發(fā)布時(shí)間：2018-07-06 10:44

  本文選題：心臟驟停 + 心肺復(fù)蘇　； 參考：《第三軍醫(yī)大學(xué)》2013年博士論文

【摘要】：心臟驟停（cardiac arrest, CA），又稱心源性猝死（sudden cardiac death，SCD）是指心臟的機(jī)械活動(dòng)停止，，同時(shí)左心室收縮不足或停止收縮。心臟驟停80%以上都發(fā)生在院外，又稱院外心臟驟停（Out-of-hospital cardiac arrest，OHCA)。據(jù)統(tǒng)計(jì)，在美國(guó)每年約有33萬(wàn)人發(fā)生OHCA，在歐洲每年約有35萬(wàn)人，而在中國(guó)這一數(shù)字則高達(dá)55.4萬(wàn)人。 心肺復(fù)蘇（cardiopulmonary resuscitation，CPR）作為全球醫(yī)學(xué)界研究的熱點(diǎn)之一，是搶救心臟驟�；颊叩奈ㄒ挥行緩�。CPR包括胸外按壓、人工通氣和體外電除顫等。美國(guó)心臟協(xié)會(huì)（American heart association, AHA）在2010年復(fù)蘇指南中進(jìn)一步強(qiáng)調(diào)，及早進(jìn)行高質(zhì)量的胸外按壓是提高CPR成功率的關(guān)鍵措施。 胸外按壓（chest compression，CC）的質(zhì)量包括按壓深度、按壓頻率和胸廓的回彈程度等。尤其是足夠的按壓深度，它是保持一定冠狀動(dòng)脈灌注壓（coronary perfusionpressure, CPP）的關(guān)鍵。CPP被證實(shí)是目前預(yù)測(cè)能否恢復(fù)自主循環(huán)（return of spontaneouscirculation，ROSC）的最直接的指標(biāo)。但是，研究表明許多心臟驟�；颊咴贑PR過(guò)程中沒有得到有效的胸外按壓，主要表現(xiàn)在按壓深度不足、按壓頻率較低以及沒有保持適當(dāng)?shù)难h(huán)血流。由于OHCA病人的第一目擊者絕大多數(shù)是非專業(yè)人員，使得院外CPR的質(zhì)量更加得不到保障，調(diào)查顯示目前全球總體CPR成功率不到10%。 目前監(jiān)測(cè)心肺復(fù)蘇質(zhì)量的手段主要有監(jiān)測(cè)CPR實(shí)施過(guò)程的CPP、按壓深度、按壓頻率等參數(shù)。CPP能很好預(yù)測(cè)心肺復(fù)蘇成功率，但是由于它需要進(jìn)行有創(chuàng)監(jiān)測(cè)而無(wú)法得到廣泛應(yīng)用。按壓深度和頻率可以通過(guò)在患者胸口上方放置加速度傳感器或位移傳感器來(lái)獲得，但需要額外增加器件是它存在的固有缺陷。盡管經(jīng)胸阻抗（Transthoracicimpedance，TTI）在心肺復(fù)蘇領(lǐng)域應(yīng)用廣泛，但利用TTI實(shí)時(shí)監(jiān)測(cè)胸外按壓質(zhì)量的研究仍未見報(bào)道，且目前尚未建立TTI變化與CPP和按壓深度之間的關(guān)系。如何利用TTI信號(hào)對(duì)心肺復(fù)蘇質(zhì)量進(jìn)行監(jiān)測(cè)并實(shí)時(shí)反饋，是一項(xiàng)具有重要意義的研究課題。 針對(duì)上述問(wèn)題，本論文對(duì)以下兩個(gè)方面內(nèi)容開展了研究： 1.建立動(dòng)物實(shí)驗(yàn)?zāi)Ｐ筒⒀芯縏TI變化值與CPP和按壓深度之間的關(guān)系。我們通過(guò)實(shí)驗(yàn)建立了家豬心跳驟停（6分鐘室顫）與不同人工心肺復(fù)蘇質(zhì)量模型，并通過(guò)高質(zhì)量按壓組和低質(zhì)量按壓組進(jìn)行對(duì)照研究。在本實(shí)驗(yàn)中，高質(zhì)量按壓組的按壓深度不低于胸部前后徑幅度的25%（即50mm），低質(zhì)量按壓組的按壓深度為高質(zhì)量按壓組的70%（即35mm）。實(shí)驗(yàn)結(jié)果顯示，高質(zhì)量按壓組所有動(dòng)物均獲得ROSC，低質(zhì)量按壓組僅2頭動(dòng)物獲得ROSC（100%vs.28.57%, p=0.021）。TTI變化值和按壓深度的相關(guān)系數(shù)為0.89（P0.001），TTI變化值和CPP的相關(guān)系數(shù)為0.83（P0.001），均具有很好的線性相關(guān)性。 2.利用TTI信號(hào)監(jiān)測(cè)心肺復(fù)蘇質(zhì)量并進(jìn)行實(shí)時(shí)反饋。為準(zhǔn)確獲取TTI信號(hào)中包含的TTI變化值、按壓頻率、按壓通氣比、按壓時(shí)間比等反映心肺復(fù)蘇質(zhì)量的指標(biāo)并進(jìn)行實(shí)時(shí)反饋，我們?cè)O(shè)計(jì)了基于TTI信號(hào)的檢測(cè)算法。算法主要包括三個(gè)部分：（1）通過(guò)極值搜索法來(lái)檢測(cè)胸外按壓和人工通氣的波形，并去除干擾信號(hào)。（2）通過(guò)特征提取和線性判別式分類，將檢測(cè)到的信號(hào)分為按壓波和通氣波。（3）計(jì)算阻抗變化值、按壓頻率、按壓通氣比、按壓時(shí)間比等參數(shù)，評(píng)價(jià)心肺復(fù)蘇質(zhì)量，通過(guò)實(shí)時(shí)顯示和反饋以更好地指導(dǎo)救援。 我們通過(guò)心肺復(fù)蘇模型的建立，研究并證實(shí)了TTI變化值與CPP和按壓深度具有顯著的正相關(guān)性。同時(shí)，利用基于TTI信號(hào)的檢測(cè)算法，準(zhǔn)確計(jì)算出評(píng)價(jià)心肺復(fù)蘇質(zhì)量參數(shù)并實(shí)時(shí)顯示，對(duì)于指導(dǎo)心肺復(fù)蘇具有重要意義。由于TTI信號(hào)可以通過(guò)除顫器的除顫電極來(lái)獲取，所以不需要額外增加電子器件。因此，基于TTI信號(hào)監(jiān)測(cè)心肺復(fù)蘇質(zhì)量的方法在心肺復(fù)蘇領(lǐng)域具有廣闊的應(yīng)用前景。
[Abstract]:Cardiac arrest (cardiac arrest, CA), also known as sudden cardiac death (SCD), refers to the mechanical activity of the heart, and the left ventricular contraction is insufficient or the contraction. More than 80% of the cardiac arrest occurs outside the hospital, also called the cardiac arrest (Out-of-hospital cardiac arrest, OHCA). According to statistics, there are about 330 thousand people in the United States. The incidence of OHCA in Europe is about 350 thousand per year, while in China the figure is as high as 554 thousand.
Cardiopulmonary resuscitation (CPR), as one of the hotspots in the global medical field, is the only effective way to rescue patients with cardiac arrest,.CPR including chest compressions, artificial ventilation and external defibrillation. The American Heart Association (American Heart Association, AHA) further emphasized in the 2010 recovery guide, as early as possible. High quality chest compression is the key step to improve the success rate of CPR.
The mass of chest compression (CC) consists of pressing depth, pressing frequency and the rebound degree of the chest. Especially enough compression depth, it is the key.CPP to maintain a certain coronary artery perfusion pressure (coronary perfusionpressure, CPP), which is confirmed to be able to restore the autonomous circulation (return of spontaneouscirculation) at present. The most direct index of ROSC). However, studies have shown that many cardiac arrest patients have not received effective chest compressions during the CPR process, mainly in the lack of compression depth, low press frequency, and no proper circulation flow. Because the majority of the first eyewitnesses of the OHCA patients are non professionals, the quality of the CPR is made out of the hospital. The volume is far from guaranteed. The survey shows that the overall global CPR success rate is less than 10%..
The main means to monitor the quality of cardiopulmonary resuscitation are CPP monitoring CPR implementation process, compression depth, compression frequency and other parameters.CPP can well predict the success rate of cardiopulmonary resuscitation, but because it needs invasive monitoring, it can not be widely used. Press depth and frequency can pass the acceleration sensor above the chest of the patient, or the acceleration sensor can be placed over the patient's chest. Displacement sensors are obtained, but additional devices are required to be inherent defects. Although Transthoracicimpedance (TTI) is widely used in the field of cardiopulmonary resuscitation, the study of real-time monitoring of the mass of chest compressions with TTI has not been reported, and the relationship between TTI changes and CPP and press depth has not yet been established. It is an important research topic to use TTI signals to monitor the quality of cardiopulmonary resuscitation and feedback in real time.
In view of the above problems, the following two aspects are studied in this paper.
1. the animal experimental model was established and the relationship between the TTI change value and the CPP and the press depth were studied. We established the quality model of the cardiac jump sudden stop (6 minute ventricular fibrillation) and the different artificial cardiopulmonary resuscitation through the experiment, and studied the high mass press group and the low mass press group. In this experiment, the press depth of the high quality press group was deep. The degree was not less than 25% (50mm) of the anterior and posterior diameter of the chest, and the compression depth of the low mass press group was 70% (35mm) of the high mass compression group. The results showed that all the animals in the high quality compression group were ROSC, and only 2 animals in the low mass press group obtained the ROSC (100%vs.28.57%, p=0.021).TTI change and the compression depth of 0.89 (P). 0.001) the correlation coefficient of TTI and CPP is 0.83 (P0.001), and all have good linear correlation.
2. using TTI signal to monitor the quality of cardiopulmonary resuscitation and carry out real-time feedback. In order to accurately obtain the TTI change values included in the TTI signal, press the frequency, pressure and ventilation ratio, press time ratio to reflect the quality of cardiopulmonary resuscitation and real-time feedback, we designed a detection algorithm based on the TTI signal. The algorithm mainly includes three parts: (1) The extreme value search method is used to detect the waveform of chest compressions and artificial ventilation and to remove interference signals. (2) the detected signals are divided into press wave and ventilatory wave through feature extraction and linear discriminant classification. (3) to calculate the change of impedance, press the frequency, pressure and ventilation ratio, press time ratio and so on to evaluate the quality of cardiopulmonary resuscitation. Display and feedback to better guide the rescue.
Through the establishment of the cardiopulmonary resuscitation model, we have studied and confirmed the significant positive correlation between the TTI change value and the CPP and the press depth. At the same time, using the detection algorithm based on TTI signal, the evaluation of the quality parameters of CPR and the real-time display are of great significance for guiding the cardiopulmonary resuscitation. Because TTI signals can be eliminated. The defibrillator electrode is obtained, so there is no need for additional electronic devices. Therefore, the method of monitoring the mass of cardiopulmonary resuscitation based on TTI signals has a broad prospect in the field of cardiopulmonary resuscitation.
【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2013
【分類號(hào)】：R459.7

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本文編號(hào)：2102528