Unexpected Cardiac Arrest and Anesthesia

æ≈æ—π∏å ∫ÿ≠¡“° • Polpun Boonmak ∫∑øóôπøŸ«‘™“°“√ • Review Article ¿“«–À—«„®À¬ÿ¥‡µâπ∑’ˉ¡à§“¥§‘¥·≈–«‘ —≠≠’«‘∑¬“ æ≈æ—π∏å ∫ÿ≠¡“° ¿“§«‘™“«‘ —≠≠’«‘∑¬“ §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬¢Õπ·°àπ Unexpected Cardiac Arrest and Anesthesia Polpun Boonmak Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002 Thailand ‚¥¬∑—Ë«‰ª¿“«–À—«„®À¬ÿ¥‡µâπ À¡“¬∂÷ß ¿“«–·∑√°´âÕπ ∑’Ë∑”„ÀâÀ—«„® à߇≈◊Õ¥‰ª‡≈’Ȭß√à“ß°“¬‰¡à‡æ’¬ßæÕ ´÷Ëß®”‡ªìπ µâÕ߉¥â√—∫°“√°¥Àπâ“Õ° ‚¥¬Õ“®√à«¡°—∫ °“√„À⬓ ·≈– °“√™ÁÕ°À—«„®¥â«¬‰øøÑ“4-6 ´÷Ë߇√“Õ“®æ∫§≈◊Ëπ‰øøÑ“À—«„® ‰¥âÀ≈“°À≈“¬µ—ßÈ ·µà§≈◊πË ‰øøÑ“À—«„®ª°µ‘ ‰ª®π∂÷ߧ≈◊πË ‰øøÑ“ ·∫∫ ventricular fibrillation ”À√—∫¿“«–À—«„®À¬ÿ¥‡µâπ ∑’Ë ‰ ¡à § “¥§‘ ¥‡ªì π ∂“π°“√≥å ∑’Ë „ Àâ ° “√¥Ÿ · ≈ºŸâ ªÉ « ¬≈”∫“° ‡π◊Ë Õ ß®“°‰¡à “¡“√∂‡µ√’ ¬ ¡°“√≈à « ßÀπâ “ ®÷ ß ¢“¥·§≈π ∑—Èß°”≈—ß§π ¬“ Õÿª°√≥åµà“ßÊ ∑”„Àâ‡√“®”‡ªìπµâÕß¡’§«“¡ ‡¢â“„®‡°’¬Ë «°—∫≈—°…≥–¿“«–À—«„®À¬ÿ¥‡µâπ∑’‰Ë ¡à§“¥§‘¥ ‡æ◊ÕË „Àâ “¡“√∂¥Ÿ·≈ºŸâªÉ«¬‰¥â„π ∂“π°“√≥å∑’Ë¡’∑√—欓°√®”°—¥ ‡π◊ÈÕÀ“ 1. §«“¡ ”§— ≠ ·≈–§”®”°— ¥ §«“¡¢Õß¿“«–À— « „® À¬ÿ¥‡µâπ∑’ˉ¡à§“¥§‘¥ 2. 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𠵓¡ª√–‡∑»·≈– ∂“π∑’Ë ∑’Ë »÷ ° …“‡π◊Ë Õ ß®“°¡’ À≈“¬ªí®®—¬∑’ˇ°’ˬ«¢âÕß ‡¡◊ÕË »÷°…“‡©æ“–„π°≈ÿ¡à ∑’¡Ë §’ «“¡‡ ¬’Ë ß ßŸ ®–æ∫Õÿ∫µ— °‘ “√≥å ‡æ‘Ë¡¢÷È𠇙àπ °“√ºà“µ—¥À—«„® (127 µàÕºŸâªÉ«¬ 10,000 √“¬) ºŸâªÉ«¬‡¥Á° ºŸâªÉ«¬ ŸßÕ“¬ÿ ‡ªìπµâπ ·µà‡¡◊ËÕ»÷°…“µ“¡«‘∏’°“√ „À⬓√–ß—∫§«“¡√Ÿâ ÷°æ∫«à“ general anesthesia ¡’Õÿ∫—µ‘°“√≥å ∑’Ë≈¥≈ß°«à“ 20 ªï∑’˺à“π¡“ ¢≥–∑’Ë regional anesthesia ·≈– • Srinagarind Med J 2008; 23(2) 215 ¿“«–À—«„®À¬ÿ¥‡µâπ∑’ˉ¡à§“¥§‘¥·≈–«‘ ≠ — ≠’«‘∑¬“ • monitored anesthesia care ¬—ߧߡ’Õÿ∫—µ‘°“√≥å∑’Ë„°≈⇧’¬ß°—∫ „πÕ¥’µ §◊Õ ª√–¡“≥ 1.5 ·≈– 0.7 µàÕºŸâªÉ«¬ 10,000 √“¬ µ“¡≈”¥—∫ ®“°°“√»÷°…“æ∫«à“¿“«–À—«„®À¬ÿ¥‡µâπ «à π„À≠à ∑’‡Ë °‘¥‰¡à‰¥â¡’ “‡Àµÿ‚¥¬µ√ß®“°«‘ ≠ — ≠’8 ´÷ßË ¿“«–À—«„®À¬ÿ¥‡µâπ ∑’Ë — ¡ æ— π ∏å °— ∫ «‘ — ≠ ≠’ ‚ ¥¬µ√ß„πºŸâ ªÉ « ¬∑—Ë « ‰ªæ∫ª√–¡“≥ 0.65 - 1 µàÕºŸâªÉ«¬ 10,000 √“¬ 5, 9 ·≈–‡¡◊ËÕ»÷°…“‡©æ“–„π ºŸâªÉ«¬‡¥Á°®–¡’Õÿ∫—µ‘°“√≥å Ÿß¢÷Èπ §◊Õ 1.4 - 4.6 µàÕºŸâªÉ«¬ 10,000 √“¬ 8, 10 ”À√— ∫ „πª√–‡∑»‰∑¬°“√»÷ ° …“¢Õß √“™«‘ ∑ ¬“≈— ¬ «‘ — ≠ ≠’ · æ∑¬å · Àà ß ª√–‡∑»‰∑¬‡°’Ë ¬ «°— ∫ °“√ ‡ 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à«π “‡Àµÿ¥â“π°“√¢“¥ÕÕ°´‘‡®π ‡™àπ √–∫∫ ∑“߇¥‘πÀ“¬„®≈⡇À≈« §«“¡¥—π‚≈À‘µµ°∑”„Àâ‡≈◊Õ¥‰ª‡≈’¬È ß à«πµà“ßÊ ¢Õß√à“ß°“¬‰¡à‡æ’¬ßæÕ ‡ªìπµâπ ‚¥¬¡—°æ∫„π‡¥Á° ºŸâªÉ«¬∑’ˉ¥â√—∫∫“¥‡®Á∫ ºŸâªÉ«¬‰¥â√—∫¬“‡°‘π¢π“¥ ºŸâªÉ«¬®¡πÈ” àߺ≈„Àâ√–∫∫À“¬„®≈⡇À≈«À√◊Õ¡’‡≈◊Õ¥‰ª‡≈’È¬ß à«πµà“ßÊ ¢Õß√à “ ß°“¬‰¡à ‡ æ’ ¬ ßæÕ∑”„Àâ Õ «— ¬ «–µà “ ßÊ ¢Õß√à “ ß°“¬ ¢“¥ÕÕ°´‘‡®π ”À√— ∫ ß“π¥â “ π«‘ — ≠ ≠’ «‘ ∑ ¬“‰¥â ¡’ ° “√»÷ ° …“ “‡Àµÿ ¢Õß¿“«–À—«„®À¬ÿ¥‡µâπ∑’Ëæ∫„π√–À«à“ßÀ√◊ÕÀ≈—ß°“√«“߬“ √–ß—∫§«“¡√Ÿâ ÷° „πÕ¥’µ “‡Àµÿ à«π„À≠৫“¡¥—π‚≈À‘µµ° ‚¥¬‡©æ“–®“°¬“ ≈∫∑’Ë„™âÀ√◊Õ°“√ Ÿ≠‡ ’¬‡≈◊Õ¥ ·≈–¿“«– ¢“¥ÕÕ°´‘‡®π‡ªìπÀ≈—° ´÷Ëßæ∫¡“°¢÷Èπ„πºŸâ ŸßÕ“¬ÿ ºŸâªÉ«¬∑’Ë¡’ Õ“°“√√ÿπ·√ß ´÷Ëß𔉪 Ÿà°“√æ—≤π“‡∑§π‘§ ¬“™π‘¥µà“ßÊ ·≈– °“√®—¥µ—ÈßÀâÕßæ—°øóôπ °“√¥Ÿ·≈ºŸâªÉ«¬Õ¬à“ß„°≈♑¥∑’Ëπ“π¢÷Èπ ®“°°“√»÷°…“„πªí®®ÿ∫—πæ∫«à“ “‡ÀµÿÀ≈—°¢Õß¿“«– À—«„®À¬ÿ¥‡µâπ8, 10, 13-17 §◊Õ §«“¡¥—π‚≈À‘µµ°‚¥¬‡©æ“–®“°°“√ æ√àÕ߇≈◊Õ¥·≈– “√πÈ”®“°°“√‡ ’¬‡≈◊Õ¥¡“°‡ªì𠓇ÀµÿÀ≈—° ∑—Èß„π™à«ß°àÕπºà“µ—¥ ¢≥–ºà“µ—¥ ·≈–™à«ßÀ≈—ßºà“µ—¥ ‚¥¬ 216 »√’π§√‘π∑√凫™ “√ 2551; 23(2) Unexpected Cardiac Arrest and Anesthesia • Srinagarind Med J 2008; 23(2) æ≈æ—π∏å ∫ÿ≠¡“° • 4. ¿“«–©ÿ°‡©‘π 5. æ∫„π‡æ»™“¬¡“°°«à“‡æ»À≠‘ß 6. πÕ°™à«ß‡«≈“∑”ß“πª°µ‘ 7. µ√’ µ—È ß §√√¿å ‚¥¬‡©æ“–‰¥â √— ∫ °“√«“߬“√–ß— ∫ §«“¡√Ÿâ ÷°·∫∫∑—Ë«‰ª 8. °“√„Àâ ∫ √‘ ° “√«‘ — ≠ ≠’ ‚ ¥¬‰¡à ‰ ¥â ‡ ªì π ∫ÿ § ≈“°√∑“ß «‘ —≠≠’ 9. Õ◊ËπÊ ‡™àπ Hematocrit πâÕ¬°«à“ √âÕ¬≈– 30 ¡’ª√–«—µ‘ malignant hyperthermia ‰¥â√—∫¬“ MAOI ¿“«–À— « „®À¬ÿ ¥ ‡µâ π ∑’Ë ‰ ¡à § “¥§‘ ¥ °— ∫ °“√©’ ¥ ¬“™“‡¢â “ ‰¢ —πÀ≈—ß Õÿ ∫— µ‘ ° “√≥å ¢ Õß¿“«–À— « „®À¬ÿ ¥ ‡µâ π °— ∫ °“√„™â ¬ “™“ ‡©æ“–∑’Ëæ∫ 1.8 µàÕºŸâªÉ«¬ 10,000 √“¬ ¢≥–∑’ËÕÿ∫—µ‘°“√≥å ¢Õß¿“«–À—«„®À¬ÿ¥‡µâπ„π°“√©’¥¬“™“‡¢â“‰¢ —πÀ≈—ßæ∫ Ÿß °«à“§◊Õ 2.9 - 3.5 µàÕºŸâªÉ«¬ 10,000 √“¬ 21-23 ¡—°æ∫„πºŸâªÉ«¬ ∑’Ë¡’ ASA physical status µË” ·≈–¡—°æ∫·∫∫‰¡à§“¥§‘¥ ´÷ßË ‡°‘¥®“° “‡Àµÿ¢Õß√–∫∫À“¬„®≈⡇À≈«∑”„À⢓¥ÕÕ°´‘‡®π ∂÷ß√âÕ¬≈– 50 24 ‡™àπ total spinal block ‡ªìπµâπ πÕ°®“°π’Ȭ—ß ‡°‘¥®“°¿“«– bradycardia 25 ∑’ˇ°‘¥®“° high spinal block À√◊Õ ®“° Bezold Jarisch Reflex À√◊ÕÕ“®‡°‘¥¿“«–¬“™“‡ªìπæ‘… ¿“«–À— « „®À¬ÿ ¥ ‡µâ π ®– — ¡ æ— π ∏å °— ∫ °“√‡°‘ ¥ §«“¡¥— π ‚≈À‘µµ°·≈–À—«„®‡µâπ™â“µË”°«à“ 60 §√—ÈßµàÕπ“∑’ ´÷Ëߧ«“¡ ¥—π‚≈À‘µµ°æ∫ª√–¡“≥√âÕ¬≈– 36.8 ‚¥¬æ∫¡“°¢÷Èπ„π ºŸâªÉ«¬ ŸßÕ“¬ÿ °“√ºà“µ—¥§≈Õ¥ °“√„Àâ “√πÈ”°àÕπ©’¥¬“™“ πâÕ¬°«à“ 500 ¡≈. √–¥—∫°“√™“ Ÿß°«à“ T4 BMI ¡“°°«à“ 30 26, 27 à«πÀ—«„®‡µâπ™â“µË”°«à“ 60 §√—ÈßµàÕπ“∑’ æ∫√âÕ¬≈– 4.9 - 10.2 ∂⓵˔°«à“ 40 §√—ÈßµàÕπ“∑’ æ∫√âÕ¬≈– 0.7 ‚¥¬æ∫¡“°¢÷Èπ ‡¡◊ËÕ√–¥—∫°“√™“ Ÿß°«à“ T4 ‡æ»™“¬ Õ—µ√“°“√‡µâπ¢Õß À— « „®µË” ¿“«– first degree AV block à « πÕ“¬ÿ π—È π ∫“ß°“√»÷°…“æ∫«à“Õ“¬ÿπÕâ ¬‡ªìπªí®®—¬‡ ¬’Ë ß26 ∫“ß°“√»÷°…“ æ∫«à“ Õ“¬ÿ¡“°‡ªìπªí®®—¬‡ ’ˬß27 πÕ°®“°π’Ȭ—ß —¡æ—π∏å°—∫°“√¥Ÿ·≈√—°…“¿“«–·∑√°´âÕπ ‰¡à‡À¡“– ¡À√◊ՙⓇ°‘π‰ª °“√≈–‡≈¬º≈¢Õ߬“Õ◊ËπÊ ∑’Ë„™â √à « ¡°— ∫ °“√©’ ¥ ¬“™“‡¢â “ ‰¢ — π À≈— ß28, 29 ºŸâ ªÉ « ¬∑’Ë ‰ ¥â √— ∫ ¬“ πÕπÀ≈—∫Õ◊Ëπ√à«¡¥â«¬3 ¿“«–©ÿ°‡©‘π ·≈–°“√„™â¬“ tetracaine °“√ªÑÕß°—π°“√‡°‘¥¿“«–À—«„®À¬ÿ¥‡µâπ °“√ªÑÕß°—π°“√‡°‘¥¿“«–À—«„®À¬ÿ¥‡µâπ‰¥â∫√√®ÿ‰«â„π ¡“µ√∞“π°“√«“߬“√–ß—∫§«“¡√Ÿâ ÷° °“√∑’Ë¡’∫ÿ§≈“°√∑’Ë¡’ §«“¡ “¡“√∂∑’Ë„Àâ°“√¥Ÿ·≈µ“¡¡“µ√∞“π ·≈–°“√¡’Õÿª°√≥å ‡ΩÑ“√–«—ß∑’ˇÀ¡“– ¡ °Á®– “¡“√∂™à«¬≈¥Õÿ∫—µ‘°“√≥å„π à«π ¢Õß«‘ —≠≠’≈߉¥â πÕ°®“°π’È„π à«π∑’ˇ°’ˬ«¢âÕß°—∫«‘ —≠≠’ ¬— ß “¡“√∂ªÑ Õ ß°— π ‰¥â ‚ ¥¬°“√≈¥§«“¡‡ ’Ë ¬ ߢÕߺŸâ ªÉ « ¬ °“√‡≈◊Õ°„™â¬“∑’Ë¡’ª√– ‘∑∏‘¿“æ °“√∑’Ë ¡’ ∫ÿ § ≈“°√∑’Ë ¡’ § «“¡ “¡“√∂∑’Ë „ Àâ ° “√¥Ÿ · ≈ µ“¡¡“µ√∞“π ∫ÿ § ≈“°√§«√¡’ § «“¡√Ÿâ §«“¡‡¢â “ „®„π ¡“µ√∞“π°“√ª√–‡¡‘πºŸâªÉ«¬∑—Èß°“√´—°ª√–«—µ‘ µ√«®√à“ß°“¬ ·≈–µ√«®∑“ßÀâÕߪؑ∫—µ‘°“√µ“¡§«“¡®”‡ªìπ32 ‡π◊ËÕß®“° ¿“«–À— « „®À¬ÿ ¥ ‡µâ π ∫“ߧ√—È ß ‡°‘ ¥ ®“°°“√‰¡à ª √–‡¡‘ π À√◊ Õ ª√–‡¡‘πºŸâªÉ«¬‰¡à¥’∑”„À≡à∑√“∫‚√§∑’˺ŸâªÉ«¬‡ªì𠬓∑’Ë·æâ √à“ß°“¬∑’Ë¡’§«“¡º‘¥ª°µ‘ πÕ°®“°π’È∫ÿ§≈“°√§«√ªØ‘∫—µ‘ß“π µ“¡¡“µ√∞“π°“√¥Ÿ · ≈°“√«“߬“√–ß— ∫ §«“¡√Ÿâ ÷ ° ∑—È ß ·∫∫ general anesthesia ·≈– regional anesthesia √«¡∑—Èß°“√ monitored anesthesia care33 ´÷Ëß®–™à«¬„Àâ¡’§«“¡ª≈Õ¥¿—¬ ¡“°¢÷Èπ ∫ÿ§≈“°√§«√µ√–Àπ—°‡¡◊ËÕ¥Ÿ·≈ºŸâªÉ«¬°≈ÿà¡∑’Ë¡’§«“¡‡ ’Ë¬ß ‡™à𠇥Á°·√°‡°‘¥ ºŸâ ŸßÕ“¬ÿ ºŸâ∑’Ë¡’‚√§ª√–®”µ—« ‡ªìπµâπ ‚¥¬ µâÕß¡’§«“¡„ à„® ‰¡à≈–‡≈¬ µàÕ¿“«–µà“ßÊ ∑’ˇ°‘¥¢÷Èπ ·≈– ¡’§«“¡√Ÿâ∑’ˇ°’ˬ«¢âÕß°—∫°“√¥Ÿ·≈¿“«–µà“ßÊ ∑’ËÕ“®π”‰ª Ÿà ¿“«–À—«„®À¬ÿ¥‡µâ𠇙àπ °“√‡ ’¬‡≈◊Õ¥ °“√„ à∑àՙ૬À“¬„® ‰¡à‰¥â ‡ªìπµâπ ‚¥¬µâÕß¡’°“√µ—¥ ‘π„®∑’ˇÀ¡“– ¡ ‡™àπ °“√∑’Ë¡’ §«“¡¥—π‚≈À‘µµ°À√◊ÕÀ—«„®‡µâπ™â“®“° spinal block §«√„Àâ °“√√—°…“∑—π∑’ ‡ªìπµâπ ∫“ß°“√»÷°…“æ∫«à“°“√¡’«‘ —≠≠’ ·æ∑¬åÀ√◊Õ«‘ —≠≠’·æ∑¬å‡©æ“–∑“ß®–™à«¬„À⇰‘¥Õÿ∫—µ‘°“√≥å πâÕ¬≈ß·≈–∑”„À⺟âªÉ«¬¡’Õ—µ√“√Õ¥™’«‘µ Ÿß¢÷Èπ34 πÕ°®“°π’È §«“¡√Ÿâ∑’Ë∑—π¬ÿ§®–™à«¬≈¥Õÿ∫—µ‘°“√≥å≈ß ‡™àπ °“√„™â goal directed therapy ‡ªìπµâ𠧫“¡√Ÿâ·≈–∑—°…–¢Õß°“√∑” BLS (basic life support), ACLS (advanced cardiac life support), PALS (pediatric advanced ªí®®—¬‡ ’ˬߢÕß°“√‡°‘¥¿“«–À—«„®À¬ÿ¥‡µâ𠇪ìπ∑’Ë∑√“∫¥’«à“ºŸâªÉ«¬∑ÿ°√“¬∑’Ë¡“√—∫°“√«“߬“√–ß—∫ §«“¡√Ÿâ ÷°¡’‚Õ°“ ∑’ˇ°‘¥¿“«–À—«„®À¬ÿ¥‡µâπ ¥—ßπ—Èπ¡“µ√∞“π °“√¥Ÿ · ≈ºŸâ ªÉ « ¬®÷ ß µâ Õ ß Ÿ ß ·≈–¡’ ° “√‡ΩÑ “ √–«— ß Õ¬à “ ß„°≈â ™‘ ¥ ‚¥¬„™â∫ÿ§≈“°√∑“ß«‘ —≠≠’·≈–Õÿª°√≥å™à«¬‡ΩÑ“√–«—ß ·µà Õ¬à“߉√°Áµ“¡ „πºŸâªÉ«¬∫“ß√“¬æ∫«à“¡’§«“¡‡ ’ˬߡ“°°«à“ ª°µ‘ ´÷ßË π‘¬¡ª√–‡¡‘πºŸªâ «É ¬µ“¡ ASA physical status πÕ°®“° π’Ȭ—ß¡’°“√»÷°…“À≈“¬°“√»÷°…“∑’Ë欓¬“¡√–∫ÿªí®®—¬‡ ’Ë¬ß ‡æ◊ÕË π”‰ª °Ÿà “√«“ß·ºπ„π°“√ªÑÕß°—π¿“«–À—«„®À¬ÿ¥‡µâπ17, 30-31 ‡™àπ 1. §«“¡√ÿπ·√ߢÕß‚√§ Ÿß À√◊Õ ASA physical status ¡“°°«à“ III 2. Õ“¬ÿπâÕ¬À√◊Õ¡“° ‡™à𠇥Á°·√°‡°‘¥ ∑“√° ºŸâ ŸßÕ“¬ÿ ‚¥¬‡©æ“–¡“°°«à“ 84 ªï 3. ‚√§µà“ßÊ ‡™àπ ‚√§À—«„®·µà°”‡π‘¥ morbid obese °“√µ‘¥‡™◊ÈÕ„π√–∫∫∑“߇¥‘πÀ“¬„® à«π∫π„π‡¥Á° »√’π§√‘π∑√凫™ “√ 2551; 23(2) Polpun Boonmak • Srinagarind Med J 2008; 23(2) 217 ¿“«–À—«„®À¬ÿ¥‡µâπ∑’ˉ¡à§“¥§‘¥·≈–«‘ ≠ — ≠’«‘∑¬“ • life support)6, 12, 17 ®–™à«¬ªÑÕß°—πÕÿ∫—µ‘°“√≥å ·≈–™à«¬≈¥ °“√‡ ’¬™’«‘µ≈߉¥â®“°°“√¥Ÿ·≈∑’ˇÀ¡“– ¡ ‚¥¬∑—Ë«‰ªæ∫«à“ ¿“¬À≈—ß°“√Ωñ°Õ∫√¡ §«“¡√Ÿâ®–§àÕ¬Ê ≈¥≈ß ´÷Ëß®”‡ªìπµâÕß ∑∫∑«πÕ¬Ÿà‡ªìπ√–¬–Ê „π∫“ß°“√»÷°…“§«“¡√ŸâÕ“®Õ¬Ÿà‡æ’¬ß 6-12 ‡¥◊Õπ35 °“√¡’Õÿª°√≥å‡ΩÑ“√–«—ß∑’ˇÀ¡“– ¡ °“√¡’Õÿª°√≥å °“√‡ΩÑ“√–«—ß∑’ˇÀ¡“– ¡ ®–™à«¬„Àâ “¡“√∂«‘π‘®©—¬ªí≠À“ ‰¥â‡√Á«¢÷πÈ ´÷ßË ®–≈¥º≈·∑√°´âÕπ≈߉¥â ‚¥¬æ∫«à“ °“√„™â‡§√◊ÕË ß pulse oximeter “¡“√∂™à«¬ªÑÕß°—πÕÿ∫µ— °‘ “√≥å‚¥¬‡©æ“–°√≥’ ∑’Ë ‡ °‘ ¥ ®“°¿“«–¢“¥ÕÕ°´‘ ‡ ®π36 à«π‡§√◊ËÕß capnogram °Á “¡“√∂™à«¬ªÑÕß°—πÕÿ∫—µ‘°“√≥å„π°√≥’∑’ˇ°‘¥®“°¿“«–¢“¥ ÕÕ°´‘‡®π ·≈–°“√ºà“µ—¥ ¡Õß34, 36 à«π‡§√◊ËÕß«—¥ bispectral index °Á “¡“√∂™à«¬≈¥°“√„À⬓ ≈∫‡°‘𧫓¡®”‡ªìπ °“√≈¥§«“¡‡ ’Ë ¬ ߢÕߺŸâ ªÉ « ¬ °“√„™â¬“°≈ÿà¡ beta blocker „π√“¬∑’¡Ë ¢’ Õâ ∫àß™’„È π°“√„™â “¡“√∂≈¥¿“«–·∑√°´âÕπ ∑“ß√–∫∫‰À≈‡«’¬π‚≈À‘µ √«¡∑—Èß≈¥Õ—µ√“°“√‡ ’¬™’«‘µ„π √–¬–¬“«37 À√◊Õ °“√ºà“µ—¥‡¡◊ÕË ºŸªâ «É ¬¡’§«“¡æ√âÕ¡∑’Ë ¥ÿ ‡ªìπµâπ °“√‡≈◊Õ°„™â¬“∑’¡Ë ª’ √– ∑‘ ∏‘¿“æ ¬“∑’„Ë ™â„π∑“ß«‘ ≠ — ≠’ ∑ÿ°«—ππ’ȇ°◊Õ∫∑—ÈßÀ¡¥∂◊Õ«à“‡ªìπ¬“∑’Ë¡’§«“¡ª≈Õ¥¿—¬ Ÿß ‡¡◊ËÕ ¡’„™âÕ¬à“ß√–¡—¥√–«—ß ·≈–¡’°“√¥Ÿ·≈¢≥–„™â¬“Õ¬à“ß„°≈♑¥ ·µàª≠ í À“∑’æË ∫ §◊Õ °“√‰¡à√–¡—¥√–«—ß°“√„™â °“√„À⬓º‘¥¢π“¥ º‘¥§π º‘¥¬“ ´÷ËßµâÕß¡’ °“√ªÑÕß°—πÕ¬à“ß√Õ∫§Õ∫ √–∫∫ß“π·≈– ‘Ëß·«¥≈âÕ¡∑’Ë¥’ √–∫∫ß“π∑’Ë¥’¡’°“√ ª√–‡¡‘πºŸâªÉ«¬°àÕπºà“µ—¥ ¡’°“√∑”ß“π‡ªìπ∑’¡·∫∫ À “¢“ ∑’Ë Õ¥§≈â Õ ß°— π √«¡∑—È ß °“√¡’ Àâ Õ ßæ— ° øóô π ∑’Ë ¥Ÿ · ≈ºŸâ ªÉ « ¬ Õ¬à “ ß„°≈â ™‘ ¥ ≈â « π·µà ™à « ¬„Àâ ‡ °‘ ¥ Õÿ ∫— µ‘ ° “√≥å ≈ ¥πâ Õ ¬≈ß ¿“æ·«¥≈âÕ¡„π∑’Ë∑”ß“π∑’Ë¥’ ¡’°“√∑”ß“π‡ªìπ∑’¡ “¡—§§’ ¡’ § «“¡æ÷ ß æÕ„®µà Õ ß“π Ÿ ß ®–™à « ¬„Àâ ª √– ‘ ∑ ∏‘ ¿ “æ¢Õß ∫ÿ § ≈“°√¥’ ¢÷È π à ß º≈≈¥°“√‡°‘ ¥ ¿“«–·∑√°´â Õ π √«¡∑—È ß °“√°”Àπ¥√–¬–‡«≈“∑”ß“π∑’Ë ‡ À¡“– ¡ ‰¡à ∑”„Àâ ‡ °‘ ¥ §«“¡‡Àπ◊Ë Õ ¬≈â “ ‡°‘ 𠉪 38 ´÷Ëߧ«“¡‡Àπ◊ËÕ¬≈â“¡—°π”‰ª Ÿà §«“¡º‘¥æ≈“¥¢Õ߇®â“Àπâ“∑’∫Ë “ß°“√»÷°…“æ∫«à“§«“¡º‘¥æ≈“¥ ‡ªì𠓇ÀµÿÀπ÷Ëß∑’Ë ”§—≠¢Õß°“√‡°‘¥¿“«–À—«„®À¬ÿ¥‡µâπ9 πÕ°®“°π’È°“√®—¥°“√∑’˙૬≈¥¿“«–À—«„®À¬ÿ¥‡µâ𠇙àπ °“√¥Ÿ·≈ºŸâªÉ«¬∑’˵âÕß„À⬓√–ß—∫§«“¡√Ÿâ ÷°‚¥¬«‘ —≠≠’ °“√®—¥ §«“¡æ√âÕ¡¢Õß ∂“π∑’Ë„π°“√√—∫Õÿ∫—µ‘°“√≥å °“√®—¥®”π«π ∫ÿ § ≈“°√„Àâ ‡ À¡“– ¡‚¥¬‡©æ“–°√≥’ ∑’Ë ¡’ ¿ “«–©ÿ ° ‡©‘ π39 ‡ªìπµâπ ‚¥¬∑’ÀË ≈“¬°“√»÷°…“æ∫«à“™à«ßπÕ°‡«≈“∑”ß“πª°µ‘ ‡ªìπ™à«ß∑’Ë¡’§«“¡‡ ’ˬߵàÕ¿“«–À—«„®À¬ÿ¥‡µâπ38 ·≈–ºŸâªÉ«¬ ®–¡’‚Õ°“ √Õ¥™’«‘µπâÕ¬≈ß„π™à«ß¥—ß°≈à“« 218 »√’π§√‘π∑√凫™ “√ 2551; 23(2) Unexpected Cardiac Arrest and Anesthesia °“√¥Ÿ · ≈ºŸâ ªÉ « ¬ ‡¡◊Ë Õ ‡°‘ ¥ ¿“«–À— « „®À¬ÿ ¥ ‡µâ π ∑’Ë ‰ ¡à §“¥§‘¥ 3, 6, 17, 40 1. ªÑÕß°—π‚¥¬¥Ÿ·≈ºŸâªÉ«¬Õ¬à“ß√Õ∫§Õ∫ „ à„®µàÕ ≠ — ≠“≥‡µ◊Õπµà“ßÊ §≈◊πË ‰øøÑ“À—«„®À“¬‰ª °“√«—¥§«“¡¥—π ‚≈À‘µ‰¡à‰¥â §≈◊Ëπ¢Õߧ“√å∫Õπ‰¥ÕÕ°‰´¥å∑’ËÀ“¬‰ª §≈◊Ëπ¢Õß ‡§√◊ÕË ß«—¥§«“¡Õ‘¡Ë µ—«¢ÕßÕÕ°´‘‡®π∑’ÀË “¬‰ª ‡ΩÑ“¥ŸºªâŸ «É ¬µ≈Õ¥ ¥Ÿ‡≈◊Õ¥ ∑’ §’Ë ≈È”≈ß ‡¢’¬« À¡¥ µ‘ Õ“°“√§≈◊πË ‰ Õâ “‡®’¬π À“¬„® ‰¡àÕ‘Ë¡ ‡Àµÿ°“√≥å‡À≈à“π’ÈÕ“®π”¡“´÷Ëß¿“«–À—«„®À¬ÿ¥‡µâπ‰¥â 2. «‘π®‘ ©—¬¿“«–À—«„®À¬ÿ¥‡µâπ °“√«‘π®‘ ©—¬¿“«–À—«„® À¬ÿ¥‡µâπ∑”‚¥¬°“√§≈”™’æ®√∑’Ë carotid artery, femoral artery À√◊Õ brachial artery („π‡¥Á°) À√◊Õ ¡’§«“¡¥—π‚≈À‘µµË”‡°‘π°«à“ ®–¡’‡≈◊Õ¥‰ª‡≈’È¬ß ¡Õ߇撬ßæÕ ´÷Ëߧ≈◊Ëπ‰øøÑ“À—«„®Õ“®‡ªìπ ≈—°…≥–„¥°Á‰¥â Õ“®‡ªìπ ventricular fibrillation, asystole, bradycardia, tachycardia À√◊Õ normal sinus rhythm °Á‰¥â6 §«“¡ º‘¥æ≈“¥∑’ËÕ“®æ∫ §◊Õ „πºŸâ„À≠à‡¡◊ËÕ¡’¿“«– pulseless electrical activity (PEA) À√◊Õ„π‡¥Á°∑’¡Ë À’ «— „®‡µâπ™â“°«à“ 60 §√—ßÈ µàÕπ“∑’·≈–¡’‡≈◊Õ¥‰ª‡≈’Ȭß√à“ß°“¬‰¡àæÕ·≈⫉¡à∑”°“√°¥ Àπâ“Õ°∑”„À⥟·≈ºŸâªÉ«¬‰¥â≈à“™â“ 3. µ—Èß µ‘ „®‡¬Áπ ∑∫∑«π ‘Ëß∑’ˇ°‘¥¢÷Èπ ∑∫∑«π§«“¡√Ÿâ ·≈–∑—°…–∑’Ë¡’ ‡æ◊ËÕ¥Ÿ·≈ºŸâªÉ«¬„À⥒∑’Ë ÿ¥ °“√∑’ËÀ“ “‡Àµÿ‰¥â‡√Á« ®–™à«¬„À⥟·≈ºŸâªÉ«¬‰¥â¥’¢÷Èπ 4. ·®â߇æ◊ËÕπ√à«¡ß“π‡æ◊ËÕ„Àâ∑√“∫‚¥¬∑—Ë«°—π ∑—Èß·æ∑¬å ‡®â“¢Õ߉¢âÀ√◊Õ»—≈¬·æ∑¬å ∑’¡æ¬“∫“≈ à߇§√◊ËÕß¡◊Õ ·≈– ‡®â“Àπâ“∑’ËÕ◊ËπÊ ‡°’ˬ«¢âÕß ‡æ◊ËÕ„Àâ∑√“∫ ∂“π°“√≥å∑’ˇ°‘¥¢÷Èπ ·≈–¢Õ§«“¡™à«¬‡À≈◊Õ∑’˵âÕß°“√ ‡™àπ Õ“®À¬ÿ¥ºà“µ—¥ À√◊Õ Õ“®„Àâ™à«¬À¬ÿ¥°“√‡ ’¬‡≈◊Õ¥ ‡ªìπµâπ 5. ªî¥¬“ ≈∫·≈–¬“∑ÿ°™π‘¥∑’ˉ¡à®”‡ªìπ ‚¥¬‡©æ“– ¬“∑’ËÕ“®°√–µÿâπ„À⺟âªÉ«¬·¬à≈ß 6. ª√–‡¡‘π∑“߇¥‘πÀ“¬„® ‡ªî¥∑“߇¥‘πÀ“¬„®·≈– ™à«¬À“¬„® ‚¥¬„ÀâÕÕ°´‘‡®π 100 ‡ªÕ√凴Áπµå·°àºŸâªÉ«¬∑ÿ°√“¬ ·≈–™à«¬À“¬„®ºà“π∑“ßÀπâ“°“° À√◊Õ∑àՙ૬À“¬„® «à π°√≥’ „ à∑àՙ૬À“¬„®·≈⫧«√µ√«® Õ∫µ”·Àπàß«à“‡À¡“– ¡ À√◊Õ‰¡à‚¥¬°“√¥Ÿ øíßÀ√◊Õ„™âÕÿª°√≥å™à«¬ „π°√≥’∑’ˉ¡à “¡“√∂ ™à«¬À“¬„®À√◊Õ„ à∑àՙ૬À“¬„®‰¥âÕ“®æ‘®“√≥“„™âÕÿª°√≥å Õ◊ËπÊ ™à«¬ ‡™àπ LMA, cricothyroidotomy ‡ªìπµâπ 7. °“√™à « ¬À“¬„®„πºŸâ ªÉ « ¬∑’Ë ¡’ ¿ “«–À— « „®À¬ÿ ¥ ‡µâ π ª√‘¡“≥≈¡®–≈¥≈ß®“°ª°µ‘§◊Õ 6-7 ¡≈. µàÕ °°. À√◊ՙ૬ À“¬„®®πÀπâ“Õ°¢¬“¬ ‡π◊ËÕß®“°ª√‘¡“≥‡≈◊Õ¥‰ª¬—ßÀ—«„®¡’ πâÕ¬°«à“ºŸâªÉ«¬ª°µ‘ ·≈–™à«¬À“¬„®·§à 8-10 §√—ÈßµàÕπ“∑’ °“√™à«¬À“¬„®¡“°‡°‘π‰ª∑”„Àâª√‘¡“≥‡≈◊Õ¥°≈—∫ ŸàÀ—«„® πâÕ¬≈ß • Srinagarind Med J 2008; 23(2) æ≈æ—π∏å ∫ÿ≠¡“° • 8. °“√°¥Àπâ“Õ°§«√∑”∑—π∑’‡¡◊ËÕ‰¡à¡’™’æ®√„πÕ—µ√“ 100 §√—Èß µàÕπ“∑’ ‚¥¬§«√°¥≈÷° 1.5-2 π‘È«„πºŸâ„À≠à °√≥’∑’Ë ‰¡à‰¥â„ à∑àՙ૬À“¬„®§«√°¥„πÕ—µ√“ 30 µàÕ 2 ¬°‡«âπ„𠇥Á°∑’¡Ë ∫’ §ÿ ≈“°√∑“ß°“√·æ∑¬å 2 §π®–„™âÕµ— √“ 15 µàÕ 2 «à π °√≥’ ∑’Ë „ à ∑à Õ ™à « ¬À“¬„®·≈â « §«√∑”°“√°¥Àπâ “ Õ°·≈– ™à«¬À“¬„®‚¥¬‰¡à —¡æ—π∏å°—π À≈—°°“√ ”§—≠§◊Õ§«“¡≈â“ ∑”„Àâª√– ∑‘ ∏‘¿“æ¢Õß°“√°¥Àπâ“Õ°≈¥≈ß ¥—ßπ—πÈ µâÕ߇ª≈’¬Ë π §π„À¡à¡“°¥Àπâ“Õ°∑ÿ° 2 π“∑’ 9. 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À¬ÿ¥°¥Àπâ“Õ°„ÀâπÕâ ¬∑’Ë ¥ÿ ‡∑à“∑’‡Ë ªìπ‰ª‰¥â ‡π◊ÕË ß®“° ®–≈¥ª√‘¡“≥‡≈◊Õ¥‰ª‡≈’Ȭß√à“ß°“¬ ‚¥¬Õ“®À¬ÿ¥°¥™—Ë«§√“« °√≥’∑’˧≈”™’æ®√ (‡¡◊ËÕ‰¡à¡’‡§√◊ËÕßµ√«®§≈◊Ëπ‰øøÑ“À—«„® À√◊Õ §≈◊Ëπ‰øøÑ“À—«„®‡ªìπ™π‘¥∑’Ëπà“®–¡’™’æ®√) Õ¥∑àՙ૬À“¬„® ‡¢â“À≈Õ¥§Õ ‡§≈◊ËÕπ¬â“¬ºŸâªÉ«¬·≈–™ÁÕ°À—«„®¥â«¬‰øøÑ“ 11. ºŸâªÉ«¬∑’Ë¡’¿“«– asystole/PEA µâÕß欓¬“¡À“ “‡Àµÿ ¢Õß¿“«–À—«„®À¬ÿ¥‡µâπ∑’Ë·°â‰¢‰¥â·≈–‡ªìπ‰ª‰¥â¡“°∑’Ë ÿ¥ ·≈â«·°â‰¢ ´÷Ëß “‡Àµÿ∑’ˇªìπ‰ª‰¥â Õ“®®”‰¥âßà“¬Ê §◊Õ 6H 6T ‰¥â·°à 11.1 6H 11.1.1 hypoxia 11.1.2 hypovolemia 11.1.3 hypothermia 11.1.4 hypoglycemia 11.1.5 hypo/hyperkalemia 11.2 6T 11.2.1 tension pneumothorax 11.2.2 cardiac tamponade 11.2.3 thrombosis myocardial ischemia 11.2.4 thrombosis pulmonary embolism 11.2.5 trauma (hypoxia, hypovolemia, severe brain injury) 12. „À⬓√—°…“µ“¡¢âÕ∫àß™’È ‚¥¬‰¡à„™â¬“¡“°À√◊ÕπâÕ¬ ‡°‘π‰ª ´÷Ëß®–∑”„À⇰‘¥º≈‡ ’¬ 12.1 °≈ÿà¡ vasopressor 12.1.1 epinephrine „™â ”À√—∫ºŸªâ «É ¬∑’¡Ë ¿’ “«– À—«„®À¬ÿ¥‡µâπ∑—Èß 2 °√≥’ ¢π“¥¬“ 1 ¡°.∑“ßÀ≈Õ¥‡≈◊Õ¥¥” À√◊ Õ intraosseous ∑ÿ ° 3-5 π“∑’ (class IIb) ·≈–∑“ß »√’π§√‘π∑√凫™ “√ 2551; 23(2) Polpun Boonmak ∑àՙ૬À“¬„® 2-2.5 ¡°. ¬“¢π“¥ Ÿß„™â°√≥’‰¥â√—∫¬“ beta blocker ·≈– Ca channel blocker ‡°‘π¢π“¥ 12.1.2 vasopressin „™â ”À√— ∫ ºŸâ ªÉ « ¬∑’Ë ¡’ ¿“«–À—«„®À¬ÿ¥‡µâπ∑—Èß 2 °√≥’ ¢π“¥¬“ 40 ¬Ÿπ‘µ ∑“ß À≈Õ¥‡≈◊Õ¥¥”À√◊Õ intraosseous §√—È߇¥’¬« 12.1.3 atropine „™â ”À√—∫ºŸâªÉ«¬∑’Ë¡’¿“«– slow PEA À√◊Õ asystole ¢π“¥¬“ 1 ¡°.∑“ßÀ≈Õ¥‡≈◊Õ¥¥” À√◊Õ intraosseous ∑ÿ° 3-5 π“∑’ √«¡‰¡à‡°‘π 3 ¡°. (¢π“¥¬“ 0.5 ¡°. „™â ”À√—∫¿“«– bradycardia) 12.2 °≈ÿà¡ antiarrhythmic 12.2.1 amiodarone „™â ”À√—∫ºŸªâ «É ¬∑’¡Ë ¿’ “«– VF/pulseless VT (class IIb) ∑’Ë≈⡇À≈«®“°°“√™ÁÕ°¥â«¬‰øøÑ“ À√◊ Õ epinephrine, vasopressin ¢π“¥¬“ 300 ¡°.∑“ß À≈Õ¥‡≈◊Õ¥¥”À√◊Õ intraosseous Õ“®„Àâ´È”‰¥âÕ’° 150 ¡°. 12.2.2 lidocaine „™â ”À√—∫ºŸªâ «É ¬∑’¡Ë ¿’ “«– VF/ pulseless VT (class indeterminate) ∑’Ë≈⡇À≈«®“°°“√™ÁÕ°¥â«¬ ‰øøÑ“À√◊Õ epinephrine, vasopressin ¢π“¥¬“ 1-1.5 ¡°.µàÕ°°. ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”À√◊Õ intraosseous “¡“√∂„Àâ´È”‰¥â 0.5-0.75 ¡°.µàÕ°°.∑ÿ° 5-10 π“∑’Õ’° 2 §√—Èß √«¡‰¡à‡°‘π 3 ¡°.µàÕ°°. 12.2.3 magnesium sulfate „™â ”À√—∫ºŸâªÉ«¬ ∑’Ë¡’§≈◊Ëπ‰øøÑ“À—«„® Torsades de Pointes (irregular/polymorphic VT with QT prolong) ¢π“¥¬“ 1-2 °. ∑“ßÀ≈Õ¥‡≈◊Õ¥¥” „π‡«≈“ 5-20 π“∑’ ° √≥’ ∑’Ë ‰ ¡à ¡’ ™’ æ ®√ ·≈– 1-2 °. ∑“ß À≈Õ¥‡≈◊Õ¥¥”„π‡«≈“ 5-60 π“∑’°√≥’∑’Ë¡’™’æ®√ 12.3 ¬“°≈ÿà¡Õ◊Ëπ Ê 12.3.1 NaHCO 3 §«√„Àâ ‡ ¡◊Ë Õ ¿“«–À— « „® À¬ÿ¥‡µâπ —¡æ—π∏å°—∫ metabolic acidosis, hyperkalemia, tricyclic antidepressant À√◊ՙ૬°Ÿâ™’æ¡“π“π à«π„π¿“«– respiratory acidosis ¡’ hypercarbia ∑’ˉ¡à‰¥â„ à∑àՙ૬À“¬„® À√◊ՙ૬À“¬„®‰¡à‰¥â ∂◊Õ‡ªìπ¢âÕÀâ“¡„™â 13. √–À«à“ߙ૬°Ÿâ™’槫√ª√–‡¡‘πºŸâªÉ«¬´È”‡ªìπ√–¬–Ê ‡æ◊ËÕ·°â‰¢ªí≠À“∑’ËÕ“®‡°‘¥¢≥–π—È𠇙àπ ∑àՙ૬À“¬„®À≈ÿ¥ ´’Ë‚§√ßÀ—° ‡ªìπµâπ ‚¥¬Õ“®„™âÕÿª°√≥å‡ΩÑ“√–«—ߙ૬„π°“√ ¥Ÿ·≈ºŸâªÉ«¬ ‡™àπ °“√„™â‡§√◊ËÕß«—¥§“√å∫Õπ‰¥ÕÕ°‰´¥å„π ≈¡À“¬„®ÕÕ°®–™à « ¬∫Õ°‚Õ°“ √Õ¥™’ «‘ µ (§à “ ¡“°°«à “ 10 ¡¡.ª√Õ∑), invasive blood pressure ‡ªìπµâπ 14. °”Àπ¥Àπâ“∑’Ë„π°“√¥Ÿ·≈ºŸâªÉ«¬„Àâ™—¥‡®π ‚¥¬‡©æ“– ºŸâπ”∑’¡ ºŸâ¥Ÿ·≈∑“߇¥‘πÀ“¬„® ºŸâ°¥Àπâ“Õ° ºŸâ„À⬓·≈– ‡µ√’¬¡‡§√◊ËÕß™ÁÕ°À—«„®¥â«¬‰øøÑ“ ºŸâ∫—π∑÷° ´÷Ëߧ«√µâÕß¡’°“√ °”Àπ¥≈à«ßÀπ⓵“¡§«“¡‡À¡“– ¡¢Õß·µà≈–‚√ß欓∫“≈ 15. ·®âß¢à“«·°à≠“µ‘·≈–ºŸâ‡°’ˬ«¢âÕß‚¥¬‡√‘Ë¡„Àâ¢âÕ¡Ÿ≈ µ—Èß·µà‡√‘Ë¡¡’Õÿ∫—µ‘°“√≥å 16. ‡¡◊ÕË ºŸªâ «É ¬°≈—∫¡“¡’ ≠ — ≠“≥™’æµâÕߥŸ·≈Õ¬à“ß„°≈♥‘ • Srinagarind Med J 2008; 23(2) 219 ¿“«–À—«„®À¬ÿ¥‡µâπ∑’ˉ¡à§“¥§‘¥·≈–«‘ ≠ — ≠’«‘∑¬“ • Unexpected Cardiac Arrest and Anesthesia ventricular fibrillation §«√√—°…“Õÿ≥À¿Ÿ¡‘°“¬µË” (therapeutic hypothermia) 32-34 Õß»“‡´≈‡´’¬ π“π 12-24 ™—Ë«‚¡ß 17. ¿“¬À≈—ß°“√¥Ÿ·≈ºŸâªÉ«¬‡√’¬∫√âÕ¬µâÕßπ”¢âÕ¡Ÿ≈∑’Ë¡’ ‡Àµÿ°“√≥å∑’ˇ°‘¥¢÷Èπ ªí≠À“∑’Ëæ∫¡“∑∫∑«π ‡æ◊ËÕ𔉪 Ÿà°“√ ªÑÕß°—π·≈–æ—≤π“°“√¥Ÿ·≈ºŸâªÉ«¬ §«√À“ ∂“π∑’Ë∑’ˇÀ¡“– ¡„π°“√¥Ÿ·≈ ‚¥¬°“√¥Ÿ·≈∑’Ë ”§—≠ §◊Õ欓¬“¡ªÑÕß°—π¿“«– hypoxia ·≈– hypo/hypercarbia §«√ ¡’°“√√—°…“√–¥—∫‡°≈◊Õ·√à„À⪰µ‘ À≈’°‡≈’¬Ë ß°“√„™â¬“πÕπÀ≈—∫ ¬“À¬àÕπ°≈â“¡‡π◊ÈÕ‚¥¬‰¡à®”‡ªìπ √—°…“Õ“°“√™—° „À⬓√—°…“ À—«„®‡µâπº‘¥ª°µ‘µàÕ‡¡◊ËÕ¡’¢âÕ∫àß™’È à«πÕÿ≥À¿Ÿ¡‘°“¬π—Èπ°√≥’ √Ÿª∑’Ë 1 · ¥ß·π«∑“ß ventricular fibrillation ·≈– pulseless ventricular tachycardia 6 √Ÿª∑’Ë 2 · ¥ß·π«∑“ß asystole ·≈– pulseless electrical activity 6 √ÿª 2. 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