昏迷抢救18rmvb.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,第二级,第三级,第四级,第五级,*,昏 迷,coma,沈燕,2006,4,20,昏迷抢救,18.rmvb,当我们身边突然出现疑似昏迷的病人时，鉴别病人是否昏迷最简单的办法是,在护送病人去医院途中，要注意做好,用棉芯轻触一下病人的角膜，正常人或轻症病人都会出现眨眼动作，而昏迷特别是深昏迷病人毫无反应。当确定病人昏迷时，应尽快送病人到医院抢救,。,教学目标,了解：,昏迷量表的使用；,昏迷与晕厥、癔症性昏睡、木僵状态、闭锁综合征的鉴别诊断,熟悉：,昏迷的常见病因；,昏迷病人瞳孔的观察,掌握：,昏迷的定义；,昏迷的临床分级；,昏迷的急救护理,Definition,意识,机体对自身及外界环境感知并能作出正确反应的状态。,意识障碍,机体对外界环境的刺激缺乏反应的一种病理状态。,昏迷,是严重的意识障碍，其主要特征为随意运动丧失，对外界刺激失去正常反应并出现病理反射活动。,判断意识障碍程度,disturbance of consciousness,区分嗜睡、意识模糊、昏睡、昏迷,嗜睡,somnolence,：,病人呈持续睡眠状态，但可被轻度刺激唤醒，醒后能正确简单回答问题，但反应迟钝。,意识模糊,confusion,：,病人对时间、地点、人物的定向能力发生障碍，思维混乱，可有错觉、幻觉、精神错乱、谵妄等表现。,昏睡,stupor,：,病人处于沉睡状态，仅能被压眼眶、用力摇动身体等较强刺激唤醒。,昏迷,coma,：,是最严重的意识障碍,。,Summary,：,Disturbance of consciousness is,impediment,(,障碍,),of having an awareness of ones environment,and ones own,existence,sensations,and,thoughts.,According to the degree of disturbance of consciousness,it can be divided:somnolence,confusion,stuporcoma,.,What is Coma and Persistent Vegetative State?,A coma is a profound or deep state of unconsciousness.An individual in a state of coma is alive but unable to move or respond to his environment.Coma may occur as a complication of an underlying illness,or as a result of injuries,such as head trauma,.,A persistent vegetative state(“brain-death”)sometimes follows a coma.Individuals in such a state have lost their thinking abilities and awareness of their surroundings,but retain non-cognitive function and normal sleep patterns.Even though those in a persistent vegetative state lose their higher brain functions,other key functions such as breathing and circulation remain relatively intact.Spontaneous movements may occur,and the eyes may open in response to external stimuli.They may even occasionally grimace(,痛苦的表情,),cry,or laugh.,Etiology,1.,颅内病变,cerebral disease,（,1,）颅内感染：如脑膜炎,(meningitis),等,（,2,）颅脑疾患：脑脓肿；脑血管疾病；颅脑外伤；脑寄生虫病；癫痫、癫痫发作后昏迷。,2.,全身性疾病,general disease,（,1,）急性感染性疾病,（,2,）内分泌与代谢障碍,（,3,）水电解质平衡紊乱,（,4,）外因性中毒,（,5,）物理性损害,Assessment,History collection,The degree of disturbance of consciousness,Vital signs,Laboratory examination,Differentiate diagnosis,History collection,发病方式：发病过程、时间急或缓,首发症状,伴随症状,发病年龄和季节,发病现场,病人思想情绪生活情况,既往史,The degree of disturbance of consciousness,昏迷程度的临床分级,浅昏迷：,病人的随意运动丧失，对周围事物和声音、强,光等刺激均无反应，仅对强烈的疼痛刺激，有,肢体简单的防御性运动和呻吟伴痛苦表情。各,种生理反射存在。脉搏、呼吸、血压无明显变,化。可出现大小便潴留或失禁。,中度昏迷：,对周围事物及各种刺激全无反应，对剧烈刺,激偶可出现 防御反射。各种生理反射均减,弱。脉搏、呼吸、血压有所变化，大小便潴,留或失禁。,深昏迷：,全身肌肉松弛，对周围事物和各种刺激全无反,应，各种反射均消失。呼吸不规则，血压下,降，大小便失禁。,The degree of disturbance of consciousness,格拉斯哥昏迷分级计分法（,P187,）,Vital signs,T,：,体温升高：如脑炎、脑膜炎等,急骤高热提示脑干出血、中暑等,体温过低：见于休克、低血糖等,P,：,脉搏变慢见于颅内压增高等,脉搏增快见于高热或感染性疾病等,脉搏先慢后快伴血压下降考虑脑疝压迫脑干,R,：,呼吸深大见于代谢性酸中毒、糖尿病等,呼吸减弱见于肺功能不全、镇静剂中毒等,呼吸异常伴气味异常,Vital signs,BP,：,血压升高见于高血压脑病等,血压速降见于休克、心肌梗塞等,Pupil,：,双侧瞳孔散大：濒死状态、严重尿毒症等,双侧瞳孔缩小：有机磷类农药中毒、脑桥出血等,一侧瞳孔散大：动眼神经麻痹、小脑幕切迹疝,一侧瞳孔缩小：脑疝发生早期、颈交感神经麻痹,eyeground,：,视神经乳头水肿等,Vital signs,Meningeal,signs,：,阳性反应见于蛛网膜下腔出血,skin,：,紫绀提示缺氧,樱桃红提示一氧化碳中毒,皮肤色素沉着,:,肾上腺皮质功能减退,mobility,：,深昏迷时肌张力完全松弛,reflection,：,昏迷时双侧对称性各种反射减弱或消失,Laboratory examination,routine,：,blood,、,urinestool,special,：,ECG,、,X,线、,B,超,Differentiate diagnosis,晕厥,突然发生，短暂的意识丧失状态，是由于大脑一时性供血不足所致。,癔症性昏睡,表现为卧床不语、双目紧闭，对针刺无反应，但翻开其眼睑可见眼球转动。生命体征平稳。,木僵状态,表现为不动不语，不进饮食，对外界刺激无反应，甚至可出现瞳孔改变、尿潴留等症状，无意识障碍。,闭锁综合征,表现为四肢瘫痪，不能张口、不能言语、眼球不能向两侧转动，但意识尚清。,Is there any treatment?,Once an individual is out of immediate dangerthe medical care team focuses on preventing infections and maintaining a healthy physical state.This will often include preventing pneumonia and,bedsores,（,褥疮,）,and providing balanced nutrition.,Physical therapy may also be used to prevent,contractures,（,挛缩,）,(permanent muscular contractions)and,deformities,（,畸形,）,of the bones,joints,and muscles that would limit recovery for those who emerge from coma.,Nursing,observation,1.,病情严重者每,15,30,分钟监测一次生命体征,2.,病情稳定者每,4,小时一次,Keep airway open,Keep balance of water/electrolytes/acid-,basse,Nursing,对症处理,1.,消除脑水肿：应用高渗溶液脱水,2.,促进脑功能恢复,3.,保持有效低温冬眠疗效,有效标志：,镇静好但呼之能应、病人对物理降温无御寒反应，体温控制在预定范围。,降温的要求：,早、低、足、稳、缓,Nursing,Etiology treatment,1.,颅内占位病变,2.,脑中风,3.,药物中毒,4.,一氧化碳中毒、放射损伤,5.,颅内感染或全身感染,6.,低血糖性昏迷、高血糖性昏迷,7.,肝昏迷,8.,纠正休克,Nursing,Preventing complications,1.,口腔护理,2.,防止坠积性肺炎,3.,预防褥疮,4.,做好留置尿管的护理,What is the prognosis?,The outcome for coma and persistent vegetative state depends on the cause,severity,and site of neurological damage.Individuals may emerge from coma with a combination of physical,intellectual,and psychological difficulties that need special attention.,Recovery usually occurs gradually,with some acquiring more and more ability to respond.Some individuals never progress beyond very basic responses,but many recover full awareness.Individuals recovering from coma require close medical supervision.A coma rarely lasts more than 2 to 4 weeks.Some patients may regain a degree of awareness after persistent vegetative state.Others may remain in that state for years or even decades.The most common cause of death for someone in a persistent vegetative state is infection,such as pneumonia.,转运途中注意事项,（,1,）病人平卧，头侧向一侧，保持呼吸道通顺。,（,2,）病人有活动性假牙，应立即取出以防误入气管。,（,3,）注意给病人保暖，防止受凉。,（,4,）密切观察病情变化，经常呼唤病人，以了解意识情况。对躁动不安者，要加强保护防止意外损伤。,思考,长期昏迷者护理,I:,昏迷护理,.doc,复习思考题,1.,什么是昏迷？,2.,临床上把昏迷分为几级，各级的临床表现是什么？,3.,如何观察昏迷病人的瞳孔变化？,4.,昏迷与晕厥、癔症性昏睡如何区别？,