shock tulane university低血容量性休克杜兰大学课件

Hypovolemic Hypovolemic ShockShock General Surgery OrientationGeneral Surgery Orientation Medical Student Lecture SeriesMedical Student Lecture Series Juan Duchesne MD,FACS,FCCP,FCCMJuan Duchesne MD,FACS,FCCP,FCCM ShockShock vvHypovolemicHypovolemic vvSepticSeptic vvCardiogenic (Obstructive)Cardiogenic (Obstructive) vvNeurogenicNeurogenic vvAdrenalAdrenal ShockShock Most common forms in surgery:Most common forms in surgery: vvHypovolemicHypovolemic vvSepticSeptic vvCardiogenicCardiogenic Hypovolemic ShockHypovolemic Shock Definition:Definition: vvReduction in intravascular volume leading Reduction in intravascular volume leading to insufficient oxygen delivery to cells to insufficient oxygen delivery to cells (mitochondria)(mitochondria) Hypovolemic ShockHypovolemic Shock Reduced intravascular volume?Reduced intravascular volume? No oxygen delivery! No oxygen delivery! No aerobic metabolism! No aerobic metabolism! ThenThen vvMetabolic acidosis (lactic acid production)Metabolic acidosis (lactic acid production) vvEndoplasmic recticulum swellingEndoplasmic recticulum swelling vvMitochondrial damageMitochondrial damage vv Cell Death! Cell Death! Hypovolemic ShockHypovolemic Shock Vascular compartments:Vascular compartments: TBW (60% of IBW) TBW (60% of IBW) Total Body Water Total Body Water ICW (40%) ICW (40%) ECW (20%)ECW (20%) Intracellular Water Intracellular WaterExtracellular Extracellular WaterWater Interstitium InterstitiumPlasmaPlasma (1/3)(1/3)(2/3)(2/3) Hypovolemic ShockHypovolemic Shock vvLoss of circulating blood volume (Plasma)Loss of circulating blood volume (Plasma) vvNormal Blood Volume:Normal Blood Volume: - 7% IBW in adults- 7% IBW in adults - 9% IBW in kids- 9% IBW in kids Hypovolemic ShockHypovolemic Shock Tension Tension Pneumothorax Pneumothorax impairment impairment of ventricular of ventricular filling.filling. Hypovolemic ShockHypovolemic Shock vvHemorrhagic shock (3 categories)Hemorrhagic shock (3 categories) vvCompensated:Compensated: 0-20% of blood loss0-20% of blood loss Blood pressure is maintained via increased Blood pressure is maintained via increased vascular tone and increased blood flow to vital vascular tone and increased blood flow to vital organsorgans HypovolemicHypovolemic ShockShock The bodys response:The bodys response: Compensated shock Compensated shock Baroreceptor mediated Baroreceptor mediated vasoconstriction!vasoconstriction! vvIncreased epinephrine, vasopressin, angiotensinIncreased epinephrine, vasopressin, angiotensin vvResults in:Results in: TachycardiaTachycardia TachypneaTachypnea Lowered pulse pressureLowered pulse pressure Slightly lowered urine outputSlightly lowered urine output Hypovolemic ShockHypovolemic Shock The Organs who win:The Organs who win: vvBrainBrain vvHeartHeart vvKidneysKidneys vvLiverLiver The Organs who lose:The Organs who lose: vvSkinSkin vvGI tractGI tract vvSkeletal MuscleSkeletal Muscle HypovolemicHypovolemic ShockShock But whyBut why vvThe body will make whatever adjustsments it can to The body will make whatever adjustsments it can to maintain.maintain. Adequate Adequate Cardiac Cardiac Output Output vvBrain and heart perfusions remain Brain and heart perfusions remain near normalnear normal while while other less critical organ systems are, in proportion to the other less critical organ systems are, in proportion to the blood volume deficit, stressed by ischemia.blood volume deficit, stressed by ischemia. Hypovolemic ShockHypovolemic Shock Uncompensated:Uncompensated: vv20-40% loss of blood volume20-40% loss of blood volume vvDecrease in BPDecrease in BP vvTachycardiaTachycardia HypovolemicHypovolemic ShockShock The bodys responseThe bodys response Uncompensated shockUncompensated shock vvThe intravascular volume deficit exceeds the The intravascular volume deficit exceeds the capacity of vasoconstrictive mechanisms to capacity of vasoconstrictive mechanisms to maintain systemic perfusion pressure.maintain systemic perfusion pressure. vvIncreased cardiac outputIncreased cardiac output vvIncreased respirationIncreased respiration vvSodium retentionSodium retention Hypovolemic ShockHypovolemic Shock Lethal exsanguination:Lethal exsanguination: 40% loss of blood volume 40% loss of blood volume Profound hypotension and inability to Profound hypotension and inability to perfuse vital organsperfuse vital organs Hypovolemic ShockHypovolemic Shock The bodys responseThe bodys response Lethal exsanguination: Lethal exsanguination: ObtundedObtunded Severe hypotensionSevere hypotension Severe tachycardiaSevere tachycardia Cold, ClammyCold, Clammy DeathDeath Hypovolemic ShockHypovolemic Shock CaveatsCaveats vvAthletesAthletes vvPregnancyPregnancy vvExtremes of ageExtremes of age vvMedicationsMedications vvHematocrit/HemoglobinHematocrit/Hemoglobin HypovolemicHypovolemic ShockShock Management:Management: vvABCs of trauma (AIRWAY is ABCs of trauma (AIRWAY is always first!)always first!) vvControl hemorrhage (splint the Control hemorrhage (splint the limb!)limb!) vvObtain IV access and resuscitate Obtain IV access and resuscitate with fluids and blood with fluids and blood 2 liters crystalloid for adults2 liters crystalloid for adults 20 cc/kg crystalloid x 2 for kids20 cc/kg crystalloid x 2 for kids vvBlood vs. Crystalloid?Blood vs. Crystalloid? vvLong term critical care Long term critical care managementmanagement Hypovolemic ShockHypovolemic Shock Your management goals AFTER securing the Your management goals AFTER securing the ABCs:ABCs: STOP THE BLEEDING!STOP THE BLEEDING! RESTORE VOLUME!RESTORE VOLUME! CORRECT ANY ELECTROLYTE/ACID-BASE CORRECT ANY ELECTROLYTE/ACID-BASE DISTURBANCES!DISTURBANCES! Hypovolemic ShockHypovolemic Shock this requires a trip to the ORthis requires a trip to the OR Hypovolemic ShockHypovolemic Shock And sometimes the ED becomes the ORAnd sometimes the ED becomes the OR Hypovolemic ShockHypovolemic Shock Volume Resuscitation What are my goals?Volume Resuscitation What are my goals? vvRapid ResponderRapid Responder Give 500cc-1 Liter crystalloid Give 500cc-1 Liter crystalloid rapid rapid improvement of BP/HR/Urine outputimprovement of BP/HR/Urine output 40% blood loss 40% blood loss STAT Surgery consult!STAT Surgery consult! Hypovolemic ShockHypovolemic Shock Is my volume resuscitation Is my volume resuscitation adequate/inadequate?adequate/inadequate? vvUrine output Urine output vvVital signsVital signs vvSkin perfusionSkin perfusion vvPulse OximetryPulse Oximetry vvAcidemia?Acidemia? Septic ShockSeptic Shock An exaggerated endogenous inflammatory An exaggerated endogenous inflammatory response to invasive infection leading to:response to invasive infection leading to: vvcirculatory collapsecirculatory collapse vvmultiple organ failuremultiple organ failure vvdeathdeath Septic ShockSeptic Shock Septic ShockSeptic Shock MortalityMortality vvover 35% (sepsis with hypotension)over 35% (sepsis with hypotension) vv45% (sustained septic shock)45% (sustained septic shock) SepticSeptic ShockShock Management:Management: vvIdentify and treat the infectious sourceIdentify and treat the infectious source eg simple incision & drainage? eg simple incision & drainage? Exploratory laparotomy? Exploratory lap