外科休克(双).ppt

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二层,第三层,第四层,第五层,HUYIN,*,2006-12-11,外科休克(双),第一节 概 论,休克 SHOCK,:,机体有效循环血容量减少、组织灌注不足，细胞代谢紊乱和功能受损的综合征,本质：,氧供障碍需求增加,恢复有效供氧,2006-12-11,HUYIN,现代的观念,序贯性事件,亚临床的灌注不足,多器官功能障碍(MODS)或衰竭(MOF),2006-12-11,HUYIN,Definition,Shock,is a severe condition that occurs when,not enough blood flows,through the body,causing very,low blood pressure,a,lack of urine,and,cell and tissue damage.,This can,damage multiple organs,.Shock requires IMMEDIATE medical treatment and can get worse very rapidly.,2006-12-11,HUYIN,分类,心源性休克,Cardiogenic,shock,低血容量性休克,Hypovolemic shock,感染中毒性休克,Toxic shock,过敏性休克,Allergic shock,神经性休克,Nervous shock,2006-12-11,HUYIN,Considerations,Major classes of shock include:,Cardiogenic shock,(associated with heart problems),Hypovolemic shock,(caused by inadequate blood volume),Anaphylactic shock,(caused by allergic reaction),Septic shock,(associated with infections),Neurogenic shock,(caused by damage to the nervous system),2006-12-11,HUYIN,Causes,Heart problems(such as,heart attack,or,heart failure,),Low blood volume(as with heavy,bleeding,or,dehydration,),Changes in blood vessels(as with infection or,severe allergic reactions,),Shock is often associated with heavy external or internal bleeding from a serious injury.,Spinal injuries,can also cause shock.,Toxic shock syndrome,is an example of a type of shock from an infection.,2006-12-11,HUYIN,病理生理,微循环变化,微循环收缩期,period of,microcirculatory,contraction,微循环扩张期,microcirculatory expanding,period,微循环衰竭期,microcirculatory failure,2006-12-11,HUYIN,病理生理,微循环收缩期,神经内分泌反应,主动脉弓和颈动脉窦,交感-肾上腺素/儿茶酚胺,球旁小体 肾素-血管紧张素,心跳加快、心排出量增加,2006-12-11,HUYIN,病理生理,微循环收缩期,选择性血管收缩,血流重新分配,小动、静脉血管平滑肌/毛细血管前括约肌,毛细血管后括约肌,回心血量下降,迷走神经抑制的降低,渗透压升高 抗利尿激素增加,垂体 肾上腺皮质激素 醛固酮,分解代谢,2006-12-11,HUYIN,微循环三条通道,动静脉短路,直捷通道,营养通路,儿茶酚胺,乳酸、丙酮酸,儿茶酚胺,微血栓DIC,2006-12-11,HUYIN,病理生理,微循环扩张期,缺氧,动静脉短路/直捷通道 开放,组织灌注下降,更缺氧,炎性物质,血液滞留 血浆外渗,休克加重,2006-12-11,HUYIN,病理生理,微循环衰竭期,血液滞留,酸性环境,高凝状态,DIC,缺氧 缺能,溶酶体破裂 酶释放 细胞自溶,器官功能受损,2006-12-11,HUYIN,病理生理,代谢改变,无氧代谢,乳酸盐/丙酮酸盐,代谢性酸中毒,能量代谢障碍,应急儿茶酚胺/肾上腺皮质激素,蛋白分解,糖异生 血糖升高,2006-12-11,HUYIN,病理生理,介 质,体液因子,神经内分泌因子,补体系统,激肽系统,前列腺素类,细胞因子,炎性介质（白介素、肿瘤坏死因子,氧自由基,2006-12-11,HUYIN,炎症介质释放和,缺血再灌注损伤,;,release of mediators of inflammation,reperfusion injury,2006-12-11,HUYIN,病理生理,细胞与器官,内脏器官的继发性损害,微循环障碍1O小时,多系统器官衰竭,MSOF,Multiple System Organ Failure,2006-12-11,HUYIN,肺,内皮细胞肺间质水肿,肺泡上皮细胞局限性肺不张,ARDS,肾,抗利尿激素醛固酮水钠潴留,肾皮质肾小管坏死肾衰,心,冠脉血流少心肌损害,脑、胃肠道、肝,2006-12-11,HUYIN,细胞的变化,膜,线粒体,内质网,溶酶体,2006-12-11,HUYIN,临床表现,C,linical Manifestation,休克代偿期,Compensatory Stage of Shock,早期休克,pre-shock stage,烦燥 口渴 面色苍白,呼吸增快 心率 80120次/分,收缩压 9.3312kPa(7090mmH),脉压2.64.0kPa,尿量正常减少(25次/分 脉博细速 140次/分,收缩压 6.679.33kPa(5070mmH)呼吸窘迫,脉压缩小 收缩压06.6kPa,尿量减少1525ml/h 比重增高 尿量015ml/h,中心静脉压(CVP)1.96kPa,2006-12-11,HUYIN,Symptoms,A person in shock has,extremely low blood pressure,.Depending on the specific cause and type of shock,symptoms will include one or more of the following:,2006-12-11,HUYIN,Anxiety,or agitation,Confusion,Pale,cool,clammy skin,2006-12-11,HUYIN,Low or no urine output,Bluish lips and fingernails,Dizziness,light-headedness,or,faintness,2006-12-11,HUYIN,Profuse sweating,moist skin,Rapid but weak pulse,Shallow breathing,Chest pain,Unconsciousness,2006-12-11,HUYIN,诊断 diagnosis,病史 case history,临床表现 clinical situation,2006-12-11,HUYIN,一般监测,genera monitoring,意识 呼吸 脑血流灌注/脑血氧,皮温 色泽 末梢血循环,脉率 血压,血容量,平均动脉压=舒张压+1/3脉压 120.6kPa,休克指数 =脉率收缩压(mmHg),尿量 肾灌流血容量,2006-12-11,HUYIN,一般监测,genera monitoring,精神状态 mental status,皮肤温度色泽 skin temperature colour,血压 blood pressure,脉率 pulse rate,尿量 urinary volume,2006-12-11,HUYIN,特殊监测,special monitoring,中心静脉压,回心血量右心搏出量,肺毛细血管楔压,心排出量(CO)心脏指数(CI),血气分析,动脉血乳酸盐,DIC的检测,胃肠黏膜内pH值,2006-12-11,HUYIN,First Aid,Call 911 for immediate medical help.,Check the persons airway,breathing,and circulation.If necessary,begin rescue breathing and,CPR,.,2006-12-11,HUYIN,First Aid,Even if the person is able to breathe on his or her own,continue to check rate of breathing at least every 5 minutes until help arrives.,2006-12-11,HUYIN,First Aid,If the person is conscious and DOES NOT have an injury to the head,leg,neck,or spine,place the person in the,shock position,.,Lay the person on the back and elevate the legs about 12 inches,.,DO NOT elevate the head.,If raising the legs will cause pain or potential harm,leave the person lying flat.,2006-12-11,HUYIN,First Aid,Give appropriate first aid for any wounds,injuries,or illnesses.,Keep the person warm and comfortable.Loosen tight clothing.,2006-12-11,HUYIN,First Aid,IF THE PERSON VOMITS OR DROOLS,Turn the head to one side so he or she will not choke.Do this as long as there is NO suspicion of spinal injury.,If a spinal injury is suspected,log roll him or her instead.Keep the persons head,neck and back in line and roll him or her as a unit.,2006-12-11,HUYIN,治疗,treatment;,一般紧急治疗,体位：躯干抬高1O一15,下肢抬高2O一30,呼吸道通畅 吸氧 保温防暑 急救,2006-12-11,HUYIN,2006-12-11,HUYIN,Do Not,DO NOT,give the person anything by mouth,including anything to,eat or drink,.,DO NOT,move the person with a known or suspected,spinal injury,.,DO NOT,wait for milder shock symptoms to worsen before calling for emergency medical help.,2006-12-11,HUYIN,治 疗,补充血容量,恢复有效循环血量,量,:,丧失量 补充量,(,扩大的毛细血管床,质,:,晶 体,(,等渗液、平衡液,),胶 体,(,全血、血浆、白蛋白,),补液恢复的标准,(,CVP,脉博、血压、尿量、皮温、神志,),2006-12-11,HUYIN,治 疗,积极处理原发病,2006-12-11,HUYIN,治 疗,纠正酸碱失衡,低碳酸血症,高乳酸血症,高碳酸血症,碳酸氢钠的应用,2006-12-11,HUYIN,治 疗,血管活性物质的应用,vasoactive drugs,血管收缩药,大计量多巴胺 多巴酚丁胺去 甲肾上腺素,间羟安,血管扩张药,酚妥拉明 阿托品 硝普钠,小计量多巴胺,强心药,西地兰,2006-12-11,HUYIN,治 疗,治疗,DIC改变微循环,（肝素/氨甲苯酸/阿司匹林）,皮质类固醇,（五大作用）,其他,2006-12-11,HUYIN,治 疗,维护重要器官的功能,防治感染,粘膜屏障-肠菌移位,2006-12-11,HUYIN,第二节 低血容量性休克,Hypovolemic shock,定义:,短时间内丢失大量全血、血浆或其它液体，超过机体的代偿限度即导致,休克综合征,2006-12-11,HUYIN,Hypovolemic shock,Hypovolemic,shock,is an emergency condition in which severe blood and fluid loss makes the heart unable to pump enough blood to the body.This type of shock can cause many organs to stop working.,2006-12-11,HUYIN,包括:,失血性休克,(20%总血量),静脉曲张出血、肝癌破裂、宫外孕,失液性休克,肠梗阻、烧伤,损伤性休克,2006-12-11,HUYIN,Causes,incidence,and risk factors,Losing about 1/5 or more of the normal amount of blood in your body causes hypovolemic shock.,Blood loss can be due to bleeding from cuts or other injury or internal bleeding such as gastrointestinal tract bleeding.The amount of blood in your body may drop when you lose too many other body fluids,which can happen with diarrhea,vomiting,burns,and other conditions.,2006-12-11,HUYIN,The greater and more rapid the blood loss,the more severe the,shock symptoms.,2006-12-11,HUYIN,病 理,血容量骤减,神经内分泌,心搏加强加快,外周/内脏血管收缩,保持心脑血供,肾 水钠储留,口渴少尿,失液 细胞外液丢失,血液浓缩,创伤,感染,2006-12-11,HUYIN,Symptoms,Rapid pulse,Pulse may be weak(thready),Rapid breathing,Anxiety,or agitation,2006-12-11,HUYIN,Cool,clammy skin,Weakness,Pale skin color,(pallor),Sweating,moist skin,2006-12-11,HUYIN,Decreased or no urine output,Low blood pressure,Confusion,Unconsciousness,2006-12-11,HUYIN,tests,CBC,CT,scan or an,x-ray,of suspected areas,Endoscopy,Echocardiogram,(heart ultrasound),Right heart(Swan-Ganz)catheterization,-can help tell the difference between hypovolemic and another type of shock called cardiogenic shock,2006-12-11,HUYIN,Gastric endoscopy,2006-12-11,HUYIN,Swan Ganz catheterization,2006-12-11,HUYIN,CBC,(complete blood count),The number of red blood cells(RBCs),The number of white blood cells(WBCs),The total amount of,hemoglobin,in the blood,The fraction of the blood composed of red blood cells(,hematocrit,),MCV(mean corpuscular volume)-the size of the red blood cells,MCH(mean corpuscular hemoglobin),MCHC(mean corpuscular hemoglobin concentration),platelet count,2006-12-11,HUYIN,一、失血性休克和失液性休克,治 疗,一补充血容量,治 疗,二药物治疗,治 疗,三病因治疗,2006-12-11,HUYIN,Treatment,Get immediate medical help.In the meantime,follow these steps:,Keep the person comfortable and warm(to avoid hypothermia).,Have the person lie flat with the feet lifted up about 12 inches to increase circulation.However,if the person has from a head,neck,back,or leg injury,leave him or her in the position in which they were found unless doing so poses other immediate danger.,2006-12-11,HUYIN,Do not give fluids by mouth.,If person is having an,allergic reaction,treat the allergic reaction,if you know how.,If the person must be carried,try to keep him or her flat,with the head down and feet lifted up.Stabilize the head and neck before moving a person with a suspected spinal injury.,2006-12-11,HUYIN,The goal of hospital treatment,to replace blood and fluids.An,intravenous,(IV)line will be put into the persons arm to allow blood or blood products to be given.,Medicines such as,dopamine,dobutamine,epinephrine,and,norepinephrine,may be needed to increase,blood pressure,and the amount of blood pumped out of the heart(cardiac output).,2006-12-11,HUYIN,Other methods,that may be used Cardiac monitoring,including Swan-Ganz cathertization,Urinary catheter to collect and monitor how much urine is produced,2006-12-11,HUYIN,补充血容量,依据,休克的程度或休克指数,(,血压、,cvp,),红细胞比积,(3O%),血清白蛋白,(,白蛋白,3g,dl),2006-12-11,HUYIN,中心静脉压和动脉压变化的处理原则,2006-12-11,HUYIN,成人,(体重5070公斤),45分钟内,平衡盐液(等渗盐水),10001500ml,中分子右旋糖酐、羟乙基淀粉(38 OR 90 次/分,呼吸急促20次/分,PaCO,2,12*10,9,/L,S,ystemic,I,nflammatory,R,esponse,S,yndrome,2006-12-11,HUYIN,Risk factors for septic shock include,Diabetes,Diseases that weaken the immune system such as,AIDS,Lymphoma,Leukemia,Diseases of the genitourinary system,biliary system,or intestinal system,Recent infection,Long-term use ofantibiotics,Recent surgeryor medical procedure.,2006-12-11,HUYIN,Symptoms,High or very low temperature,chills,Lightheadedness,Shortness of breath,Palpitations,Cool,pale extremities,Restlessness,agitation,lethargy,or confusion,Rapid heart rate,Low blood pressure,especially when standing,Low urine output,(due to kidney failure),2006-12-11,HUYIN,临床表现,原有的感染病变 (败血症),休克表现,冷休克 低排高阻型,热休克 高排低阻型,并发系统器官衰竭 (DIC、ARDS),2006-12-11,HUYIN,临床表现,临床表现,冷休克,热休克,神志,躁动淡漠嗜睡,清醒,皮肤色泽,苍白紫绀花斑,淡红潮红,皮肤温度,湿冷冷汗,温暧干燥,毛细血管充盈时间,延长,12秒,脉博,细速,慢博动清楚,脉压(k pa),4,尿量/h,30ml,2006-12-11,HUYIN,Signs and tests,Blood gases,revealing low oxygen concentration and acidosis,Blood cultures,or blood count detecting infection,Low blood pressure,Chest x-ray,revealing pneumonia or pulmonary edema,Blood tests,detecting poor organ function or organ failure,2006-12-11,HUYIN,Treatment,Septic shock is a medical emergency.Patients are usually admitted to the,intensive care unit,of the hospital.,2006-12-11,HUYIN,The goal of treatment,Provide oxygen,and relieve respiratory distress(if present),Give fluids,by I.V.to restore blood volume,Give vasoactive drugs,to treat,low blood pressure,2006-12-11,HUYIN,Treat underlying infections,with antibiotics and surgery,if needed,Support,any poorly functioning organs,Reverse abnormal blood clotting with drugs,2006-12-11,HUYIN,There are new drugs that act against the hyperinflammatory response seen in septic shock.These may help limit the damage to vital organs.,2006-12-11,HUYIN,Hemodynamic monitoring,-the evaluation of the pressures in the heart and lungs-may be required.This can only be done with specialized equipment and intensive care nursing.,2006-12-11,HUYIN,治 疗,补充血容量,replenish blood volume,控制感染,纠正酸碱平衡失调,acid-base imbalance,心血管药物的应用,2006-12-11,HUYIN,治 疗,皮质激素,cortical hormone,其它治疗,2006-12-11,HUYIN,谢谢,2006-12-11,HUYIN,