小儿急症课件

TheSickChildBeverlyYoung,MD2010TheWarrenAlpertMedicalSchoolofBrownUniversity小儿急症Haveyouseenchildrendie?

你见过儿童死亡吗？

Discusswithyourpartner:

与你周围的人讨论：Whatwasthecauseofdeath?死因是什么？Whattreatmentdidthechildreceive?孩子接受过什么治疗？Whatworked,andwhatdidn’t?哪些治疗有效，哪些无效？小儿急症Childrendiein2ways:

儿童死亡的两个原因：Respiratoryfailure呼吸衰竭Inadequatetissueperfusion体液丢失小儿急症3causesforinadequatetissueperfusion

体液缺乏的3个因素:Hypovolemia血容量不足Poordistributionofbodyfluids体液分布异常Heartdysfunction心脏功能障碍小儿急症Majorcausesofchilddeath儿童死亡的主要原因:CardiacDysfunction心脏功能障碍

Congenitalheartdisease先天性心脏病Myocarditis心肌炎RespiratoryFailure呼吸衰竭InadequatePerfusion体液不足Blockageofmajorairways气管堵塞

Choking气管异物-Epiglottitis会厌炎

Abscess脓肿

Mass肿块Blockageof

smallAirways小气道堵塞

Asthma哮喘

Bronchiolitis支气管炎Lungdisease肺疾病

Pneumonia肺炎

Heartdisease心脏疾病Hypovolemia血容量不足*Mostcommon*Hemorrhage出血

Dehydration脱水Maldistributionofbodyfluids体液分布不良

Massiveinfection

肿块感染(septicshock感染性休克)

Anaphylaxis

过敏反应

Severeburns

烧伤小儿急症Children’sRespiratoryRate

儿童呼吸频率Theyoungerthechild,thefastertherespiratoryrate.孩子越小，呼吸频率越快Fastbreathingisasignofrespiratorydistressorotherillness.呼吸加快是呼吸窘迫或其它疾病的迹象Ifasickchild’srespiratoryratedrops,itmaysignalimpendingrespiratoryfailure.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。Age0–1岁year2–4岁years4–10岁years>10岁yearsNormalRespiratoryRate20-4020-3020-2512-20小儿急症IdentifyingRespiratoryDistress

判断呼吸窘迫Increasedrespiratoryrate呼吸频率加快Nasalflaring鼻翼扇动Retractions–abovethesternalnotch,belowtheribs凹陷—胸骨上窝，膈肌凹陷Decreasedairmovementonauscultation听诊呼吸音减弱Wheezing,cracklesonauscultation哮鸣音、湿啰音Lethargy嗜睡Cyanosis紫绀Sometimesthereisanobviouscause–choking,historyofasthma,knownpneumoniaorheartdisease有时会有一个明显的病因—窒息、哮喘史、肺炎或心脏疾病小儿急症IdentifyingInadequatePerfusion

辨认体液不足HeartRate心率SystemicPerfusion体循环BloodPressure血压小儿急症Children’sHeartRates儿童心率Age年龄Birth–3mos3mos–2yrs2yrs–10yrs>10yrsNormalHeartRate正常心率85–205100–19060–14060-100Theyoungerthechild,thefastertheheartrate.孩子越小，心率越快Whenachildissick,theheartrateincreasesasthebodytriestoincreaseperfusion.当孩子生病时，心率增快，因为机体努力改善体循环Alowheartrateindicatesthattheheartisalreadyfailingandisasignofveryseriousillness.心率减低说明心脏已经衰竭，是严重疾病的迹象。小儿急症IdentifyingDecreasedSystemicPerfusion

辨认体循环减弱WeakpulsesOR“bounding”pulses脉搏减弱或弹跳脉搏（水冲脉）Decreasedskinperfusion皮肤循环减少Cool冰凉Capillaryrefilltime>2seconds毛细充盈时间大于2秒Mottlingandpallor(peripheralbeforecentral)斑影与苍白（先周围，后中央）小儿急症IdentifyingDecreasedSystemicPerfusion

辨认体循环减弱Mentalstatuschanges精神面貌改变Early:irritability,slightconfusion早期：烦躁，轻度迷糊Late:lethargy,lossofconsciousness后期：嗜睡，意识不清Decreasedurineoutput尿量减少Infants(<1year):nourinefor>6hours婴儿（小于1岁）：无尿超过6小时Olderchildren(>1year):nourinefor>12hours稍大的儿童（大于1岁）：无尿超过12小时小儿急症Children’sBloodPressure儿童血压Theolderthechild,thehigherthebloodpressure孩子越大，血压越高Approximatesystolicbloodpressureforchildren1–10yearsold:90mmHg+(2×ageinyears) Diastolicbloodpressureshouldbeapproximately2/3ofthesystolicbloodpressure.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2/3Lowbloodpressureinachildisasignofveryseriousillness!儿童低血压是严重疾病的迹象小儿急症IdentifyingHypovolemia

辨认血容量不足Historyofbloodorfluidloss出血或体液丢失:Traumaticinjurycausingexternalorinternalbleeding

创伤导致内或外出血Diarrhea/vomiting

腹泻/呕吐Excessiveurination

过度排尿Lackoffluidintake

液体摄入不足Sunkeneyes眼睛凹陷小儿急症IdentifyingHypovolemia

辨认血容量不足Drymucousmembranes(mouth,lips)&absenceoftearsifcrying粘膜干燥（口腔、嘴唇），哭时无泪Weakpulses脉搏弱Poorskinturgor皮肤弹性减弱Peripheralcapillaryrefill>2seconds末梢回血时间大于2秒Infants:sunkenfontanel婴儿：前囟凹陷Decreasedurineoutput尿量减少<1yearold:nourinefor>6hours小于1岁的孩子：超过6小时无尿>1yearold:nourinefor>12hours大于1岁的孩子：超过12小时无尿小儿急症IdentifyingSepticShock辨认感染性休克Thismaylookdifferentfromotherkindsofshock:

它不同于其它种类的休克Increasedheartrate

心率增加Fever

发热Boundingpulses

水冲脉Increaseddistancebetweensystolicanddiastolicbloodpressures(>1/3systolic)

脉压差增大（大于收缩压的1/3）Theremaybeanobvioussourceofinfection(ortheremaynot)可能会有明显的感染源（也可能没有）小儿急症Majorcausesofchilddeath儿童死亡的主要原因:CardiacDysfunction心脏功能障碍

Congenitalheartdisease先天性心脏病Myocarditis心肌炎RespiratoryFailure呼吸衰竭InadequatePerfusion体液不足Blockageofmajorairways气管堵塞

Choking气管异物-Epiglottitis会厌炎

Abscess脓肿

Mass肿块Blockageof

smallAirways小气道堵塞

Asthma哮喘

Bronchiolitis支气管炎Lungdisease肺疾病

Pneumonia肺炎

Heartdisease心脏疾病Hypovolemia血容量不足*Mostcommon*Hemorrhage出血

Dehydration脱水Maldistributionofbodyfluids体液分布不良

Massiveinfection

肿块感染(septicshock感染性休克)

Anaphylaxis

过敏反应

Severeburns

烧伤小儿急症TreatingRespiratoryFailure

治疗呼吸衰竭Treattheunderlyingcause(i.e.,asthma)治疗潜在的病因（如：哮喘）Bag-maskventilation呼吸气囊小儿急症TreatingInadequatePerfusion治疗体液不足Giveoxygen,ifavailable如有可能，吸氧GetIVaccess–usealarge-boreneedle静脉输液—用大号针3.Give20ml/kgofnormalsalineasfastaspossible:over5–10minutes

在5-10分钟内按每公斤体重20毫升，补充生理盐水4.Reassessheartrate,perfusion,bloodpressure

重新测心率、体循环、血压小儿急症TreatingInadequatePerfusion治疗体液不足5.Ifthesearestillabnormal:repeat20ml/kgnormalsaline+reassessment–asmanytimesasneeded!

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.Stillnoresponse?Dopamineorepinephrineifyouhaveit7.Getthechildtothehospitalimmediately!

仍然没效果，可以给多巴胺或肾上腺素；建议尽快送医院小儿急症#1A5yearoldboycomestoyouwith2daysofsorethroatandrunnynose.Todayhehadafeverto38degreesinthemorning.Hehasbeenabitsleepyandcrankysincehehashadthefever.Hismothergavehimparacetamol2hoursagoanditbroughthisfeverdownandhehasbeenactingnormalsincethen.Hisheartrateis110andhisrespiratoryrateis23.Heiseatinganddrinkingandurinatingasusual.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。小儿急症#1A5yearoldboycomestoyouwith2daysofsorethroatandrunnynose.Todayhehadafeverto38degreesinthemorning.Hehasbeenabitsleepyandcrankysincehehashadthefever.Hismothergavehimparacetamol2hoursagoanditbroughthisfeverdownandhehasbeenactingnormalsincethen.Hisheartrateis110（60－

140）

andhisrespiratoryrateis23（20－25）.Heiseatinganddrinkingandurinatingasusual.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。小儿急症＃2A1yearoldgirlcomestoyouwith2daysofrunnynoseandcongestionandcough.Thismorningshehasbeenwheezingabit.Sheisfebrileto38.4degrees,herheartrateis190,andherrespiratoryrateis60.Shehasretractionsabovethesternalnotchandbelowtheribs,andsheisflaringhernostrilswhenshebreathes.Shelookstiredandirritable.Shehasnotbeenfeedingwell.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。小儿急症＃2A1yearoldgirlcomestoyouwith2daysofrunnynoseandcongestionandcough.Thismorningshehasbeenwheezingabit.Sheisfebrileto38.4degrees,herheartrateis190（100－

190）,andherrespiratoryrateis60（20－40）.Shehasretractionsabovethesternalnotchandbelowtheribs,andsheisflaringhernostrilswhenshebreathes.Shelookstiredandirritable.Shehasnotbeenfeedingwell.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。小儿急症＃3A7yearoldboycomestoyouwith5daysofvomitinganddiarrhea.Hehashadafeverto38degreesfor2days.Hisheartrateis120andhisrespiratoryrateis24.Heappearslethargic,hiseyesappearsunken,hislipsaredry,andhiscapillaryrefilltimeis4seconds.Hehasbeeneatinganddrinkingverylittleandhehasnoturinatedfor24hours.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。小儿急症＃3A7yearoldboycomestoyouwith5daysofvomitinganddiarrhea.Hehashadafeverto38degreesfor2days.Hisheartrateis120（60－

140）andhisrespiratoryrateis24（20－25）.Heappearslethargic,hiseyesappearsunken,hislipsaredry,andhiscapillaryrefilltimeis4seconds.Hehasbeeneatinganddrinkingverylittleandhehasnoturinatedfor24hours.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。小儿急症＃4A4yearoldgirlcomestoyouwith4daysofdiarrhea.Shehasnothadafeverandhasbeeneatinganddrinkingasusual.Herheartrateis100andherrespiratoryrateis21.Sheisalertandplayfulandherlipsappearmoist.Shehasbeenurinatingasusual.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。小儿急症＃4A4yearoldgirlcomestoyouwith4daysofdiarrhea.Shehasnothadafeverandhasbeeneatinganddrinkingasusual.Herheartrateis100（60－

140）andherrespiratoryrateis21（20－25）.Sheisalertandplayfulandherlipsappearmoist.Shehasbeenurinatingasusual