小儿急症ppt课件

The Sick ChildBeverly Young, MD 2010The Warren Alpert Medical School of Brown UniversityHave you seen children die?你 见过 儿童死亡 吗 ？Discuss with your partner:与你周 围 的人 讨论 ： What was the cause of death? 死因是什么？ What treatment did the child receive? 孩子接受 过 什么治 疗 ？ What worked, and what didnt? 哪些治 疗 有效，哪些无效？Children die in 2 ways:儿童死亡的两个原因： Respiratory failure 呼吸衰竭 Inadequate tissue perfusion 体液 丢 失3 causes for inadequate tissue perfusion体液缺乏的 3个因素 : Hypovolemia 血容量不足 Poor distribution of body fluids 体液分布异常 Heart dysfunction 心 脏 功能障碍Major causes of child death儿童死亡的主要原因 :Cardiac Dysfunction 心 脏 功能障碍- Congenital heart disease先天性心 脏 病-Myocarditis-心肌炎Respiratory Failure呼吸衰竭 Inadequate Perfusion体液不足Blockage of major airways 气管堵塞- Choking 气管异物- Epiglottitis 会 厌 炎- Abscess 脓肿- Mass 肿块 Blockage of small Airways 小气道堵塞- Asthma 哮喘- Bronchiolitis 支气管炎Lung disease肺疾病- Pneumonia 肺炎- Heart disease 心 脏 疾病Hypovolemia 血容量不足* Most common* -Hemorrhage 出血- Dehydration 脱水Maldistributionof body fluids体液分布不良- Massive infection 肿块 感染(septic shock感染性休克 )- Anaphylaxis 过 敏反 应- Severe burns 烧伤Childrens Respiratory Rate儿童呼吸 频 率 The younger the child, the faster the respiratory rate.孩子越小，呼吸频 率越快 Fast breathing is a sign of respiratory distress or other illness.呼吸加快是呼吸窘迫或其它疾病的迹象 If a sick childs respiratory rate drops, it may signal impending respiratory failure.如果患儿的呼吸 频 率急速下跌，可能 预 示着即将发 生呼吸衰竭。Age 0 1 岁 year 2 4 岁 years 4 10 岁 years 10岁 yearsNormal Respiratory Rate 20 - 40 20 - 30 20 - 25 12 - 20Identifying Respiratory Distress判断呼吸窘迫 Increased respiratory rate 呼吸 频 率加快 Nasal flaring 鼻翼扇 动 Retractions above the sternal notch, below the ribs凹陷 胸骨上 窝 ，膈肌凹陷 Decreased air movement on auscultation 听 诊 呼吸音减弱 Wheezing, crackles on auscultation 哮 鸣 音、湿 啰 音 Lethargy 嗜睡 Cyanosis 紫 绀 Sometimes there is an obvious cause choking, history of asthma, known pneumonia or heart disease 有 时 会有一个明 显 的病因 窒息、哮喘史、肺炎或心 脏 疾病Identifying Inadequate Perfusion辨 认 体液不足Heart Rate心率Systemic Perfusion体循 环Blood Pressure血 压Childrens Heart Rates儿童心率Age年 龄 Birth 3 mos 3 mos 2 yrs 2 yrs 10 yrs 10 yrsNormal Heart Rate 正常心率85 205 100 190 60 140 60 -100The younger the child, the faster the heart rate.孩子越小，心率越快When a child is sick, the heart rate increases as the body tries to increase perfusion. 当孩子生病 时 ，心率增快， 因 为 机体努力 改善体循 环A low heart rate indicates that the heart is already failing and is a sign of very serious illness.心率减低 说 明心 脏 已 经 衰竭，是 严 重疾病的迹象。Identifying Decreased Systemic Perfusion辨 认 体循 环 减弱 Weak pulses OR “bounding” pulses 脉搏减弱或 弹 跳脉搏（水冲脉） Decreased skin perfusion 皮肤循 环 减少 Cool 冰凉 Capillary refill time 2 seconds 毛 细 充盈 时间 大于 2秒 Mottling and pallor (peripheral before central) 斑影与 苍 白 （先周 围 ，后中央）Identifying Decreased Systemic Perfusion辨 认 体循 环 减弱 Mental status changes 精神面貌改 变 Early: irritability, slight confusion 早期： 烦 躁， 轻 度 迷糊 Late: lethargy, loss of consciousness 后期：嗜睡，意 识 不清 Decreased urine output 尿量减少 Infants ( 6 hours 婴 儿（小于 1岁 ）：无尿超 过 6小 时 Older children (1 year): no urine for 12 hours 稍大的儿童（大于 1岁 ）：无尿 超 过 12小 时Childrens Blood Pressure 儿童血 压 The older the child, the higher the blood pressure 孩子越大，血 压 越高 Approximate systolic blood pressure for children 1 10 years old:90 mmHg + (2 age in years)Diastolic blood pressure should be approximately 2/3 of the systolic blood pressure. 1-10岁 的儿童的收 缩压 大 约 是： 90+（2年 龄 ），舒 张压 大 约 是收 缩压 的 2/3 Low blood pressure in a child is a sign of very serious illness! 儿童低血 压 是 严 重疾病的迹象Identifying Hypovolemia 辨 认 血容量不足 History of blood or fluid loss出血或体液 丢 失 : Traumatic injury causing external or internal bleeding 创伤导 致内或外出血 Diarrhea/vomiting 腹泻 /呕 吐 Excessive urination 过 度排尿 Lack of fluid intake 液体 摄 入不足 Sunken eyes 眼睛凹陷Identifying Hypovolemia 辨 认 血容量不足 Dry mucous membranes (mouth, lips) & absence of tears if crying 粘膜干燥（口腔、嘴唇），哭 时 无泪 Weak pulses 脉搏弱 Poor skin turgor 皮肤 弹 性 减弱 Peripheral capillary refill 2 seconds 末梢回血 时间 大于 2秒 Infants: sunken fontanel 婴 儿： 前囟凹陷 Decreased urine output 尿量减少 6 hours 小于 1岁 的孩子： 超 过 6小 时 无尿 1 year old: no urine for 12 hours 大于 1岁 的孩子： 超 过 12小 时 无尿Identifying Septic Shock辨 认 感染性休克 This may look different from other kinds of shock: 它不同于其它种 类 的休克 Increased heart rate 心率增加 Fever 发热 Bounding pulses 水冲脉 Increased distance between systolic and diastolic blood pressures ( 1/3 systolic) 脉 压 差增大（大于 收 缩压 的 1/3） There may be an obvious source of infection (or there may not) 可能会有明 显 的感染源（也可能没有）Major causes of child death儿童死亡的主要原因 :Cardiac Dysfunction 心 脏 功能障碍- Congenital heart disease先天性心 脏 病-Myocarditis-心肌炎Respiratory Failure呼吸衰竭 Inadequate Perfusion体液不足Blockage of major airways 气管堵塞- Choking 气管异物- Epiglottitis 会 厌 炎- Abscess 脓肿- Mass 肿块 Blockage of small Airways 小气道堵塞- Asthma 哮喘- Bronchiolitis 支气管炎Lung disease肺疾病- Pneumonia 肺炎- Heart disease 心 脏 疾病Hypovolemia 血容量不足* Most common* -Hemorrhage 出血- Dehydration 脱水Maldistributionof body fluids体液分布不良- Massive infection 肿块 感染(septic shock感染性休克 )- Anaphylaxis 过 敏反 应- Severe burns 烧伤Treating Respiratory Failure治 疗 呼吸衰竭 Treat the underlying cause (i.e., asthma) 治 疗 潜在的病因（如：哮喘） Bag-mask ventilation 呼吸气囊Treating Inadequate Perfusion治 疗 体液不足1. Give oxygen, if available 如有可能，吸氧2. Get IV access use a large-bore needle 静脉 输 液 用大号 针3. Give 20 ml/kg of normal saline as fast as possible: over 5 10 minutes在 5-10分 钟 内按每公斤体重 20毫升， 补 充生理 盐 水4. Reassess heart rate, perfusion, blood pressure重新 测 心率、 体循 环 、血 压Treating Inadequate Perfusion治 疗 体液不足5. If these are still abnormal: repeat 20 ml/kg normal saline + reassessment as many times as needed!如果仍然不正常：再次按每公斤体重 20毫升， 补 充生理 盐 水，再重新 测 量，只要需要，重 复 。6. Still no response? Dopamine or epinephrine if you have it7. Get the child to the hospital immediately!仍然没效果，可以 给 多巴胺或 肾 上腺素；建 议 尽快送医院# 1 A 5 year old boy comes to you with 2 days of sore throat and runny nose. Today he had a fever to 38 degrees in the morning. He has been a bit sleepy and cranky since he has had the fever. His mother gave him paracetamol 2 hours ago and it brought his fever down and he has been acting normal since then. His heart rate is 110 and his respiratory rate is 23. He is eating and drinking and urinating as usual. 一个 5岁 男孩，喉痛流涕 2天，今天 发热 ，上午 38度， 发热 后他有一点嗜睡和 烦 躁， 2小 时 前他 妈妈让 他服用扑 热 息痛，现 在体温正常，孩子活 动 正常，他的心率是 110次 /分，呼吸频 率是 23次 /分，食 纳 可，二便正常。# 1 A 5 year old boy comes to you with 2 days of sore throat and runny nose. Today he had a fever to 38 degrees in the morning. He has been a bit sleepy and cranky since he has had the fever. His mother gave him paracetamol 2 hours ago and it brought his fever down and he has been acting normal since then. His heart rate is 110 （60 140） and his respiratory rate is 23 （20 25）. He is eating and drinking and urinating as usual. 一个 5岁 男孩，喉痛流涕 2天，今天 发热 ，上午 38度， 发热 后他有一点嗜睡和 烦 躁， 2小 时 前他 妈妈让 他服用扑 热 息痛，现 在体温正常， 孩子活 动 正常 ，他的心率是 110次 /分 （60 140），呼吸 频 率是 23次 /分 （20 25），食 纳 可，二便正常。 2 A 1 year old girl comes to you with 2 days of runny nose and congestion and cough. This morning she has been wheezing a bit. She is febrile to 38.4 degrees, her heart rate is 190, and her respiratory rate is 60. She has retractions above the sternal notch and below the ribs, and she is flaring her nostrils when she breathes. She looks tired and irritable. She has not been feeding well. 1岁 的女孩，流涕、鼻塞和咳嗽 2天，今天早上有一点喘，体温 38.4度，心率 190次 /分，呼吸 频 率是 60次 /分，胸骨上 窝 和膈肌凹陷，呼吸 时 鼻翼扇 动 ，她看上去很累， 烦 躁，食欲不振。 2 A 1 year old girl comes to you with 2 days of runny nose and congestion and cough. This morning she has been wheezing a bit. She is febrile to 38.4 degrees, her heart rate is 190 （100 190）, and her respiratory rate is 60 （20 40）. She has retractions above the sternal notch and below the ribs, and she is flaring her nostrils when she breathes. She looks tired and irritable. She has not been feeding well. 1岁 的女孩，流涕、鼻塞和咳嗽 2天，今天早上有一点喘，体温 38.4度， 心率 190次 /分 ，呼吸 频 率是 60次 /分 ，胸骨上 窝 和膈肌 凹陷 ，呼吸 时 鼻翼扇 动 ，她看上去很 累， 烦 躁 ，食欲不振 。 3 A 7 year old boy comes to you with 5 days of vomiting and diarrhea. He has had a fever to 38 degrees for 2 days. His heart rate is 120 and his respiratory rate is 24. He appears lethargic, his eyes appear sunken, his lips are dry, and his capillary refill time is 4 seconds. He has been eating and drinking very little and he has not urinated for 24 hours. 7岁 男孩，呕吐和腹泻 5天， 发热 38 有 2天，心率 120次 /分，呼吸 频 率 24次 /分，嗜睡、眼睛凹陷、嘴唇干，末梢充血 时间是 4秒，吃得很少，喝一点， 24小 时 无尿。 3 A 7 year old boy comes to you with 5 days of vomiting and diarrhea. He has had a fever to 38 degrees for 2 days. His heart rate is 120 （60 140） and his respiratory rate is 24 （ 20 25）. He appears lethargic, his eyes appear sunken, his lips are dry, and his capillary refill time is 4 seconds. He has been eating and drinking very little and he has not urinated for 24 hours. 7岁 男孩，呕吐和腹泻 5天， 发热 38 有 2天，心率 120次 /分 （60 140） ，呼吸 频 率 24次 /分 （ 20 25），嗜睡 、眼睛凹陷、嘴唇干 ，末梢充血 时间 是 4秒 ，吃得很少，喝一点 ， 24小 时无尿 。 4 A 4 year old girl comes to you with 4 days of diarrhea. She has not had a fever and has been eating and drinking as usual. Her heart rate is 100 and her respiratory rate is 21. She is alert and playful and her lips appear moist. She has been urinating as usual. 4岁 女孩，腹泻 4天，不 发热 ，吃喝正常，心率 100次 /分，呼吸频 率 21次 /分，精神好，玩耍，嘴唇湿 润 ，尿量正常。 4 A 4 year old girl comes to you with 4 days of diarrhea. She has not had a fever and has been eating and drinking as usual. Her heart rate is 100 （60 140） and her respiratory rate is 21 （ 20 25）. She is alert and playful and her lips