全髋关节置换手术84例，所有的患者均进行CPR、ESR监测。其中股骨颈骨折(头下型、经颈型)患者51例，年龄均大于65岁;股骨头缺血坏死(外伤、激素、酒精、特发原因)28例;类风湿关节炎2例;人工关节返修3例。
1.2 观察方法 术后3、6、9、14天采取空腹血检查CPR、ESR数值。
2 结果
2.1 非感染组 80例患者手术切口无红肿，切口愈合良好，拆线出院，随访无感染发生。CPR、ESR统计结果见表1。表1 非感染组CPR、ESR平均值统计结果
2.2 感染组患者 所有病例中有4例感染患者： 1例术后手术切口红肿分泌物，术后20天行切开置管冲洗 ，最后取出假体;1例双侧人工全髋置换术后术后局部感染窦道形成后经通常引流冲洗后窦道闭合。2例人工全髋关节返修出现红肿，加强抗菌消炎后红肿消退。CPR、ESR统计结果见表2。表2 感染组CPR、ESR平均值统计结果
3 讨论
人工关节置换术后感染是一种严重的并发症，给患者带来极大的痛苦。正确早期的诊断有助于减少晚期的并发症。所有患者术前CPR、ESR均正常，并且感染组与非感染组并无差异。术后出现不同程度的升高，非感染组3天即达到峰值，此后迅速下降，术后1～2周后降至接近正常。术后感染组术后6～9天急速上升并达到峰值，后逐渐下降，下降的情况与感染控制情况相关。
早期的非感染组患者的CPR、ESR考虑为手术伤口组织分解产物被吸收以及人工关节假体的植入造成。它的数值的升高可在短时间内下降接近正常水平，或在略高于正常值水平持续一段时间。而感染组CPR、ESR表现为术后急速上升持续不降或略降后复升，与手术创面的细菌感染相关， CPR比血沉反映更快。感染组患者早期的CPR、ESR的显著升高是一个特征性改变，CPR血沉升高时有患者只出现体温升高或白细胞升高，故CPR比体温及WBC变化更敏感。
ESR虽不是反映和诊断关节术后感染的特意指标，但它是感染活动的一种表现，也是感染是否控制的标准之一，绝大多数患者的ESR与病变活动相一致，感染越严重，血沉越快。对临床关节术后感染的诊断与鉴别诊断具有指导意义。CPR是肝细胞合成的非特异性急时相蛋白，在正常人体中含量极微，但在关节感染的急性炎症反映阶段其在人体含量6h内迅速增高，于24～48h到达峰值，由于反应蛋白的半衰期小于24h，故控制感染后会迅速降至正常[2]。与反应蛋白相比血沉动态的上升下降要缓慢。据Wemstem报道反应蛋白升高和出血量、手术时间、使用药物、年龄以及性别无关，与是否细菌感染、损伤组织类型及程度有关。细菌感染时其阳性率高达80%～95%，因而可作为鉴别细菌感染或免疫反应及时观察疗效调整药物等的指标。
CPR、ESR术后出现持续性的升高或第二个峰值预示有感染可能。CPR、ESR比体温、血象增高更快、更敏感，更能准确地反映感染程度，动态监测时间越长，升高越快或极度增高则更具诊断价值。尤其是CPR、ESR显著地急速或极度地增高，持续不降，则更具有诊断价值。
【参考文献】
1 胥少汀，葛宝丰，徐印坎.实用骨科学，第3版.北京，人民军医出版社，2006,2092.
2 陈文彬,潘祥林.诊断学，第7版.北京：人民卫生出版社，2008，261;439.
【关键词】 心肺脑复苏;研究;新进展
心跳骤停 WHO规定，发病或受伤后24h内心脏停搏，即为心跳骤停。它可见于原发全身和心脏相对正常或无严重疾病的情况，如急性缺血、触电及急性药物反应等，也见于严重的器质性心脏病。心肺复苏是研究心跳呼吸骤停后，由于缺血缺氧所造成的机体组织细胞和器官衰竭的发生机制及其阻断并逆转其发展过程的方法，目的在于保护脑和心、肺等重要脏器不致达到不可逆的损伤程度，并尽快恢复自主呼吸和循环功能。现代心肺脑复苏(cardiac pulmonary cerebral resuscitation,CPCR)的方法是在20世纪50～60年代逐渐发展起来的，从1956除颤器的应用，1958年口对口人工呼吸及1960年胸外按压的应用，到70年代被广泛采用。随着心肺复苏(CPR)知识的普及与急救技术的培训，近40年来复苏成功率不断提高，现将心肺脑复苏研究新进展综述如下。
1 CPR的时间
复苏最重要的要求是在4min内给予合理的基础生命支持。常温下，脑血流中断超过4min将造成不可逆性脑损害。因此，CPCR开始的时间越早越好。
2 CPR程序
常规为ABC，即气道保持(airway)、人工通气(breathing)和人工循环(circulation)。2005年国际心肺复苏指南(以下简称新指南)重申：心脏骤停最初几分钟血中氧浓度仍高，而心排量与心脑血流量则急剧减少，这种变化与血中氧浓度下降是不平行的。因此认为人工呼吸不如胸外按压重要。CPR的顺序应为CAB。但对创伤、药物过量、溺水及儿童心脏骤停等发病机制主要由窒息引起的，CPR时胸外按压与人工呼吸同等重要。鉴于我国急诊医疗服务体系还不够完善，急救呼叫反应时间长，一般都超过10min，对大多数心脏骤停的院前急救来说，循环复苏与呼吸复苏并重更为务实。过多强调循环复苏比呼吸复苏更重要，容易引起误导。
3 心前区拳击
适应证为目击或监护下发生的心跳骤停的病人，已知有Ⅲ度房室传导阻滞的患者。需在心脏骤停1min内进行，一次拳击可产生5瓦秒电能(用力时可达20～25瓦秒)，可使Ⅲ度房室传导阻引起的心室停搏恢复一次心搏，可阻断折返而终止刚开始的室性心动过速或室颤。拳击仅能1～2次，反复拳击有损心肌。
4 胸外按压与人工呼吸
按压部位为胸骨下半部中点，两乳头连线之间。按压深度4～5cm，按压频率100次/min，按压与放松时间大致相等，按压后充分放松，应尽量减少按压的中断，按压人每2min轮换，保证按压质量。口对口人工呼吸开始时，立即给病人进行两次人工通气，随后通气频率为8～10次/min，每次通气>1s，并可见胸廓运动。无论单人还是双人复苏，胸外按压与人工呼吸比例均为30：2。目的是减少按压的中断，增加冠状动脉灌注。CPR时进入肺内的血量有所减少，相当于正常肺血量的25%～33%，用低于正常的潮气量及低于正常的呼吸频率，可以使通气/血流比值保持正常。过度通气不必要，而且有害。过度通气使胸内压增高，减少回心血量，减少心排量，还会引起胃扩张，肺顺应性降低，不利于复苏。出于对有传染病等方面的担心，大多数人不愿对陌生人做口对口人工呼吸，从而阻碍了CPR的实施。对突发性心脏停搏，主动通气没有必要。CPR早期可不行口对口人工呼吸，只做胸外按压。
5 胸外按压辅助措施
临床上研究比较多的有充气背心和充气腹带在CPR时的应用，以及间歇腹部按压和抗休克裤等，现仍处于实验阶段，目前尚未证明其能改善预后，且操作复杂，不利于普及实施，在复苏时不提倡使用。
6 电除颤
心脏骤停的心电图表现90%以上为室颤，而治疗室颤的最有效手段是电除颤。除颤的时机转瞬即逝(室颤若不处理数分钟内就会转为心室停搏或电机械分离)，因此电除颤应越早越好，除颤能量一般为360J(200～400J)。自动体外除颤器包括单相和双相波二种除颤波形，双相波选择能量低，成功率优于单相波，除颤能量双相直线120J，双相方波150～200J。近来的研究表明，电击后5s心电显示心搏停或无电活动均可视为电除颤成功。这一时间的规定是根据电生理研究结果而定的，成功除颤后一般心脏停搏的时间应为5s，临床比较易于检测。新指南提出电除颤未能使心脏重新跳动，电击使心脏顿抑，终止室速及其他电活动，此时心脏如仍有活力，正常节律点将重新活动，出现有效心电图及血灌注。有资料表明，室颤电击后60s，仅25%～40%患者出现有节律性心律，有效血灌注则更少。因此，电击后仍需做CPR。
7 先做CPR还是先电除颤
新指南提出，由公众目击复苏时，如公共场所有自动体外除颤器应尽快电除颤。由急救人员复苏应先作5个周期CPR(2min)，再给予电除颤。因为急救人员到达现场延迟，室颤超过4～5min电除颤成功率不高，先做CPR能为心脑提供少量但至关重要的血流，提高电除颤成功率。
8 肾上腺素在复苏中的用量
一直存在争议。现仍用标准剂量，不推荐用大剂量。理由是大剂量的肾上腺素并不比标准剂量提高自主循环，且对出院存活率以及神经功能恢复无益。这可能是与肾上腺素的β效应(包括变力性作用和变时性作用)，增加心肌耗氧，加剧心肌缺血有关，同时还可能导致肺血流重新分布，肺内动静脉分流，加重动脉低氧血症。
9 血管加压素的应用
血管加压素直接兴奋平滑肌V1受体，使周围血管平滑肌收缩，且该药没有β肾上腺素能样活性，所以在心肺复苏时不会增加心肌耗氧量，作为肾上腺素的替代或备选药物，从目前的研究现状看，虽然多数基础研究结果支持其在复苏中的许多有益作用，但已发表的临床试验结果还难以令人满意。新指南对其再评价是血管加压素与肾上腺素作为一线药物，两者差异无显著性;除颤后无反应应考虑血管加压素，后加肾上腺素;血管加压素对心跳停搏可能有效，但不能证明改善神经系统预后。
10 胺碘酮
既往将利多卡因作为心肺复苏的一线药物，理论是利多卡因可以提高室颤阈值，预期能降低死亡率。但临床试验结果却恰恰相反，利多卡因组死亡率增加。2000年国际心肺复苏指南已将胺碘酮列为一线药物，新指南对胺碘酮的再评价是可明显提高入院抢救成功率，出院率较前无明显改善，仍推荐使用。
11 CPR标准用药
室颤：血管加压素40IU单次用药或肾上腺素1mg，每3～5min重复一次;加胺碘酮300mg，每3～5min重复150mg或利多卡因50～100mg，每3～5min重复一次。心室停搏与电机械分离：肾上腺素1mg，每3～5min重复一次，加阿托品1mg，每3～5min重复一次。待自主心跳恢复后，可根据情况选用多巴胺、多巴酚丁胺、硝普钠和碳酸氢钠等药物。
12 碳酸氢钠
心跳呼吸停止早期，可发生呼吸性酸中毒和代谢性酸中毒。因此，很长时间以来碳酸氢钠一直作为心肺复苏的一线用药。但现在的观点不推荐过早应用。理由是：(1)短暂的碱中毒，使氧解离曲线左移，减少血红蛋白中氧的释放，加重组织缺氧;(2)电解质平衡紊乱，降低游离钙和非游离钙之比，使血清中钾离子进入细胞内，诱发恶性心律失常，并产生高血钠，增加血浆渗透压;(3)直接抑制心功能，降低儿茶酚胺的活性;(4)在体内分解产生CO2。原有代谢性酸中毒，严重的高钾血症，有效通气及胸外按压10min后pH值级<7.2时，用碳酸氢钠是有益的。
13 脑复苏
脑复苏是CPCR的难点及研究热点，关键是尽早恢复自主循环，打通脑微循环灌注，拮抗再灌注损伤，降低脑细胞代谢。脑低温可以降低脑代谢，保护脑细胞，改善预后，推荐降温深度32℃～34℃，持续12～24h。还可采用高压氧舱,镇静止惊,应用脱水剂、钙拮抗剂、激素、肝素、血液稀释和抑制脑代谢药物(依托咪酯，硫喷妥钠等)等措施，但迄今无确定有效的脑复苏、脑保护手段。
目前，虽然心跳呼吸骤停的复苏成功率已有较大提高，但心肺脑复苏的研究仍处于起步阶段，很多工作尚待完成。
The new first step is doing chest compressions instead of first establishing the airway and then doing mouth to mouth. The new guidelines apply to adults, children, and infants but exclude newborns.
The old way was A-B-C -- for airway, breathing and compressions.
The new way is C-A-B -- for compressions, airway, and breathing.
"By starting with chest compressions, that's easy to remember, and for many victims that alone will be lifesaving," says Michael R. Sayre, MD, chair of the emergency cardiovascular care committee for the American Heart Association and co-author of the executive summary of the 2010 AHA guidelines for CPR and emergency cardiovascular care.
The old approach, he says, was causing delays in chest compressions, which are crucial for keeping the blood circulating.
The new guidelines may inspire more people to perform CPR, says Sayre, an associate professor of emergency medicine at Ohio State University, Columbus. "Mouth to mouth is hard if you're not trained," he tells WebMD. ''Anybody can do chest compressions, whether they have had a class or not. Good chest compressions really help save lives. In many cases, there is a reserve of oxygen left in the patient's blood and lungs, from the last breath, and we can take advantage of that oxygen reserve and just do chest compressions."
Here is a step-by-step guide for the new CPR:
1. Call 911 or ask someone else to do so.
2. Try to get the person to respond; if he doesn't, roll the person on his or her back.
3. Start chest compressions. Place the heel of your hand on the center of the victim's chest. Put your other hand on top of the first with your fingers interlaced.
4. Press down so you compress the chest at least 2 inches in adults and children and 1.5 inches in infants. ''One hundred times a minute or even a little faster is optimal," Sayre says. (That's about the same rhythm as the beat of the Bee Gee's song "Stayin' Alive.")
5.? If you're been trained in CPR, you can now open the airway with a head tilt and chin lift.
6. Pinch closed the nose of the victim. Take a normal breath, cover the victim's mouth with yours to create an airtight seal, and then give two, one-second breaths as you watch for the chest to rise.
7. Continue compressions and breaths -- 30 compressions, two breaths -- until help arrives.
Oct. 5, 2010 -- Bystanders who perform chest-compression-only CPR instead of traditional CPR with mouth-to-mouth resuscitation (rescue breathing) save more lives, a study shows.
Researchers found that adults who experienced cardiac arrest in a non-hospital setting, such as a restaurant or mall, were 60% more likely to survive if they received compression-only CPR than if they received traditional CPR or no CPR until an emergency medical services (EMS) crew arrived at the scene.
The findings are published in the Oct. 6 issue of TheJournal of the American Medical Association.
The researchers say chest-compression-only CPR may be easier to learn and remember than traditional CPR, which alternates between chest compressions and mouth-to-mouth resuscitation. Non-medical personnel may be more willing to perform chest-compression-only CPR, as they may not want to do mouth-to-mouth resuscitation -- especially on strangers.
There may be additional benefits to this method as well. The survival edge may occur because interrupting chest compressions --- even just for rescue breathing-- may further hamper blood flow, and it takes longer to get that blood flow back when it is time for more chest compressions, explains study researcher Bentley J. Bobrow, MD, of the Arizona Department of Health Services in Phoenix.
The new study adds to a growing body of literature that supports the use of chest-compression-only CPR by bystanders during cardiac arrest. Guidelines due out later this year are expected to endorse this method as equal to, if not better than, traditional CPR for nonmedical bystanders, according to information in an accompanying editorial.
The new study looked at rates and types of CPR performed by lay people following a five-year statewide public education effort in Arizona that aimed to teach and encourage chest-compression-only CPR. Outreach included radio spots and interviews, inserts in utility bills, and free training in various settings.
The researchers analyzed outcomes among 4,415 adults who had cardiac arrest outside of a hospital and received either no CPR until EMS crews arrived, chest-compression-only CPR, or traditional CPR. Emergency personnel verified the type -- if any -- of CPR that was administered prior to their arrival.
Overall, 13.3% of those who received chest-compression-only CPR survived to hospital discharge compared with 7.8% of those who received traditional CPR, and 5.2% of those who received no CPR from bystanders, the study shows. What's more, the public health education strategy influenced the amount of people willing to provide any type of CPR, researchers report. The number of bystanders who performed chest-compression-only CPR instead of traditional CPR also increased during the study period.
The survival benefit seen in the new study was "modest," points out David C. Cone, MD, in an editorial published along with the study. Cone is an emergency room doctor at Yale University School of Medicine in New Haven, Conn.
But "this finding is important when considering that the survival rate from out-of-hospital cardiac arrest has remained dismally low?despite decades of study," he writes.
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July 28, 2010 -- Bystanders who perform CPR on patients with suspected heart attacks can safely skip the rescue breathing -- typically called mouth-to-mouth resuscitation -- and just perform the chest compressions, according to two new studies.
''We feel comfortable saying chest compressions alone, when performed by a layperson, will provide at least the benefit that conventional CPR, with rescue breathing, will provide," researcher Thomas D. Rea, MD, medical director for King County, Wash., Medic One, tells WebMD.
The suggestion to skip the mouth-to-mouth part of CPR, he emphasizes, does not apply to emergency medical personnel, but only to laypeople who may be able to provide CPR after a suspected heart attack while waiting for professional medical help to arrive.
Rea's study, along with another head-to-head comparison of the two CPR approaches, is published in the New England Journal of Medicine.
''We are trying urgently, desperately, to make CPR more accessible to bystanders," Rea says, noting that performing CPR soon after a heart attack can increase the likelihood of survival twofold. Hopefully, he says, the finding that the rescue breathing is not crucial will make the technique simpler and perhaps more palatable for people.
CPR was first proposed about 50 years ago, when researchers suggested that external chest compression could provide blood circulation to the brain and heart after a heart attack. The mouth-to-mouth breathing was added later.
But in recent studies, researchers have focused on whether both components are always crucial. In 2008, the American Heart Association issued an advisory for the public, advocating hands-only CPR for bystanders not trained in CPR with rescue breathing.
Rea's team evaluated 1,941 patients who had out-of-hospital heart attacks and were given CPR from bystanders being instructed by emergency dispatchers. Patients were randomly assigned to get either chest compression only or conventional CPR with rescue breathing.
The researchers looked at the percent in each group that survived to hospital discharge.
"We found that survival in the chest compression alone group was 12.5% and survival in the conventional CPR group was 11%," Rea tells WebMD.
Rea's study was supported in part by the Medic One Foundation and the Laerdal Foundation for Acute Medicine. In the second study, Swedish researchers evaluated 1,276 patients with suspected out-of-hospital heart attacks, assigning half to conventional CPR and half to compression-only.
The rate of 30-day survival was similar in the groups -- 8.7% of those getting compression-only CPR and 7% of those getting conventional CPR. The Stockholm County Council, SOS Alarm, and the Swedish Heart-Lung Foundation supported the study.
The two new studies are good news for bystanders, some of whom have been reluctant to do the rescue breathing part of CPR, says Myron L. Weisfeldt, MD, chairman of the department of medicine at Johns Hopkins University School of Medicine, Baltimore, who wrote an editorial to accompany the studies.
Sept. 16, 2009 -- Vigorous cardiopulmonary resuscitation (CPR) with more chest compressions on people with sudden cardiac arrest can improve the survival rate, a new study shows.
"Chest compressions move blood with oxygen to the heart and the brain to save the brain and prepare the heart to start up its own rhythm when a shock is delivered with a defibrillator," says study researcher Jim Christenson, MD, of the University of British Columbia. "We found that even short pauses in chest compressions were quite detrimental."
Sudden cardiac arrest kills about 325,000 Americans a year, or 800 per day, and can occur without warning, as in the case of NBC newsman Tim Russert, who died in June 2008.
In sudden cardiac arrest, the heart suddenly stops pumping blood effectively to the brain and body, causing a person to collapse. The most common reason for sudden cardiac arrest is a very chaotic heart rhythm (ventricular fibrillation), which occurs as a result of a heart attack.
Rarely, ventricular fibrillation can occur without a heart attack but in the presence of an underlying structural heart abnormality -- as is occasionally the case when a young athlete collapses and dies out of the blue. When sudden cardiac arrest occurs, death comes within a few minutes unless the victims' heart muscles are successfully jolted back into a normal rhythm with an electrical shock.
CPR traditionally involves providing chest compressions to help circulate blood around the body and breathing support, such as mouth-to-mouth ventilation. Interruptions to chest compressions are common during CPR, with rescuers typically spending only 50% of their time giving chest compressions.
In the new study, published in Circulation: Journal of the American Heart Association, researchers analyzed data from 78 emergency medical services agencies to determine the effect of chest compressions on patient outcome. They specifically looked at something called the "chest compression fraction" (CCF), which refers to the percentage of time spent performing chest compressions relative to the entire time that CPR is performed.
In the 506 cases studied, a "return to spontaneous circulation" was achieved 58% of the time when the CCF was 0% to 20%, but rose to 79% when CCF was 81% to 100%. Return to spontaneous circulation means that the heart began to beat effectively again on its own.
Survival to hospital discharge occurred in 12% of patients with a CCF between 0% and 20%. ??Survival more than doubled to 29% when CCF increased to 61% to 81%, the researchers say.? Survival rates fell slightly to 25% with CCF ratios greater than 81%.
"There was roughly a 10% increase in the chance of survival for every 10% increase in the chest compression fraction,'' Christenson says.
According to the researchers, the slight drop in survival in people with the highest CCFs was likely due to the small sample size of the study. However, the possibility of a plateau effect in CCF exists.
【关键词】 心肺复苏；心搏骤停；成功率；成活率
对本院2002年1月～2008年1月238例心搏、呼吸骤停心肺复苏（CPR）患者的资料进行回顾性研究，报告如下。
1 资料与方法
1.1 一般资料 238例患者中男130例，女108例，年龄24～86岁，平均（65.2±11.38）岁；病因主要为心血管病、脑血管病、创伤、电击伤、溺水、中毒、药物过敏、窒息、呼吸疾病、电解质紊乱等，其中发生在院外者多病因不明。排除慢性疾病终末期及预期死亡的恶性肿瘤患者。将238例患者按随机原则分组，在院外或“120”转运过程中发生心搏、呼吸骤停，并立即行CPR的29例为A组；院外发生心搏、呼吸骤停未立即进行CPR或15min后行CPR的161例为B组；院内发生心搏、呼吸骤停并立即行CPR的48例为C组。
1.2 心搏骤停诊断标准 患者意识突然丧失；大动脉搏动消失；并经心电图证实（心室纤颤、无脉搏性电活动、心脏停搏）［1］，“第一目击者”可通过意识丧失、呼吸停止、面色苍白或青紫等判断［2］。
1.3 抢救方法 立刻进行胸外按压、气管插管、机械通气、电除颤、静脉注射肾上腺素等各种复苏药物。头部低温、脱水、糖皮质激素、高压氧疗等各种心肺脑复苏方法，同时治疗原发病。
1.4 CPR成功标准 心跳恢复；面、唇由发绀转为红润；出现自主呼吸或机械通气下心跳恢复正常，经皮血氧饱和度（SpO2）>0.95；瞳孔由大变小，并有对光反射或眼球活动。
1.5 统计学方法 对数据进行χ2检验，P<0.05为差异有统计学意义。
2 结果
三组患者CPR成功率、24 h存活率和存活出院率比较结果，见表1。A、C组CPR成功率均显著高于B组，且C组明显高于A组；A、C组24 h存活率及存活出院率均高于B组，差异有统计学意义（均P<0.05），但A组与C组间比较差异无统计学意义（均P>0.05）。表1 三组患者CPR成功率、24 h存活率和存活出院率比较注：与A组比较，aP<0.05;与B组比较，bP<0.05
3 讨论
由于心搏、呼吸骤停4～6 min后脑细胞可发生不可逆损害［1］，故必须在心跳停止后4～5 min内进行有效的CPR，恢复脑细胞的氧供，促进脑功能的恢复。对于发生于院外的心搏骤停患者，急救人员能否在发病现场迅速准确判断、紧急抢救是提高复苏成功率的关键，要求现场急救人员有较高的急救专业水平，掌握标准的复苏急救措施，在5 min的急救黄金时间内建立有效的急救平台。
现场进行及时有效的CPR是急救成功的重要环节，心搏、呼吸骤停后，复苏开始的时间是决定复苏能否成功的关键。2000年国际CPR指南强化了生存链的概念，成人的生存链是由“四早”组成，即早进入急救系统、早初级CPR、早除颤、早高级CPR［3］。如上述任何一个环节出现问题，生存的机会都会减少，要在第一时间迅速进行规范的人工CPR，早期单独胸外按压更为重要。2005年美国心脏学会CPR与心血管急救指南进一步强调了有效不间断胸外按压的重要性。在心搏骤停后，立即进行胸外按压，此时心脏内有氧合的血，即使出现心室纤颤也会在几秒内恢复正常，且胸外按压及其后的胸廓回弹有助于肺通气［4］。
本研究结果表明，当心搏、呼吸骤停发生时，立即给予CPR能够得到有效的治疗，说明及早进行CPR的重要性。B组较A组心搏、呼吸骤停者多几倍，说明许多心搏、呼吸骤停者发病时没有他人帮助，这表示掌握标准的复苏急救措施的人很少，如果运用多种方法加强对大众进行标准的复苏急救措施的培训，减少院外心搏、呼吸骤停发生时无人救助的比例，就可有效提高CPR的成功率、24 h生存率及存活出院率。A组与C组CPR成功率有差异是因为没有做到“四早”中的早除颤、早高级CPR及急救人员操作的标准化。
“120”急救人员是对院外心搏、呼吸骤停者实施急救复苏的主要人员，经过多年的建设，急救医疗服务体系的启动时间和反应时间有了明显的缩短［5］。但到达现场的时间仍在10 min以上，如在15 min内未予CPR，除非在低温等特殊情况下，否则几乎无存活［6］。
总之，心搏、呼吸骤停抢救的关键是CPR开始的时间。必须提高全民的急救意识，加强对CPR知识和技术的普及，使心搏、呼吸骤停患者能在第一时间内得到基本生命支持。在此基础上普及加强院外、院内标准化的训练，是提高CPR成功率和存活率的根本途径。
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（本文编辑：江 宇）
作者单位：621100 四川，绵阳市三台县人民医院
Oct. 17, 2008 -- The Bee Gees disco song "Stayin' Alive" might help people stay alive when they get cardiopulmonary resuscitation (CPR) -- if their rescuer knows the 1977 tune.
It turns out that "Stayin Alive" has a beat that's in sync with the recommended pace for chest compressions given during CPR. So researchers put the pop tune to the test.
In a small study, 15 adults -- mainly doctors, most of whom had performed CPR in recent months -- got a refresher course in CPR. During that class, they listened to "Stayin' Alive" and were asked to time their chest compressions to the beat.
Five weeks later, participants took a CPR test. This time, no music was played.
Participants said they felt they were better and more confident at CPR while listening to the music, note the researchers, who included David Matlock, MD, of the University of Illinois College of Medicine at Peoria, Ill.
"Properly performed CPR can triple survival rates for cardiac arrest, but many people hesitate to jump in because they don't feel confident about maintaining the proper rhythm," Matlock says in a news release. "Our research subjects felt that listening to "Stayin' Alive" improved their ability to perform chest compressions at the proper speed, and indeed their performance even five weeks later was excellent," Matlock says.
The results, which will be presented on Oct. 27 in Chicago at the American College of Emergency Physicians' annual meeting, are "encouraging" but should be checked in larger studies, write Matlock and colleagues.
