小儿急症PPT课件.ppt

The Sick Child,Beverly Young, MD 2010 The Warren Alpert Medical School of Brown University,1,Have 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？,2,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,3,3 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,4,Major causes of child death儿童死亡的主要原因:,5,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。,6,Identifying 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,7,Identifying Inadequate Perfusion 辨认体液不足,8,Childrens Heart Rates儿童心率,The 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。,9,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）,10,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,11,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,12,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,13,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,14,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）,15,Major causes of child death儿童死亡的主要原因:,16,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,17,Treating Inadequate Perfusion治疗体液不足,Give oxygen, if available 如有可能，吸氧 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,18,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 it 7. 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,19,# 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。,20,# 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。,21, 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。,22, 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。,23, 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。,24, 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。,25, 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。,26, 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 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 （60 140） ，呼吸频率21次/分 （ 20 25），精神好，玩