摘要目的 调查急诊心搏骤停(CA)患者心肺复苏(CPR)现状.方法 采用多中心前瞻性观察性研究方法,选择2015年7月1日至2017年7月31日华北、华南、华东、西南地区6省市13家医院急诊科收治的CA患者.应用Utstein模式收集患者临床资料,包括一般资料、CA相关数据及预后;主要结局指标为自主循环恢复(ROSC)率,次要结局指标为28 d存活率.采用Logistic回归分析筛选ROSC的影响因素.结果 共纳入13家医院613例CA患者数据.北京市和广东省医院CA患者ROSC率较高,但不同省市医院28 d存活率差异无统计学意义.① 在613例CA患者中,院内心搏骤停(IHCA)413例(占67.4%),院外心搏骤停(OHCA) 200例(占32.6%);208例患者ROSC至少1次(占33.9%),仅20例患者28 d存活(占3.3%).IHCA患者ROSC率显著高于OHCA患者〔37.3%(154/413)比27.0%(54/200),P<0.01〕,而28 d存活率差异无统计学意义.接受徒手按压、电除颤或肾上腺素≤4 mg患者的ROSC率更高,但28 d存活率差异无统计学意义.多因素Logistic回归分析显示,IHCA〔优势比(OR)=1.893,95%可信区间(95%CI)=1.253~2.858,P=0.002〕、徒手按压(OR=0.506,95%CI=0.348~0.736,P=0.000)、电除颤(OR=0.458,95%CI=0.300~0.699,P=0.000)、肾上腺素≤4 mg(OR=0.317,95%CI=0.216~0.464,P=0.000)是CA患者ROSC的保护因素.② 在200例OHCA患者中,有49例ROSC(占24.5%),仅5例存活(占2.5%).年龄<65岁、目击者实施CPR及接受徒手按压、电除颤或肾上腺素≤4 mg患者的ROSC率更高,且在救护车上发生CA的ROSC率高于家庭和公共场所,但28 d存活率差异无统计学意义.多因素Logistic回归分析显示,年龄<65岁(OR=2.749,95%CI=1.192~6.336, P=0.018)、徒手按压(OR=0.196,95%CI=0.072~0.535,P=0.001)、电除颤(OR=0.263,95%CI=0.108~0.641, P=0.003)、肾上腺素≤4 mg(OR=0.122,95%CI=0.049~0.303,P=0.000)及救护车上发生CA(OR=2.441, 95%CI=1.334~4.468,P=0.004)是OHCA患者ROSC的保护因素.结论 急诊CA患者CPR成功率较低.早期电除颤、徒手胸外按压、CA发生在院内或救护车上、目击者实施CPR等均可提高CA患者的ROSC率;而过多使用肾上腺素对CA患者无益.临床试验注册 美国临床试验数据库(Clinical Trials),NCT01987245.

abstractsObjective To investigate the status of cardiopulmonary resuscitation (CPR) in patients with sudden cardiac arrest (CA) in the emergency department. Methods A multicenter prospective observational study was conducted. The patients with CA admitted to 13 hospitals from 6 provinces in four different regions, including North China, Southern China, East China, Southwest China, from July 1st, 2015 to July 31st, 2017 were enrolled. A modified Utstein template was applied to collect clinical data, including general data, CA related data and prognosis, and primary outcome indicator was the return of spontaneous circulation (ROSC) rate, and the secondary outcome indicator was 28-day survival rate. The influence factors of ROSC were screened by Logistic regression analysis. Results The data of 613 patients with CA in 13 hospitals were enrolled. The ROSC rate in Beijing and Guangdong Province was higher, but there was no significant difference in 28-day survival rate among hospitals from different provinces. ① In 613 patients with CA, there were 413 patients suffering from in-hospital cardiac arrest (IHCA, 67.4%), and 200 suffering from out-hospital cardiac arrest (OHCA, 32.6%). 208 patients had ROSC at least once (33.9%), only 20 patients survived within 28 days (3.3%). ROSC rate in IHCA patients was significantly higher than that in OHCA patients [37.3% (154/413) vs. 27.0% (54/200), P < 0.01]. There was no statistic difference in 28-day survival rate between patients with IHCA and OHCA. The patients received manual chest compression, electric defibrillation, or epinephrine ≤ 4 mg had higher ROSC rate, but 28-day survival rate showed no significant difference. Multivariate Logistic regression analysis showed that IHCA [odds ratio (OR) = 1.893, 95% confidence interval (95%CI) = 1.253-2.858, P = 0.002], manual chest compression (OR = 0.506, 95%CI = 0.348-0.736, P = 0.000), electric defibrillation (OR = 0.458, 95%CI = 0.300-0.699, P = 0.000), and total adrenalin ≤ 4 mg (OR = 0.317, 95%CI = 0.216-0.464, P = 0.000) were the protective factors of ROSC in CA patients. ② In 200 OHCA patients, there were 49 patients had ROSC (24.5%), only 5 patients survived (2.5%). The patients aging < 65 years, with witnesses of CPR, received manual chest compression, electric defibrillation, or epinephrine ≤ 4 mg had higher ROSC rate, and the ROSC rate was higher in ambulances than that at home and in public sites, but 28-day survival rate showed no significant difference. Multivariable Logistic regression analysis showed that age < 65 years old (OR = 2.749, 95%CI = 1.192-6.336, P = 0.018), manual chest compressions (OR = 0.196, 95%CI =0.072-0.535, P = 0.001), electric defibrillation (OR = 0.263, 95%CI = 0.108-0.641, P = 0.003), total adrenaline dose ≤4 mg (OR = 0.122, 95%CI = 0.049-0.303, P = 0.000) and the ambulance CA (OR = 2.441, 95%CI = 1.334-4.468, P = 0.004) were protective factors of ROSC in OHCA patients. Conclusions The survival of sudden CA in emergency department was still poor. Early electric defibrillation, manual chest compression, CA occurred in hospital or in ambulance, and witness CPR can improve the ROSC rate of CA patients. Excessive use of adrenaline is not beneficial to patients with CA. Clinical Trial Registration Clinical Trials, NCT01987245.