Advanced cardiac life support?or ACLS is a structured way to respond to an unresponsive person with cardiac arrhythmias?and cardiac arrest.

高級心臟生命支持或ACLS是的一種標(biāo)準(zhǔn)結(jié)構(gòu)化的方式，可運(yùn)用于因心律失常和心臟驟停而失意識的患者。

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ACLS can be done by an individual or by a team that's led by a team leader.

ACLS可以單人或由團(tuán)隊(duì)完成。

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When we suspect a person maybe in need of assistance，?the first thing we need to do is determine their level of consciousness.

當(dāng)我們懷疑某人可能需要幫助時,?我們需要做的第一件事就是判斷他們的意識水平。

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Talk loudly at them，rub their sternum，or apply pressure to their nail beds?or earlobeswhile simultaneously checking for absent or abnormal breathing.

大聲呼喚他們，摩擦他們胸部，或者對他們的甲床或耳垂施加壓力，與此同時檢查他們是否存在呼吸暫?；虿徽５暮粑\(yùn)動。

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If they're not responsive，check the carotid pulse for about 10 seconds.

如果他們對于以上動作沒有反應(yīng)，接著檢查頸動脈脈搏大約10秒鐘。

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If there's no pulse first immediately activate the emergency response system?to get more help and an AED or defibrillator.

如果頸動脈搏動消失，立即啟動應(yīng)急反應(yīng)系統(tǒng)，來獲得更多幫助并獲取AED設(shè)備或除顫器。

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Then move on to the ACLS algorithm.

然后繼續(xù)ACLS的一些列步驟。

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The first thing to do is cardiopulmonary resuscitation or CPR，which combines chest compressions?and artificial ventilation.

首先要做心肺復(fù)蘇術(shù)，即CPR， 它包括胸外按壓和人工通氣。

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The big picture goal of CPR is to maintain blood flow to the brain while a patient is pulseless.

心肺復(fù)蘇術(shù)的總體目標(biāo)是使病人在無脈搏的情況下，仍能保證大腦的血供。

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Because the patient's heart is not functioning，the team is mechanically squeezing the heart to ensure blood flows to the brain.

由于患者此時的心臟不能正常工作，搶救人員通過胸外按壓機(jī)械性的擠壓心臟以確保血液流向大腦。

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In a person over 8 years of age，chest compressions are done by placing the heel of one hand in the center of the chest?，then placing the other hand on top?，interlocking the fingers，and without flexing the elbows，pushing down on the chest.

對于8歲以上的患者，搶救人員在施行胸部按壓時，應(yīng)將一只手的掌跟放在患者胸部的中心，另一只手與之十指相扣放在上面，進(jìn)行胸外按壓時肘部不能彎曲。

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This should be done to a depth of at least 5 cm or 2 inches which is about the same size as a closed fist is lengthwise.

按壓深度應(yīng)該做到至少5厘米（或2英寸）大致和握緊的拳頭的縱向長度相同。

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Compressions are done at a rate of about 100 compressions per minute【注1】，which you can remember if you do them to the beat of “staying alive” by the Bee Gees.

按壓的速度約為100次/分，你可以通過Bee Gees的歌“staying alive”的節(jié)奏去做。

【注1】目前的指南已對此觀念有更新，目前推薦按壓速度不低于100次/分，在100～120次/分為宜。

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Additionally，the team attempts to artificially ventilate the patient, so oxygen can enter the lungs and carbon dioxide can leave.

此外，團(tuán)隊(duì)通過為病人人工通氣，這樣氧氣就可以進(jìn)入肺部，同時二氧化碳排出。

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Artificial ventilation includes a variety of ways to assist respiration for a person who isn't breathing or making sufficient respiratory effort on their own.

人工通氣包括多種方法來幫助一個沒有呼吸或者自己不足以維持足夠的呼吸的患者。

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The options for ventilation usually involve a bag valve mask device to push air in.?????

輔助通氣的選擇中，常用的有通球囊通氣。

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A bag valve mask can be applied directly to the person's mouth, or with an oral airway, a supraglottic airway like laryngeal mask airway (LMA), or an endotracheal tube.

球囊呼吸器可以通過面罩直接扣在患者口鼻部，還可以通過口咽途徑，或者聲門上途徑，如使用喉罩通氣，又或者也可以通過氣管內(nèi)插管途徑。

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Directly applying the bag valve mask is the simplest option since it's just positioned over the nose and mouth of the patient，creating a tight seal so air does not escape around the sides of the mask.

直接使球囊面罩呼吸器最簡單辦法，它只需要將面罩叩在患者的口鼻上方，使用時注意貼合密閉，這樣氣體就不會從面罩邊緣漏出。

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If the bag valve mask is ineffective or difficult to perform，like in the case of an air leak because of an abnormally large face, then a supraglottic airway can be placed blindly into the airway through the mouth by pushing towards the throat.

如果球囊面罩使用效果不佳，例如在臉部比較大的患者可能由于面罩貼合困難而導(dǎo)致氣體漏出，此時可以將輔助通氣設(shè)備從患者口部向喉部推進(jìn)，盲插入氣道從而建立聲門上氣道。

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This is generally preferred over endotracheal tube intubation because it's faster to perform and minimizes the interruption of chest compressions.【注2】

這種方法通常優(yōu)于氣管插管，因?yàn)樗僮髌饋砀杆?，可以最大程度減少胸外按壓的中斷時間。

【注2】此處觀點(diǎn)目前已有一些變化，我的老師Dr. Tian在與西雅圖學(xué)者的交流中得知他們目前已接受的觀念是即便是使用氣管插管，也可以做到不間斷的胸外按壓，甚至在胸外按壓的過程中更有助于氣管插管的進(jìn)行，因?yàn)樵谛赝獍磯簳r氣體從肺部被擠出，聲門開放，可順勢插入氣管插管；所以目前已有學(xué)者認(rèn)為并經(jīng)過實(shí)踐證實(shí)可以在不中斷胸外按壓的情況下進(jìn)行氣管插管，熟練地掌握并運(yùn)用這項(xiàng)技能或可大大提高救治成功率。

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Time and time again, researchers have shown that the most important part of ACLS is high quality uninterrupted chest compressions followed by defibrillation in those who need it,?that's why intubation is done only if the patient can't be ventilated by other means.【注3】

在一次次的嘗試中，研究發(fā)現(xiàn)成功的ACLS中最重要的是保持不間斷的高質(zhì)量胸外按壓，并按需除顫。這就是為什么只有在患者采用其他通氣方式均失效時才選用氣管內(nèi)插管。

【注3】此處觀念變化同【注2】

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Continuous capnography should be performed in addition to clinical assessment for both confirming and monitoring correct tracheal tube placement and for monitoring the quality of CPR and return of spontaneous circulation.

應(yīng)進(jìn)行持續(xù)的CO2監(jiān)測以及臨床評估，來確認(rèn)并保證氣管導(dǎo)管的位置放置正確，同時也有助于監(jiān)測CPR的實(shí)行質(zhì)量以及自主循環(huán)的恢復(fù)。

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Capnography is a recording of the amount of expired carbon dioxide coming out of the tube。

CO2描記圖是經(jīng)過管道呼出的CO2的量的記錄。

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When ventilating a patient in cardiac arrest，100% oxygen should be used.

當(dāng)為心臟驟停的患者進(jìn)行通氣時，應(yīng)使用100%的氧氣。

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In a person over 8 years of age，the rate of compressions and breath should be 30 to 2 for both single and two person CPR.

在對大于8歲的患者施行心肺復(fù)蘇時，按壓與通氣的比例應(yīng)該為30：2，無論是單人或是雙人的CPR都是如此。

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Finally，it's important to have access with an Intravenous (IV) line or Intraosseous(IO) line in place as soon as possible so that it's ready in case you need to start giving medications.

最后一點(diǎn)，盡可能快速建立靜脈通道（IV）或骨髓腔輸液通道（IO）也同樣重要，這樣可以隨時按需給藥。

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Compressions and ventilation are started immediately on patient without a pulse, however as soon as an AED or cardiac monitor or defibrillator is available，using it becomes the most important step.

對于無脈的患者，應(yīng)第一時間進(jìn)行胸外按壓以及人工通氣，但是當(dāng)AED、心臟監(jiān)護(hù)儀、或除顫儀送到時，使用這些儀器則成為了最重要的事。?

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The ACLS team needs to troubleshoot the non-functioning heart by diagnosing the cardiac rhythm and defibrillating if indicated.

ACLS團(tuán)隊(duì)需要對患者心臟的節(jié)律進(jìn)行分析并按需除顫，來治療患者不能工作的心臟。

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Chest compressions should be paused briefly to apply and use the AED or cardiac monitor，this allows accurate assessment of the rhythm on the ECG and determines whether it's a shockable rhythm like ventricular fibrillation（?VFib?）and pulseless ventricular tachycardia（VT）, as well as a non-shockable rhythm like asystole and pulseless electrical activity(PEA)?

胸外按壓可短暫中斷以使用AED或心電監(jiān)護(hù)儀，這樣一來就可以通過心電圖準(zhǔn)確地獲取患者心臟的節(jié)律，看是否是可除顫心律如室顫和無脈性室性心動過速，或是不可除顫節(jié)律如心臟停搏或無脈性電活動。

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In ACLS, ECG interpretation is guided by 3 questions：

Is the rhythm fast or slow？

Are the QRS complex is wider or narrow？

And is the rhythm regular or irregular？

在施行ACLS的過程中，心電圖的解讀需要從以下三個方面入手：節(jié)律是快還是慢？

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Rhythms where a defibrillator can be used to shock a patient,

---shockable rhythms are ones that are fast and have a wide QRS complex, after that VT is a regular rhythm whereas VFib is an irregular rhythm, if either VT or VFib is found?，defibrillation should be done as soon as possible.

可以使用除顫器進(jìn)行除顫的心律---即可除顫心律，表現(xiàn)為快速的心率，并且有寬大的QRS波群，其中室性心動過速心律規(guī)則，而室顫心律不規(guī)則。如果患者出現(xiàn)了室性心動過速或者室顫，應(yīng)盡快電除顫。

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Defibrillation with a synchronized shock is given when there's a regular rhythm like in VT, whereas an unsynchronized shock is given when there's no regular rhythm like in VFib.

電除顫時，同步電擊適用于心律規(guī)則的情況如室性心動過速，而非同步電擊適用于心律不規(guī)則的情況如室顫。

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The initial dose of energy that the defibrillator delivers typically ranges between 120 to 200 jewels, but a maximum dose can always be used even on the first attempt, immediately after delivering the shock chest compressions must be resumed right away without reassessing the rhythm.

除顫最開始使用的能量通常在120~200J，不過在第一次除顫時就可以使用最大能量。在放電后，第一時間應(yīng)該做的是繼續(xù)胸外按壓，而不是重新評估心律。

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After 2 minutes of chest compressions, there's a new evaluation of the rhythm through ECG，if the rhythm is still shockable, a second shock is given using the maximum available dose of energy.

在2分鐘的胸外按壓之后，應(yīng)通過心電圖重新評估患者心臟節(jié)律，如果仍然是可除顫心律，應(yīng)使用最大能量進(jìn)行第二次電除顫。

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In addition，1 mg of epinephrine is given using the IV line，all medication should be followed by a saline flush or by raising the patient's arm to guarantee that the medication travels all the way to the heart

除此以外，靜脈注射1mg腎上腺素，所有注射的藥物都行繼之以鹽水沖洗，或者通過抬高患者的手臂保證藥物到達(dá)心臟。

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Once we start using epinephrine, it's continuously given every 3 to 5 minutes, while chest compressions are being performed.

當(dāng)開始使用腎上腺素后，應(yīng)在胸外按壓的過程中，每3~5分鐘持續(xù)給藥。

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After 2 minutes of chest compressions or when there's a rotation of the person doing CPR，the rhythm is checked again.

在完成2分鐘的胸外按壓后，或是完成一輪的CPR后，要重新評估患者的心律。

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The rhythm is still shockable after a third defibrillation attempt, 300 mg of amiodarone may be administered intravenously as well, with a repeat dose of 150 mg IV as indicated, if amiodarone is unavailable, it may be replaced by 1 to 1.5 milligrams per kilogram of lidocaine given every 5 to 10 minutes.

如果經(jīng)過三次電除顫后患者仍然表現(xiàn)為可除顫心律，可靜脈注射300mg胺碘酮，并在有適應(yīng)癥的情況下重復(fù)使用150mg靜脈注射。如果沒有胺碘酮，可以使用利多卡因替代，劑量為1~1.5mg/kg，每5~10分鐘使用一次。

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Additionally，2 grams of magnesium sulfate followed by a maintenance infusion of 1 to 2 grams per hour may be used in case of polymorphic ventricular tachycardia consistent with torsade de pointes, but it's not recommended for routine use in ACLS.

除此以外，2g的硫酸鎂以1~2g/hr的速度持續(xù)滴注可以防止多形性室性心動過速如尖端扭轉(zhuǎn)型室速，但是并不推薦在常規(guī)的ACLS過程中使用。

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This whole process is repeated for however long it's needed, there's no absolute standard.?

這整個過程只要需要就可以不斷重復(fù)，并沒有絕對的停止標(biāo)準(zhǔn)。

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Generally，it's interrupted if there's a clinical change in the patient like breathing or regaining consciousness.

通常來說，當(dāng)患者臨床表現(xiàn)出現(xiàn)變化，如出現(xiàn)自主呼吸或意識恢復(fù)，此時可以停止。

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Alternatively, it may be stopped if it looks like a patient won't survive, like after 30 minutes of unsuccessful resuscitative effort or in patients with an end-tidal CO2 below 10 millimeters of mercury(mmHg).

另一方面，當(dāng)患者以沒有生存希望時也是可以停止的情況，比如

That’s because a low end-tidal CO2 following prolonged resuscitation (over 20 minutes) is a sign of absence circulation and a strong predictor of death.

因?yàn)樵陂L時間的復(fù)蘇過程中（一般大于20分鐘），如果呼氣末CO2分壓一直很低，這通常標(biāo)志著患者缺乏自主循環(huán)并且死亡率很高。

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End-tidal CO2 values are a function of carbon dioxide production and venous return to the right heart and pulmonary circulation. This is evaluated through capnography.

呼氣末CO2分壓可以體現(xiàn)CO2的排出功能、靜脈血的回心功能以及肺循環(huán)功能。呼氣末CO2分壓可以由CO2描記圖得到。

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Now，moving on to non-shockable rhythms, the most frequent one is asystole, which is where there's a complete absence of electrical and mechanical cardiac activity，the other one is pulseless electrical activity (PEA)which is a mix of electrocardiographic rhythms which result in insufficient mechanical contraction of the heart to produce a palpable pulse or measurable blood pressure.

現(xiàn)在，讓我們來看不可除顫心律，最常見的是心臟停搏，即心臟的電活動以及機(jī)械活動完全停止了，另一種是無脈電活動（PEA），即患者有心電活動但是不足以使心臟產(chǎn)生足夠的機(jī)械收縮，使得患者脈搏無法觸及或血壓無法測得。

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PEA can be associated with any electrocardiographic rhythm, and actually sinus rhythm is the most frequent type of PEA.

PEA可以出現(xiàn)在任何心電節(jié)律的情況中，事實(shí)上最常見的是竇性心律。

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Once a non-shockable rhythm is diagnosed, 1mg of epinephrine is given right away, and then given every 3 to 5 minutes while CPR is performed.

一旦診斷了不可電擊心律，應(yīng)立即給予1mg腎上腺素，并在CPR的 過程中每3~5分鐘給予一次。

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After 2 minutes of CPR the cardiac rhythm is reassessed，if it becomes shockable，defibrillation may be done, otherwise CPR must be resumed for 2 minutes and then the rhythm is reassessed，this is repeated for however long it's needed.

在2分鐘的CPR之后，重新評估心臟節(jié)律，如果轉(zhuǎn)變?yōu)榭沙澬穆?，則進(jìn)行電除顫；如果沒有轉(zhuǎn)變，則繼續(xù)2分鐘的CPR新一輪循環(huán)，然后再重新評估心律。這一過程可以不斷重復(fù)。

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If a patient improves with ACLS, the immediate post cardiac arrest treatment includes an assessment using the ABCD approach.

當(dāng)心臟驟停的患者經(jīng)過ACLS之后出現(xiàn)好轉(zhuǎn)，接著要做的就是用“ABCDE”方法進(jìn)行評估。

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That stands for?

Airways -checking if they're clear

Breathing -looking for signs of respiratory distress

Circulation-evaluating tissue perfusion and signs of bleeding

Disability-using the Glasgow Coma Scale

Exposure or examination-by doing a head to toe assessment in getting the clinical history

ABCD方法如下：

A氣道-檢查氣道是否通暢

B呼吸-檢查是否存在呼吸困難

C循環(huán)-檢查組織的灌注情況以及出血情況

D功能-通過GCS量表

E檢查-收集病史，從頭到腳對患者進(jìn)行評估

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Any additional treatable underlying causes should be identified and managed as quickly as possible.

任何可以治療的潛在的病因都應(yīng)該快速的識別并治療。

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These include hypoxia, metabolic disorders, poisoning, hypovolemia, hypothermia, tension pneumothorax, cardiac tamponade and cardiac or pulmonary thrombosis.

包括低氧，代謝紊亂，中毒，低血容量，低體溫，張力性氣胸，心包填塞，體循環(huán)或肺循環(huán)栓塞。

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All right，as a quick recap，in an unconscious patient，first you check for a pulse. In a pulseless patient，you try to see if the patient speaks or moves, then you check breathing.?

現(xiàn)在快速的小結(jié)：對于一個失去意識的患者，首先要做的是檢查脈搏。對于脈搏無法觸及的患者，檢查患者是否能說話或活動，然后檢查呼吸。

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ACLS begins in patients that are unresponsive and not breathing normally.?

當(dāng)患者沒有反應(yīng)且呼吸不正常時，開始進(jìn)行ACLS。

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Resuscitation begins with chest compressions, attaching the defibrillator, placing monitors and IV lines and obtaining the ECG.

復(fù)蘇過程以胸外按壓開始，還包括取來除顫儀，進(jìn)行心電監(jiān)護(hù)，建立靜脈通道，檢查心電圖。

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The ECG analysis will show either a shockable rhythm, like ventricular fibrillation and pulseless ventricular tachycardia,

or non-shockable rhythm like asystole and pulseless electrical activity.

通過心電圖可以看患者是處于可除顫心律（如室顫、室性心動過速），還是不可除顫心律（如心臟停搏或無脈性電活動）

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A shockable rhythm should get defibrillated as soon as possible with IV medications given each round.

患者若為可除顫心律，應(yīng)立即進(jìn)行電除顫，并在每一輪操作中靜脈給藥。

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In a non-shockable rhythm epinephrine is given right away while CPR is performed.

對于不可除顫心律，應(yīng)立即給予腎上腺素，同時進(jìn)行CPR。

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ACLS is repeated for however long it's needed.

ACLS的流程只要需要就可以不斷重復(fù)。

翻譯：star

校正：Dr.Tian