 Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical Features and Implications for and Public Responses 阿片类药物相关的院外心脏骤停:独特的临床特征和对医疗和公众的影响 A Scientific Statement From the American Heart Association 美国心脏协会的科学声明 Cameron Dezfulian, MD, Vice Chair Aaron M. Orkin, MD, MSc, MPH Bradley A. Maron, MD, Chair Jonathan Elmer, MD, MS Saket Girotra, MD, SM Mark T . Gladwin, MD Raina M. Merchant, MD Ashish R. Panchal, MD, PhD Sarah M. Perman, MD, MSCE Monique Anderson Starks, MD Sean van Diepen, MD, MSc Eric J. Lavonas, MD, MS On behalf of the American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; and Council on Clinical Cardiology ABSTRACT Opioid 阿片类药物的overdose药量过多 is the leading cause of death for Americans 25 to 64 years of age, and opioid use disorder affects >2 million Americans. The epidemiology 流行病学of opioid-associated阿片类相关药物 out-of-hospital cardiac arrest心跳骤停 in the United States is changing rapidly迅速地, with exponential increases in death resulting from synthetic opioids and linear increases线性增加 in heroin海洛因 deaths more than offsetting modest reductions减少 in deaths from prescription处方 opioids. The pathophysiology病理生理学 of polysubstance toxidromes involving opioids, asphyxial death窒息死亡, and prolonged hypoxemia长时间低氧血症 leading to global ischemia全身缺血 (cardiac arrest) differs from that of sudden cardiac arrest. People who use opioids may also develop bacteremia菌血症, central nervous system神经中枢系统 vasculitis血管炎 and leukoencephalopathy脑白质病, torsades de pointes尖端扭转性室速, pulmonary vasculopathy肺血管疾病, and pulmonary edema肺水肿. Emergency management of opioid poisoning requires recognition by the lay public or emergency dispatchers, prompt emergency response, and effective ventilation coupled有效通气结合 to compressions in the setting of opioid-associated out-of-hospital cardiac arrest（心跳骤停）. Effective ventilation有效通气 is challenging to teach, whereas naloxone纳诺酮, an opioid antagonist拮抗剂, can be administered by emergency medical personnel, trained laypeople训练有素非专业人员, and the general public with dispatcher instruction to prevent cardiac arrest. Opioid education and naloxone distributions programs have been developed to teach people who are likely to encounter a person with opioid poisoning how to administer naloxone, deliver high-quality compressions高质量的心外按压, and perform rescue breathing. Current American Heart Association recommendations call for laypeople and others who cannot reliably establish the presence of a pulse to initiate cardiopulmonary resuscitation（CPR） in any individual who is unconscious and not breathing normally; if opioid overdose is suspected, naloxone should also be administered. Secondary prevention二级预防, including counseling, opioid overdose education with take-home naloxone, and medication for opioid use disorder, is important to prevent recurrent opioid overdose. 阿片类药物过量是25至64岁美国人死亡的主要原因，阿片类药物使用障碍影响着200万美国人。在美国，与阿片类药物相关的院外心脏骤停的流行病学正在迅速发生变化，合成阿片类药物导致的死亡呈指数增长，海洛因死亡呈线性增长，这足以抵消处方阿片类药物导致的死亡略有减少。涉及阿片类、窒息死亡和长时间低氧血症导致全身缺血(心脏骤停)的多物质毒性制剂的病理生理学不同于心脏骤停。使用阿片类药物的人还可能发生菌血症、中枢神经系统血管炎和白质脑病、尖部扭转、肺血管病和肺水肿。阿片类药物中毒的紧急管理需要由非专业的公众或紧急调度员进行识别，迅速的紧急反应，在阿片类药物相关的院外心脏骤停的情况下，有效的通气与按压相结合。 有效的通气是具有挑战性的教学，而纳洛酮，一种阿片类拮抗剂，可以由紧急医疗人员，训练有素的非专业人员，和普通公众在派遣人员指导下使用，以防止心脏骤停。阿片类药物教育和纳洛酮分发项目已经开发出来，以教导可能遇到阿片类药物中毒患者的人们如何使用纳洛酮、提供高质量的按压和进行抢救呼吸。目前美国心脏协会的建议是，在昏迷和呼吸不正常的情况下，应由非专业人士和不能确定存在可靠脉搏的人来启动心肺复苏;如果怀疑阿片类药物过量，也应使用纳洛酮。二级预防，包括咨询，带纳洛酮回家的阿片类药物过量教育，以及阿片类药物使用障碍的药物治疗，对预防阿片类药物过量复发很重要。 Key Words: AHA Scientific Statements ■ analgesics opioid阿片类镇痛药 ■ heart arrest心脏停搏 ■ naloxone 纳洛酮 ■ out-of-hospital cardiac arrest院外心跳骤停 ■ pharmacoepidemiology药物流行病学 ■ public policy公共政策 ■ resuscitation复苏 DOI: 10.1161/CIR.0000000000000958 图1.阿片类药物流行史 图2.在过量死亡和纳洛酮使用背景下阿片类药物相关的院外心脏骤停(OA-OHCA)发生率 OHCA的发生率 不同年龄院外心脏骤停的用药过量与心脏原因的比例 图4.阿片类药物相关(OA)院外心脏骤停(OHCA)引起的器官损伤 图5：对阿片中毒的提示反应 图6 院外心脏骤停(OHCA)实施有效急救的改良乌斯坦公式
图7 阿片类药物相关院外心脏骤停(OA-OHCA)的知识缺口和研究重点
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