《2025美国心脏协会心肺复苏与心血管急救指南》解读——成人心肺复苏

· 指南解读 ·

《2025 美国心脏协会心肺复苏与心血管急救指南》解读——成人心肺复苏

马雯$^{1,2}$, 唐颂龄$^{1,2}$, 吴洋$^{1,2}$, 徐崇喜$^{1,2}$, 王智渊$^{1,2}$, 谢旭欣$^{1,2}$, 彭浩然$^{1,2}$, 李越涛$^{1,2}$, 邓雅露$^{1,2}$, 姚鹏$^{1,2}$, 陈瑶$^{1,2}$, 刘志昊$^{1,2}$, 甘露$^{1,2}$, 曹钰$^{1,2}$

1. 四川大学华西医院急诊科,灾难医学研究所/急诊医学研究所(成都 610041)

2. 四川大学灾难医学中心(成都 610041)

 曹钰:三级教授、主任医师、博士研究生导师。四川大学华西医院副院长,灾难医学研究所/急诊医学研究所执行所长。美国Thomas Jefferson 大学医院访问学者。现任中华医学会急诊医学分会副主任委员,中国医师协会急诊医师分会副会长,中华预防医学会灾难预防医学分会副主任委员,中华医学会灾难医学分会常务委员,中国急诊专科医联体副主席,四川省医学会急诊医学专业委员会主任委员,四川省医师协会急诊医师分会会长。兼任Signal Transduction and Targeted Therapy (STTT)、World Journal of Emergency Medicine 等期刊编委。具有丰富的急诊医学和灾难医学临床、教学、科研和管理经验。牵头制定行业/团体标准2项,牵头/参与撰写临床指南与专家共识38项。主持

纵向课题22项,其中国家自然科学基金项目6项。以第一/通信作者在STTT、Circulation Research、Journal of the American College of Cardiology、American Journal of Respiratory and Critical Care Medicine、Nano Letters、Resuscitation 等期刊发表SCI论文99篇。获授权发明专利8项;主(副)编/译教材和专著9部,其中规划教材5部。获四川省科学技术进步奖二等奖等科研成果5项。获详“全国医德楷模”“四川省新时代健康卫士”“天府青城计划-天府名医”“四川省优秀教师”等荣誉。

【摘要】 美国心脏协会于2025年10月在Circulation 杂志发布《2025美国心脏协会心肺复苏与心血管急救指南》。新版指南将原先针对不同场景和人群的成人多条生存链整合为统一的“六环生存链”,并对多个关键环节提出更新与推荐。此次更新特别强调了以下内容:基础生命支持中,施救者与患者体位优化、肥胖或俯卧位患者按压策略、气道异物梗阻系统性处理流程及自动体外除颤器应用细节;高级生命支持中,强化肾上腺素核心地位、规范血管活性药物的使用;特殊情境下(高致病性呼吸道病原体暴露、挥发性经类中毒等)的复苏策略更新;心脏骤停后综合治疗中,进一步更新呼吸与循环支持、目标体温管理与神经预后评估;救治体系层面提出公共获取纳洛酮,基于视频的调度响应以及复苏中心建设的相关建议。该文对指南核心推荐内容进行解读,以期为临床实践和教学提供参考。

【关键词】 2025美国心脏协会指南；心脏骤停；心肺复苏；生存链；除颤；气道异物梗阻

Interpretation of the "2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care": adult cardiopulmonary resuscitation

MA Wen$^{1,2}$, TANG Songling$^{1,2}$, WU Yang$^{1,2}$, XU Chongxi$^{1,2}$, WANG Zhiyuan$^{1,2}$, XIE Xuxin$^{1,2}$, PENG Haoran$^{1,2}$, LI Yuetao$^{1,2}$, DENG Yalu$^{1,2}$, YAO Peng$^{1,2}$, CHEN Yao$^{1,2}$, LIU Zhihao$^{1,2}$, GAN Lu$^{1,2}$, CAO Yu$^{1,2}$

1. Department of Emergency Medicine, Institute of Disaster Medicine and Institute of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China 2. Disaster Medical Center, Sichuan University, Chengdu, Sichuan 610041, P. R. China Corresponding author: CAO Yu, Email: caoyu@wchscu.cn

DOI: 10.7507/1002-0179.202511157 基金项目: 国家自然科学基金(82272241, 82402574); 四川省自然科学基金(2024NSFSC1531, 2023NSFSC1472); 四川大学华西医院高端人才支持计划(ZYGD23035) 通信作者: 曹钰, Email: caoyu@wchscu.cn

华西医学 2025年11月第40卷第11期

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【Abstract】 The American Heart Association published the "2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" in the journal Circulation in October 2025. The new guideline integrates the previously separate adult survival chains for different scenarios and populations into a unified "six-link survival chain" and provides updates and recommendations for multiple key components. Key updates emphasize the following contents: in basic life support, optimization of rescuers' and patients' positions, compression strategies for obese or prone patients, systematic management procedures for foreign-body airway obstruction, and details of automated external defibrillator application; in advanced life support, strengthening the core role of epinephrine and standardizing the use of vasoactive agents; updated resuscitation strategies for special situations (such as exposure to highly pathogenic respiratory pathogens and volatile hydrocarbon poisoning); in post-cardiac arrest care, further updates to respiratory and circulatory support, targeted temperature management, and neurological prognosis assessment; and recommendations at the system of care level, including public access to naloxone, video-based dispatch response, and the establishment of resuscitation centers. This article interprets the core recommendations of the guideline to offer references for clinical practice and education.

【Key words】 2025 American Heart Association guidelines; cardiac arrest; cardiopulmonary resuscitation; survival chain; defibrillation; foreign-body airway obstruction

心脏骤停是全球范围内导致死亡的主要公共卫生问题之一,尽管诊疗策略不断进步,其总体存活率仍然偏低。2025年10月25日,美国心脏协会(American Heart Association, AHA)在Circulation杂志发布最新《2025美国心脏协会心肺复苏与心血管急救指南》(以下简称“2025指南”)[1-6],基于最新循证研究,对院前、院内心肺复苏以及相关心血管急救策略进行全面更新与完善,提出760项具体推荐,包括233项1级、451项2级和76项3级推荐。2025指南的突出特点之一,是将以往按人群及情境分别构建的成人生存链整合为统一的单六环生存链,并围绕其核心环节提出新的或修订后的证据推荐。本文对2025指南中各项重要推荐进行解读,重点关注具有临床意义、争议性或可能改变成人复苏培训与实践的内容,以期为临床救治与科研实践提供高质量参考。

1 基础生命支持

1.1 施救者与患者的体位

高质量胸外按压是改善心脏骤停患者预后的核心要素之一。通过优化施救者与患者的体位,可提高按压深度、频率及连续性,改善复苏质量。

1.1.1 施救者按压体位 2025 指南推荐:对于成人心脏骤停患者,施救者实施胸外按压时,应尽可能使患者躯干保持与自身膝盖基本齐平(推荐级别1级;证据水平B-NR级)。施救者体位相对于患者的位置会直接影响胸外按压的生物力学效率。多项随机对照试验(randomized controlled trial, RCT)显示,相较于站立位,跪立位的按压更省力[7-8],更易维持高质量的按压,包括更长的有效按压时间、

更多的按压次数和更合格的按压深度[9-10]。在转运途中,与步行按压相比,骑跨担架按压可获得更佳的按压质量[111],该优势在女性施救者中更明显[12]。然而,也有研究提示,在转运车上,骑跨按压与传统按压在按压质量与施救者疲劳方面相当,无显著差异[13]。因此,未来仍需更多高质量研究以验证转运环境下骑跨按压的优势与适应情境。

1.1.2 患者体位 ① 俯卧位按压。2025 指南推荐：对于俯卧位发生心脏骤停的成年患者，在条件允许时，应将其翻转为仰卧位后再实施胸外按压；若无法安全翻转，则可在确保气道管理的前提下考虑俯卧位下实施胸外按压（推荐级别2b级；证据水平C-LD级）。回顾性临床研究证实，当仰卧位胸外按压无法立即实施且气道得到充分保护时，俯卧位按压可作为可行替代方案[14-15]。2025年一项系统综述纳入21例神经外科或脊柱手术中发生心脏骤停并接受俯卧位按压的患者，均恢复自主循环[16]。相较于仰卧位，俯卧位按压可能获得更高的收缩压、更短启动除颤的时间[17]，但现有证据主要来源于小样本观察性研究及案例报道，缺乏大规模临床试验，其适用人群及优势仍需进一步验证。

②头高位心肺复苏(head-up cardiopulmonary resuscitation, HU-CPR)。2025指南推荐:除临床试验外,不建议对成人心脏骤停患者实施HU-CPR(推荐级别3级;证据水平C-LD级)。HU-CPR的猪模型研究结果存在相互矛盾[18-19]。虽然多个临床研究均显示出HU-CPR的益处[20-22],但最近国际复苏联络委员会(International Liaison Committee on Resuscitation, ILCOR)的一项系统综述认为,纳入HU-CPR的观察性分析研究有显著的方法学局限,

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West China Medical Journal, Nov. 2025, Vol. 40, No. 11

存在高偏倚风险及其他研究质量问题[23]。因此ILCOR 将 HU-CPR 在“出院存活率”及“出院时神经功能良好存活率”等关键结局上的证据水平评定为“极低”。HU-CPR的临床应用仍需等待高质量 RCT 验证。

1.2 胸外按压

1.2.1 肥胖成人患者 2025 指南推荐: 对于肥胖成人心脏骤停患者,应采用与非肥胖患者相同的标准心肺复苏技术(推荐级别1级;证据水平C-LD级)。2024年一项系统综述纳入36项关于肥胖患者心肺复苏的原始研究[24],结果显示:肥胖与非肥胖患者心肺复苏结局缺乏一致结论[25-28],目前鲜有研究直接比较肥胖与非肥胖患者复苏质量评价指标或技术的差异。因此现阶段尚无充分证据支持针对肥胖患者实施差异化心肺复苏策略。

2025 指南推荐:对于肥胖成人心脏骤停患者,为达到推荐按压深度(≥5cm),施救者可能需要施加更大的按压力(推荐级别2b级;证据水平C-EO级)。研究提示,按压产生的压强大小受物体表面特性影响[29]。因此对于肥胖心脏骤停患者,为达有效按压深度(至少5cm),施救者可能需加大按压力度。1.2.2 按压效果分析 2025 指南推荐:对于成人心脏骤停患者,伪迹滤除算法识别胸外按压期间自主心律恢复的有效性尚未明确(推荐级别2b级;证据水平C-LD级)。胸外按压可导致心电图产生伪迹而干扰潜在自主心律的识别。伪迹滤除等创新技术能够识别心肺复苏时潜在的心律,从而在尽量减少胸部按压中断的同时提供诊断优势。一项横断面研究发现,采用伪迹滤除算法分析自主心律指导按压可显著提高胸外按压分数(77% vs. 72%),缩短心室颤动(室颤)再发至电击时间(117 vs. 53 s),但患者的出院生存率无显著差异[30],且尚无高质量RCT证实其可以改善生存结局[31]。

1.2.3 机械胸外按压 2025指南推荐:不推荐在成人心脏骤停中常规使用机械按压设备(推荐级别3级:无益;证据水平B-R级)。多个大型RCT与系统综述一致显示,机械胸外按压在成人院外心脏骤停(out-of-hospital cardiac arrest, OHCA)中并不优于人工按压的常规策略,甚至在部分研究中出现更差的神经结局或潜在伤害[32-39];动物实验普遍显示,机械胸外按压可提供更优的血流动力学参数,如更高的冠状动脉灌注压、脑灌注、平均动脉压(mean arterial pressure, MAP)以及更少的肋骨骨折等,转运环境下也可维持更稳定参数[40-44],但这些生理优势未能转化为明确的生存获益。

1.3 气道异物梗阻 (foreign-body airway obstruction, FBAO)

1.3.1 清醒FBAO 2025指南推荐:对于清醒成人出现严重FBAO,应反复实施5次背部拍击后,紧接5次腹部冲击,直至异物排出或患者失去意识(推荐级别1级;证据水平B-NR级)。气道阻塞时间越长,死亡率越高[45],及时解除FBAO可改善1个月生存率及神经功能预后[46]。加拿大一项纳入709例FBAO患者的回顾性研究显示,相较于腹部冲击及胸部冲击,背部拍击具有更高的FBAO缓解率和出院存活率[47],且干预相关性损伤更少[48-49]。然而,目前尚缺乏大样本、前瞻性临床试验证实,故该建议仍部分借鉴儿童指南的相关依据。

1.3.2 昏迷 FBAO 2025 指南推荐:若严重 FBAO患者失去反应,施救者应立即开始心肺复苏,首选胸外按压,并尽快启动紧急呼救系统(推荐级别1级;证据水平C-LD级)。胸外按压可产生足够的气道压力以排出异物[50]。日本一项研究纳入138例因气道异物阻塞失去意识的患者(其中69例发生心脏骤停),结果显示,胸外按压可有效改善昏迷FBAO患者的神经功能预后[51]。在实施心肺复苏前,应去除可见异物,但避免盲目探取不可见异物,以防进一步损伤或推挤异物[52]。

1.3.3 特殊 FBAO 2025 指南推荐: 对于救援人员无法环绕患者,无法实施腹部冲击(如妊娠晚期、体型限制等)的FBAO患者,可采用5次背部拍击加5次胸部冲击的组合策略,直至异物排出或患者失去意识(推荐级别1级;证据水平C-LD级)。对于此类特殊情境,目前证据有限。气道清除装置是一种基于非动力吸引的设备,其可能是解除FBAO的有效替代方式。如LifeVac与Dechoker在221例患者中恢复正常呼吸的成功率为96.38%[53-54]。但其安全性与有效性仍需进一步临床验证。

1.4 自动体外除颤器(automated external defibrillator, AED)

1.4.1 电极片放置 ①电极片位置。2025指南推荐:针对成人心脏骤停患者可将电极片置于前外侧或前后位置,并建议使用直径>8 cm的贴片(推荐级别2a级;证据水平C-LD级)。尽管多项研究证实前后位置除颤可以改善患者预后[55-56],但总体证据显示,两种电极片位置的除颤成功率差异无统计学意义[57],最佳的电极片位置仍有待进一步研究。

②胸罩位置。2025指南推荐:放置除颤电极片时可调整胸罩位置,而非必需将其脱下以完全暴露胸部(推荐级别2b级;证据水平C-EO级)。一系列

华西医学 2025年11月第40卷第11期

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列研究表明,女性 OHCA 患者在公共场所的 AED 使用率显著低于男性[58-60],其可能原因包括暴露患者隐私顾虑、潜在的法律责任以及被指控不当接触等[61]。一项猪模型研究证实,将 AED 电极片直接置于胸罩金属钢圈上方,仍能取得100%首次除颤成功率,且无电弧、导电偏移或皮肤灼伤等不良事件[62]。尽管目前缺乏关于“是否需常规去除胸罩”的直接临床证据,但通过“调整胸罩而非脱除”,既可确保电极片与皮肤充分接触,也有望减少施救顾虑、缩短电极片放置时间、提高 AED 使用率,减少关键措施延误。

1.4.2 室颤波形分析 2025 指南推荐：室颤波形分析[如频谱振幅面积(amplitude spectrum area, AMSA)]指导复苏的临床价值尚未正确证（推荐级别2b 级；证据水平 C-LD 级）。一项小规模 RCT 显示，与标准除颤相比，采用 AMSA 指导除颤并未提高室颤终止率(74% vs. 75%)[63]；另一项多中心观察性研究则发现，AMSA 与除颤成功率存在相关性，但其预测效能因使用胺碘酮而降低[64]，提示 AMSA 更适合作为除颤成功的生理指标或风险分层工具。最新一项纳入 1646 例可除颤 OHCA 患者的研究显示，首个 AMS 值可有效区分“真正难治性室颤”与“反复性室颤”，提示其可作为早期识别难治性室颤亚型的潜在标志物。但现有研究多为回顾性分析，且唯一前瞻性随机研究受样本量限制，尚不足以证明 AMSA 指导除颤可改善生存或神经预后[65]，未来需开展更大样本、高质量的临床试验予以验证。

1.4.3 除颤策略 ①双相波除颤。2025指南推荐:对于成人心脏骤停快速性心律失常患者应优先使用双相波除颤(推荐级别2a级;证据水平B-R级)。一项大CT显示,与200~360J单相波除颤相比,150J双相波的除颤成功率(96% vs.59%)和自主循环恢复(storrelation of spontaneous circulation,ROSC)率更高(76% vs.54%),且出院时短期良好神经功能患者的比例更高(87% vs.53%)[66]。虽然现有研究一致认为,双相波可实现更高的电除颤成功率,但其对患者长期生存结局的改善仍缺乏一致性证据[67-69]。

② 单次除颤策略。2025指南推荐:对于成人心脏骤停患者,倡导“单次除颤策略,避免叠加连续除颤(推荐级别2a级;证据水平B-NR级)。随着双相波技术的发展,首次除颤成功率显著提高,而叠加电击会增加按压暂停时间,影响冠状动脉与脑灌注[70]。基于临床数据分析显示,除颤前暂停或围电击总暂停时间每延长5s,出院生存率分别下

降约18%与14%,提示更长的暂停时间与更差的生存结局相关[71-73]。目前,已有研究通过设备与算法优化缩短除颤前/后暂停,从流程层面进一步支撑减少中断、提升复苏质量的策略,但其对长期生存的影响仍需更多临床研究加以验证[74]。

③双重序贯除颤。2025指南推荐:针对心脏骤停且在连续3次及以上除颤后仍持续室颤/无脉性室性心动过速(室速)的成年患者,改变电击矢量及双重序贯除颤的有效性尚不确定(推荐级别2b级;证据水平B-R级)。加拿大一项纳入405例难治性心室颤动患者的多中心随机交叉试验结果显示,与标准除颤相比,矢量改变除颤和双重序贯除颤均可显著提高患者出院生存率(21.7% vs. 13.3%和30.4% vs. 13.3%),且双重序贯除颤可显著改善患者神经功能预后[55]。然而,目前关于替代除颤策略的研究报道有限,且不同研究存在异质性大、质量参差不齐及潜在偏倚等问题,证据的有效性尚未确定[75]。

2 高级生命支持

2.1 药物

2.1.1 肾上腺素 2025指南推荐:对于成人心脏骤停患者,建议使用肾上腺素进行治疗(推荐级别1级;证据水平B-R级),但不建议常规使用大剂量肾上腺素(推荐级别3级:无益处;证据水平B-R级)。肾上腺素仍是治疗心脏骤停的标准疗法,该指南推荐进一步强化其在高级生命支持中的核心地位。目前仍缺乏高质量证据明确肾上腺素的最佳给药次数、累积剂量上限及最优给药时机,这将是未来研究方向。

2.1.2 胺碘酮 2025指南推荐:成人心脏骤停患者若出现对除颤无反应的室颤或无脉性室速,可考虑使用胺碘酮或利多卡因(推荐级别2b级;证据水平B-R级)。此推荐延续2020指南并结合新证据[76]。一项纳入1112例OHCA患者的研究表明胺碘酮的复律效果呈“时间依赖性下降”,即给药越晚,ROSC率越低;利多卡因未表现出类似规律。这提示在难治性室性心律失常中“尽早给药”可能更有利于恢复自主循环[76]。

2.1.3 钙剂 2025指南推荐:复苏过程中,不推荐常规使用钙剂、碳酸氢钠、镁剂(推荐级别3级;证据水平B-R级)。对于疑似高钾血症导致的心脏骤停,静脉给予钙剂或碳酸氢钠的有效性仍不明确(推荐级别2级;证据水平C-LD/C-EO级)。Dillon 等[77]的一项回顾性研究表明,经验性使用钙剂与入院生

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存率下降呈正相关。系列 OHCA 钙剂应用研究提示：在 OHCA 患者中，基于心电图表现的经验性钙剂应用可能增加不良结局风险[78-79]。常规经验性使用钙剂的风险可能高于潜在收益。

2.2 给药途径

虽然本指南未新增给药途径推荐,但近年证据显示骨通道可作为静脉的替代通路。一项纳入1007例 OHCA患者的研究表明,与“仅静脉”相比,“静脉+骨通道”策略可显著提高血管通路建立成功率、缩短首次给肾上腺素时间,但未改善ROSC率及生存结局[80]。2025年发表的2项大型RCT一致显示,骨通道与静脉途径在ROSC率、30d存活率及神经功能预后方面差异无统计学意义[81-82]。这些结果强调:复苏时关键在于迅速建立可用通路并尽早完成肾上腺素给药,而非特定途径本身的优劣。

3 心脏骤停后治疗

心脏骤停后 ROSC 的患者仍面临多器官功能障碍的风险,系统性、精准化的呼吸支持、循环管理及神经预后评估是改善预后的关键。2025指南在此部分提出多项循证更新。

3.1 呼吸支持

3.1.1 吸入氧浓度 2025 指南推荐: 对于成人ROSC患者, 在获得可靠脉搏血氧饱和度或动脉血氧分压监测前, 应持续给予100%吸入氧浓度(推荐级别1级; 证据水平B-R级)。一项针对ROSC后昏迷患者的RCT研究比较入院早期采用低氧饱和度目标(90%~94%)与高氧目标(98%~100%)对生存率的影响, 结果显示低氧目标未改善生存率, 反而增加低氧事件风险[83]。

3.1.2 脉搏血氧仪偏差 2025 指南推荐: 脉搏血氧仪可能在深肤色患者中系统性高估氧饱和度,导致“隐匿性低氧血症”,因此临床人员应警惕其潜在缺氧风险(推荐级别2b级;证据水平C-LD级)。3项观察性研究一致显示:深肤色患者中脉搏血氧饱和度相较真实动脉血氧分压存在显著性偏差[84-86]。可能导致低氧识别延迟、延误干预。临床实践中需结合动脉血气分析或多源监测以降低风险。

3.2 循环支持

2025 指南推荐:避免低血压,维持MAP≥65 mm Hg(1 mm Hg=0.133 kPa)(推荐级别1级;证据水平B-R级)。多项观察性研究证实:ROSC后低MAP与生存率下降以及不良神经功能预后相关[87-89]。然而,多项RCT结果显示,与“较低MAP目标”相比,并未发现“较高MAP目标”可改

善结局[90-91]。2025年发表的贝叶斯分析提示,对于年轻患者,较低MAP目标(如63mm Hg)可能更有优势[92],说明个体化管理可能成为未来方向。因此,2025指南删除了传统收缩压指标,明确以MAP作为核心管理目标。

3.3 高碳酸血症管理

2025 指南推荐:对于ROSC后仍昏迷的患者,应将动脉血二氧化碳分压维持在正常生理范围(35~45 mm Hg)(推荐级别1级;证据水平 B-R级)。最新RCT发现,正常碳酸血症组(35~45 mm Hg)与轻度高碳酸血症组(50~55 mm Hg)患者在6个月神经功能结局及次要结局(如存活率)方面差异均无统计学意义[93]。尽管一项Meta分析提示高碳酸血症可能改善短期神经结局[94],但更多系统综述显示其不改善死亡率或住院时长[95-96],因此指南维持“正常碳酸血症”策略。

3.4 目标体温管理

2025 指南推荐: 对 ROSC 后昏迷的患者, 应将目标体温维持在 32 ~ 37.5℃ (推荐级别 1 级; 证据水平 B-R 级)。一项系统综述纳入 6 项随机试验, 显示低温 (32 ~ 34℃) 与常温 (36℃ 或自然体温) 在生存率方面差异无统计学意义[97]。然而, 对于脑损伤程度较重或不可除颤心律的患者, 低温管理仍可能带来潜在的神经保护效应[98-99]。因此 2025 指南采取“范围式体温管理”, 同时更强调避免发热。

3.5 神经预后评估

神经预后应采用多模式评估(临床检查、电生理、影像学、生物标志物等),不应在ROSC后过早作出不可逆性判断。2025指南推荐:心脏骤停后72 h 内血清神经元特异性烯醇酶(neurone specificenolase, NSE)或神经丝径链(neurofilament light chain, NfL)高表达,联合其他预后评估,可辅助判断ROSC后昏迷患者的不良神经预后(推荐级别2b级;证据水平B-NR级)。2025指南新增NfL为神经损伤标志物,多项研究证据显示NfL在心脏骤停后的动态变化(尤其是24~72 h内),与神经预后密切相关[100-101]。ROSC后72 h NfL持续升高提示不良神经结局,其预测的敏感性和特异性均优于传统标志物 NSE[102]。

4 特殊情境的复苏

4.1 高致病性呼吸道病原体

2025 指南推荐:在2021疫情后进一步扩展相关推荐,将高致病性呼吸道病原体纳入一般复苏情境管理。核心内容包括:识别气溶胶产生操作、个

华西医学 2025年11月第40卷第11期

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人防护装备优化、气道管理策略(含插管方式优化)、人员配置与环境控制。指南强调需要在“防护”与“复苏质量”之间取得平衡,即在避免传播的同时尽可能减少个人防护装备使用带来的按压延迟或操作质量下降。《2021年欧洲复苏委员会指南》中已提出新型冠状病毒感染疫情期间的心肺复苏救治建议,本团队此前已对该内容进行解读[103]。

4.2 高钾血症

2025 指南推荐: 对于疑似高钾血症所致心脏骤停,钙剂与碳酸氢钠的复苏疗效仍不确定(推荐级别2b级;证据水平C-LD/C-EO级)。最新一项大动物模型研究显示,碳酸氢钠在高钾心脏骤停模型中显著提高ROSC率并缩短复苏时间,氯化钙则未显示明显作用[104]。但缺乏高质量临床研究,因此临床管理仍需谨慎。

4.3 高热与低温

4.3.1 高热 2025 指南推荐: 对危及生命的高热成人患者, 应在标准复苏的同时启动主动降温(推荐级别1级; 证据水平 C-EO); 其中冰水浸泡(1~5℃)优于其他方式(推荐级别2a级; 证据水平 B-R级)。一项系统综述纳入63项研究显示, 针对成人中暑, 冰水浸泡具有最快降温速率[105], 与2025年重症医学学会中暑指南一致[106]。目前尚无随机试验评估高热伴心脏骤停患者降温策略。

4.3.2 低温 2025指南推荐:对于危及生命的环境性低体温且无明显致命的患者,应立即开展全面复苏并同步复温(推荐级别1级;证据水平C-LD级)。3项研究显示,重度低体温患者在复温前实施积极复苏可提升存活率,且体外生命支持复温在部分病例中具有显著生存优势[107-109]。

4.4 中毒

2025 指南推荐：针对“挥发性烃类物质”致危及生命且常规治疗无效的室性心律失常，使用β-受体阻滞剂可能合理（推荐级别2b级；证据水平C-EO级）。β-阻滞剂可降低心肌对内源性儿茶酚胺的敏感性，一项回顾性研究显示8例使用肾上腺素的患者全部死亡，而未使用肾上腺素的6例患者均存活至出院，其中5例神经功能良好[110]。针对苯二氮草类、心血管药物等中毒的复苏策略，AHA既往指南已作出具体推荐意见，本团队此前已发表相关内容的专题解读[111-112]。

5 心脏骤停救治体系

5.1 统一生存链

2025 指南推荐：简化救治流程，将原先按成

人/儿童、院外/院内分别设计的多条生存链简化为统一的六环结构:“识别与启动-高质量心肺复苏-除颤-高级复苏-心脏骤停后照护-康复与生存”。全链条适用于不同类型的心脏骤停,从系统层面提出多项关键策略,以进一步提升院前与院内救治效率。高质量心肺复苏的标志已更新为包含按压和呼吸的形式,用肺部图标表示,这一调整认可了呼吸在儿童心脏骤停复苏以及相当一部分成人心脏骤停(如溺水或阿片类药物中毒引起的心脏骤停)复苏中的重要性。指南强调该生存链仍缺乏“预防和准备”环节。

5.2 公众获取纳洛酮

2025 指南推荐:鼓励立法保障非专业人员可合法持有与使用纳洛酮,以降低阿片类药物过量相关死亡率(推荐级别1级;证据水平B-NR级)。大量观察性研究表明:放宽处方限制可降低阿片相关心脏骤停死亡率[113-114],社区纳洛酮分发计划具有剂量依赖的死亡率降低效应[115-117]。指南高度肯定非专业人员获取纳洛酮对公共卫生的价值。

5.3 基于视频的响应调度

2025 指南推荐: 对具备能力的急救系统, 基于视频的OHCA响应调度可能是一种合理策略(推荐级别2b级; 证据水平B-NR级)。基于视频的OHCA响应调度系统能够让调度员实时观察患者状态, 可更精准指导胸外按压, 若按压质量不足可及时纠正。初步观察性研究显示: 视频指导的电话心肺复苏在院前ROSC、存活至出院及良好神经功能结局方面优于传统心肺复苏[118-119], 模拟研究一致支持视频指导可提高按压质量[120]。但应用率低(<20%)、视频连接时间延迟等问题需进一步评估。

5.4 复苏中心建设

2025 指南推荐:若当地机构无法提供全面复苏后治疗时,应将 ROSC 患者转运至具备专科能力的复苏中心(推荐级别2b级;证据水平B-R级)。最新RCT结果表明,与转诊至地理位置最近的急诊科相比,被送往特定复苏中心的患者30d全因死亡率没有差异[121]。但另一项观察性研究发现,当患者来自较小的急诊科时,直接或间接转运至特定复苏中心对患者出院神经功能恢复更有益[122]。因此指南持“条件性推荐”,强调因地制宜。

6 总结

2025 指南在结构上将多场景生存链整合为统一的六环模型,并在基础生命支持、高级生命支持、心脏骤停后治疗、特殊情境管理与救治体系建

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设方面提供多项循证更新。这些推荐反映以下趋势:持续强化高质量胸外按压核心地位(体位优化、减少停顿、策略更新);复苏后管理更趋向精准化(氧管理、二氧化碳目标、MAP目标、体温管理、NIK.标志物);更强调特异性复苏,在毒物、感染性病原体等情境提供可操作指南;急救体系建设强调公共卫生与系统资源整合(纳洛酮获取、视频调度、复苏中心转运)。然而指南也暴露出证据不足的领域,例如:俯卧位按压、HU-CPR、双重序贯除颤、通气策略、难治性室颤识别与特殊中毒复苏。上述知识空白亟待更多大样本、高质量的RCT填补。

利益冲突:所有作者声明不存在利益冲突。

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收稿日期: 2025-11-14 修回日期: 2025-11-20

本文编辑: 孙艳梅