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Ani Kalp Olumu ANİ KALP ÖLÜMÜ Klinik ve Teknik İpuçları ile: TEMEL ve İLERİ YAŞAM DESTEĞİ AKUT TEDAVİ VE KORUNMA Yazar Prof. Dr. Rasim ENAR İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi Kardiyoloji ABD NOBEL TIP KİTABEVLERİ © 2016 Nobel Tıp Kitabevleri Tic. Ltd. Şti. ANİ KALP ÖLÜMÜ Klinik ve Teknik İpuçları ile TEMEL ve İLERİ YAŞAM DESTEĞİ AKUT TEDAVİ VE KORUNMA Yazar: Prof. Dr. Rasim Enar ISBN: 978-605-335-?????????????????????????? Arka kapak fotoğrafı Adnan Şentürk kolleksiyonundan alınmıştır. 5846 ve 2936 sayılı Fikir ve Sanat Eserleri yasası hükümleri gereğince herhangi bir bölümü, resmi veya yazısı, yazarların ve yayınlayıcısının yazılı izni alınmadan tekrarlanamaz, basılamaz, kopyası çıkarılamaz, fotokopisi alınamaz veya kopya anlamı taşıyabilecek hiçbir işlem yapılamaz. NOBEL TIP KİTABEVLERİ TİC. LTD. ŞTİ. Millet Cad. No: 111 Çapa-İstanbul Tel : (0212) 632 83 33 Faks : (0212) 587 02 17 DAĞITIM Tel : (0212) 771 52 11 - (0212) 771 33 09 Faks : (0212) 771 52 03 - (0212) 771 06 18 Yayımcı : Nobel Tıp Kitabevleri Tic. Ltd. Şti. Millet Cad. No:111 34104 Fatih-İstanbul Yayımcı Sertifika No : 15710 Baskı / Cilt : No-bel Matbaacılık San. Tic. Ltd. Şti. Ömerli mevki İhsangazi Cad. Tunaboyu sk. No. 3 Arnavutköy – Hadımköy – İstanbul Matbaa Sertifika No : 12565 Sayfa Tasarımı - Düzenleme : Nobel Tıp Kitabevleri Kapak Tasarım : Nobel Tıp Kitabevleri Baskı Tarihi : ???? 2016 - İstanbul Kitabın yazım aşamasının son evresinde kaybettiğim (13 Ocak 2016) sevgili annem Piraye Enar’ın aziz anısına... Prof. Dr. Rasim Enar YAZARIN DİĞER ESERLERİ 1. Trombolitik Tedavi, (Yazar) 1997 2. AMİ El Ki ta bı, (Editör, Yazar) 1998 3. AMİ Komp li kas yon lar, (Editör, Yazar) 1998 4. AMİ Trom bo kar di yo lo ji, (Yazar) 2004 5. Ka nı ta Da ya lı Akut Mi yo kard İn fark tü sü Kitabı, (Editör, Yazar) 2005 6. Akut Miyokard İnfarktüsü Teşhis ve Tedavi Kılavuzu, (Yazar) 2006 7. Temel Kardiyoloji, (Editör, Yazar) 2007 8. Kalp ve Damar Sağlığı Kılavuzu, (Yazar) 2007 9. Kanıta Dayalı Kalp Yetersizliği Kitabı, (Editör, Yazar) 2010 10. Temel Kardiyoloji, Kalbin Fizik Muayenesi: Tekniği ve Klinik İpuçları, (Yazar) 2012 11. Pratik İnvazif Kardiyoloji, (Editör, Yazar) 2015 iv TEŞEKKÜR Kitabın özgün yapısının oluşturulmasında katkısı olan Cerrahpaşa Tıp Fakültesi Kar- diyoloji ABD asistanları Uz. Dr. Abdülcelil Sait Ertuğrul (Bölüm 10), Uz. Dr. Hasan Ali Barman (Bölüm 8’in ikinci editi, Bölüm 10) ve kateterizasyon laboratuarı sekreteri Doğukan Düzce ile İç Hastalıkları 5. kat görevlileri Selami Geren ve Mümin Güler’e teşekkürlerimle... Ve ayrıca kitabın hazırlanmasında bana destek olan Prof. Dr. Teoman Soysal’a sevgi ve saygılarımla... Prof. Dr. Rasim ENAR İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi Kardiyoloji ABD v ÖNSÖZ Bilim bilgeliktir; doğruları öğrenip, öğretmek ve uygulamaktır . Tıp bilmi ise bilginin özsuyu ile klinik pratiğin hamurunun yoğrulması ve ortaya doğru ürünü çıkarmaktır” (NR). Akut kardiyak arrest (ARA) ve Ani kalp ölümünün (AKÖ) akut tedavisi ve öncesinde alınması gereken önlemler son çeyrek asırdır gelişmiş acil Tıp ve müdahale sistem- lerine rağmen önemi ve güncelliğini korumuştur. Bunun başlıca sebebi olayın doğa- sından kaynaklanan AKA’nın “birdenbire, beklenmedik” meydana gelişi ve önerilen optimal tedavi olanaklarının (defibrilatör ve eğitimli kurtarıcı) olayın meydana geldiği mekana kurbanın beyin hasarı gelişmeden önce ulaştırılmasının imkansızlığıdır. Bu sorunların aşılmasında göz önünde bulundurulması gereken en mantıklı yaklaşım AKÖ’ye yatkınlığı ve riski bulunan kişilerin önceden tanınması ve AKA’yı presipite eden, tetikleyen faktörlerin saptanıp bertaraf edilmesidir. Bu amaçla, “1981-2002 yıllarında Enstitü’de aktif akut kardiyoloji yaşamımın kazandırdığı bilgi, deneyim, bilgelik ve sonrasında yaklaşık 8-10 yıl üçüncü sınıf tanımlanamayan bir yerlerde izlemek zorunda bırakıldığım akut kardiyolojinin yanlış ve eksikliklerini sergileyen cehaletin sınırsız ve pervasız eylemlerine tanık olmanın verdiği sorumluluk ile kitabım 2005’den günümüze konu ile ilgili yayınlan- mış tüm önemli çalışma, metaanaliz, makaleler, uzman görüşleri, güncellemeler ve de özellikle bir bölümü aşağıda belirtilmiş uluslararası kardiyoloji cemiyetlerinin kılavuz- larının içerdiği yüzlerce sayfalık bilgi, kanıt ve tavsiye okunup, derlenerek düzenlen- miş ve yatakbaşı pratik kullanıma uygun hale getirilmiştir. Dolayısı ile kitabın tüm bilgi tavsiyeleri kanıta dayalı tıbba ve/veya gerçek hayatta olay yerinde uygulanmış uzman görüşleri ve deneyimlerine dayanmaktadır. Kitap, AKÖ ve AKA’nın konu ile ilişkili klasik ve 2015’de güncellenmiş modern bilgile- rini kapsayan ve yatakbaşı fizik muayenesi ve standart 12 derivasyonlu yüzey EKG’si ile teşhisi, Temel- ve İleri-Yaşam Destekleri ile Post-Ressüsitasyon bakımını, bir de ventrikülerin taşiaritmilerin akut ve uzun dönem tedavilerini içermektedir. • ACC/AHA/ESC 2006 Guidelines for Management of Patients WithVentricular Arrhythmias and the Prevention of Sudden Cardiac Death. Circulation. 2006;114:e385-e484. • 2010 American Heart AssociationGuidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S729-S767 (doi: 10.1161/CIRCULATIONAHA.110.970988) • 2013- HRS/EHRA/APHRS Expert Consensus Statement on the Diagnosis and Management of Patients with Inhe- rited Primary Arrhythmia Syndromes. Heart Rhythm 2013; 10 (12): 1932-52 (http://dx.doi.org/10.1016/j.hrthm. 2013.05.014). • 2014 EHRA/HRS/APHRS Expert Consensus on Ventricular Arrhythmias. Heart Rhythm, Vol 11, No 10, 2014 (http:// dx.doi.org/10.1016/j.hrthm.2014.07.024 ). • 2012 ACCF/AHA/HRS Focused Update IncorporatedInto the ACCF/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. JACC 2013; Vol. 61, ( 3): e6–75. • 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardio- vascular Care. Circulation 2015;132[suppl 2]:S315–S367. DOI: 10.1161/CIR.0000000000000252). • 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. European Heart Journal (doi:10.1093/eurheartj/ehv316) Prof. Dr. Rasim ENAR İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi Kardiyoloji ABDvii İÇİNDEKİLER BÖLÜM 1 Başlarken .................................................................................................................................1 BÖLÜM 2 Ani Kalp Ölümü ...................................................................................................................13 Ani Kalp Ölümünün Sebepleri ve Altta Yatan Patolojiler ...............................16 AKÖ Riski Majör Kalp-Damar Hastalıkları .............................................................29 Kardiyak Arrestli Hastanın Klinik Özellikleri ........................................................75 BÖLÜM 3 “Pratik ve Teknik İpuçları ile” Erişkinde Temel Yaşam Desteği (ABLS-‘Adult basic life support’) ...................................................................................81 Erişkinde Temel Yaşam Desteği (BLS) Dizisi Pratiği ..........................................84 Özel Canlandırma Durumları ................................................................................105 Sağlık Uzmanlarının Pratik Temel Yaşam Desteği (BLS) Uygulama Dizisi ......................................................................................................107 BÖLÜM 4 Erişkinde İleri Kardiyovasküler Yaşam Desteği (ACLS) ................................115 Havayolu Ekleri ve Aletleri (Cihazlar) ..................................................................118 Kardiyak Arreste Yaklaşım ......................................................................................132 Kardiyak Arrest Sırasında Parenteral İlaç Verilmesi .......................................148 Semptomatik Bradikardi ve Taşikardinin Tedavisi .........................................160 BÖLÜM 5 Kardiyak Arrest Sonrası (Post-Kardiyak Arrest) Bakım ................................187 Post-Arrest Hastalarında Vazoaktif İlaçların Kullanımı .................................201 BÖLÜM 6 CPR Teknikleri ve Cihazlar ..........................................................................................209 CPR teknikleri ..............................................................................................................209 CPR cihazları ................................................................................................................213 ix x İçindekiler BÖLÜM 7 Elektriksel Tedaviler ......................................................................................................219 Otomatik Eksternal Defibrilatör (OED) ...............................................................228 Senkronize Kardiyoversiyon ..................................................................................230 • GÜNCELLENMİŞ 2015 AHA ECC UYGULAMA KILAVUZU: KARDİYOPULMONER RESÜSSİTASYON VE ACİL KARDİYOVASLÜLER BAKIM İÇİN KILAVUZLARI ....................................235 BÖLÜM 8 Ventriküler Taşikardi: Yatakbaşı 12-D EKG ile “Teşhisten Tedaviye” ....................................................................................................245 BÖLÜM 8-1 Geniş QRS Kompleksli Taşikardinin Tanı Kriterleri ................................245 Geniş QRS Kompleksli Taşikardinin Pratik Ayırıcı Tanısı Algoritması .......................................................................................................260 BÖLÜM 8-2 Ventriküler Taşikardi’de Tedavi Yaklaşımları ..........................................277 Tekrarların Önlenmesinde VT’nin Uzun-Dönem Tedavisi
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