医学临床危象双语

第十章第十章 常见临床危象常见临床危象 Chapter 10Chapter 10 Common Emergency CrisisCommon Emergency Crisis Definition of Common Emergency CrisisDefinition of Common Emergency Crisis Clinical crisis is not an independent disease but a Clinical crisis is not an independent disease but a group of syndromes manifested progress of certain group of syndromes manifested progress of certain disease.disease. It can threaten the vital organs, particularly the It can threaten the vital organs, particularly the brain.brain. 是指某一疾病在进展中所表现的一组综合征。死亡率和致是指某一疾病在进展中所表现的一组综合征。死亡率和致 残率较高残率较高 The mortality and morbidity would be high The mortality and morbidity would be high The common precipitating factors of the crisis: The common precipitating factors of the crisis: 常见诱因：常见诱因： Exhaustion, infection, trauma, surgery, delivery Exhaustion, infection, trauma, surgery, delivery The crisis can be controlled The crisis can be controlled DefinitionDefinition： is an excessive and unusual elevation of body is an excessive and unusual elevation of body temperature greater than 41temperature greater than 41.It is medical It is medical emergencyemergency , , accompanied by convulsion, coma, accompanied by convulsion, coma, shock, hemorrhage, etcshock, hemorrhage, etc a medical emergencya medical emergency 是指体温异乎寻常升高至是指体温异乎寻常升高至4141以上，是一种医疗急症以上，是一种医疗急症 。高热同时伴随抽搐、昏迷、休克、出血等，通常是。高热同时伴随抽搐、昏迷、休克、出血等，通常是 致命的，需紧急处理。致命的，需紧急处理。 Section1 hyperpyrexia crisis 第一节 超高热危象 一、病因一、病因 EtiologyEtiology .Infectious HyperpyrexiaInfectious Hyperpyrexia 感染性发热感染性发热 .Non-infectious Hyperpyrexia Non-infectious Hyperpyrexia 非非感染性发热感染性发热 1.1. Allergic reactionAllergic reaction 变态反应变态反应 Such as serum disease Such as serum disease , infusion reactions , infusion reactions 2.2. Dysfunction of the body Dysfunction of the body s temperature regulation s temperature regulation center center 体温调节中枢异常体温调节中枢异常 3.3. Endocrine and metabolic diseases Endocrine and metabolic diseases 内分泌和代谢性疾病内分泌和代谢性疾病 .病情评估病情评估 AssessmentAssessment ( (一一) )病史收集病史收集 Collecting Medical HistoryCollecting Medical History 1. 1. Epidemiological dataEpidemiological data 流行病学资料流行病学资料 2. 2. The characteristics of fever The characteristics of fever 发热特点发热特点 Many febrile Many febrile发热的发热的 illnesses have a specific fever illnesses have a specific fever pattern pattern （二）体格检查（二）体格检查 Physical ExaminationPhysical Examination the patient the patient s face , skin rash or petechias face , skin rash or petechia瘀点瘀点 , , enlargement of lymph node or liver and spleen.enlargement of lymph node or liver and spleen. （三）实验室检查（三）实验室检查Laboratory InspectionLaboratory Inspection Blood routine, urine routine , stool routine , and Blood routine, urine routine , stool routine , and cerebrospinal fluid routine testcerebrospinal fluid routine test .First Aid Care .First Aid Care 救治和护理救治和护理 （一）严密观察病情（一）严密观察病情.MonitoringMonitoring 1.1. Monitor the changes of vital signs , such Monitor the changes of vital signs , such as consciousness , breathing , blood pressure as consciousness , breathing , blood pressure , pulse , temperature and peripheral , pulse , temperature and peripheral circulation , particular the changes of circulation , particular the changes of temperature falls too fast as this may lead temperature falls too fast as this may lead to collapse of the patient.to collapse of the patient. 2.2. Observe for the changes of concomitant Observe for the changes of concomitant symptoms symptoms 伴随症状伴随症状that can assist the physician that can assist the physician to make diagnosis.to make diagnosis. 3.3. Record intake and output of the patient. Record intake and output of the patient. Adequate fluids should be supplemented.Adequate fluids should be supplemented. .First Aid Care.First Aid Care （二）降温（二）降温.Cooling.Cooling It is vitalIt is vital （关键）（关键）to decrease the body temperature to decrease the body temperature to 38.5 quickly and effectively in hyperpyrexia to 38.5 quickly and effectively in hyperpyrexia crisis.crisis. 1.1. Physical coolingPhysical cooling物理降温物理降温 is a preferred simple is a preferred simple（首（首 选）选） , safe and effective measure., safe and effective measure. （1 1）方法：冰水擦浴；温水擦浴；酒精擦浴；冰敷。）方法：冰水擦浴；温水擦浴；酒精擦浴；冰敷。 （2 2）注意事项：）注意事项： 2. 2. Cooling with medication Cooling with medication 3.3. Hibernation therapy Hibernation therapy冬眠降温冬眠降温 .Identify Causes.Identify Causes寻找病因寻找病因 1.1. Choose appropriate antibioticsChoose appropriate antibiotics合理选用抗生素合理选用抗生素 2.2. To the disease highly suspected To the disease highly suspected 诊断性治疗诊断性治疗 diagnostic treatment can be provided. diagnostic treatment can be provided. 3.3. For unexplained fever, continuous For unexplained fever, continuous observation and further examinations are observation and further examinations are required.required. 对原因不明者对原因不明者-进一步观察进一步观察 （四）加强基础护理（四）加强基础护理 . Strengthen Primary Care. Strengthen Primary Care a quiet environment a quiet environment 休息环境休息环境 provide sufficient water , nutrition, provide sufficient water , nutrition, vitamins; vitamins; 充足的营养、水份、维生充足的营养、水份、维生 素素 protect normal function of vital organs protect normal function of vital organs sedate patients sedate patients 镇静镇静 administer oxygen to patients who have administer oxygen to patients who have dyspnea dyspnea 吸氧吸氧 endotracheal intubationsendotracheal intubations 机械通气机械通气 （五）对症护理（五）对症护理 Symptomatic CareSymptomatic Care 1. Ice pack need to be replaced in time1. Ice pack need to be replaced in time 及时更换冰袋及时更换冰袋 2.2. Skin Care Skin Care 皮肤护理皮肤护理 3.3. Oral care Oral care 口腔护理口腔护理 4.4. Strengthen management of respiratory tractStrengthen management of respiratory tract 加强呼吸道管理加强呼吸道管理 5.5. Patients who are irritable or having Patients who are irritable or having convulsion should be placed bed with convulsion should be placed bed with side side railsrails up, and may need limbs constraint to up, and may need limbs constraint to prevent falling from the bed or self-injury.prevent falling from the bed or self-injury. 保护及约束保护及约束 Section 3 Hyperthyroidism CrisisSection 3 Hyperthyroidism Crisis 甲亢危象甲亢危象 DefinitionDefinition Hyperthyroidism crisis (also known as thyrotoxic Hyperthyroidism crisis (also known as thyrotoxic storm) is an uncommon medical emergency caused by an storm) is an uncommon medical emergency caused by an exacerbation of primary hyperthyroidism exacerbation of primary hyperthyroidism characterized by decompensationcharacterized by decompensation代偿不全代偿不全 of one or of one or more organ systems.more organ systems. 甲亢危象是一种由甲状腺功能亢进恶化的，以一个或多个器甲亢危象是一种由甲状腺功能亢进恶化的，以一个或多个器 官功能失代偿为特征的罕见的医疗急症。官功能失代偿为特征的罕见的医疗急症。 发病率发病率 甲亢危象一般可占住院甲亢病人数的甲亢危象一般可占住院甲亢病人数的1%1%2%2% ，女性明显高于男性本症可发生于任何年龄，女性明显高于男性本症可发生于任何年龄 ，儿童少见。，儿童少见。 甲亢危象在老年人较多见。甲亢危象在老年人较多见。 主要并发症有严重的心律失常心力衰竭、休主要并发症有严重的心律失常心力衰竭、休 克等克等 . Precipitants and PathogenesisPrecipitants and Pathogenesis 诱因与发病机制诱因与发病机制 Precipitants can be divided into two categories:Precipitants can be divided into two categories: i.i. Medical PrecipitantsMedical Precipitants 内科性诱因内科性诱因 Medical precipitants refer to precipitants other Medical precipitants refer to precipitants other than surgical factors.than surgical factors. 1. 1. Serious infections: Serious infections: 严重感染，临床上最常见的因素严重感染，临床上最常见的因素 2.stress 2.stress 应激：过度紧张、高热、过度疲劳、情绪激动。 应激：过度紧张、高热、过度疲劳、情绪激动。 3. Emotional stimulus: 3. Emotional stimulus: 精神刺激：对诱发本症有明显作用精神刺激：对诱发本症有明显作用 4. 4. Suddenly withdrawal of or non-compliance with anti-thyroid Suddenly withdrawal of or non-compliance with anti-thyroid medication medication 忽然停用或不适应抗甲状腺药物忽然停用或不适应抗甲状腺药物 5.Others: Squeezing the thyroid excessively results in 5.Others: Squeezing the thyroid excessively results in massive thyroxin released intomassive thyroxin released into blood. blood. 挤压甲状腺挤压甲状腺 ( (二二) )外科性诱因外科性诱因 Surgical precipitantsSurgical precipitants If hyperthyroidism crisis developed in a If hyperthyroidism crisis developed in a patient with hyperthyroidism during the patient with hyperthyroidism during the operation of 416 hours after surgeryoperation of 416 hours after surgery 与术前准备不充分，肾上腺皮质激素分泌不足有与术前准备不充分，肾上腺皮质激素分泌不足有 关。常发生于手术时和术后关。常发生于手术时和术后4-164-16小时小时 （三）发病机制（三）发病机制 PathogenesisPathogenesis The pathogenesis of hyperthyroidism crisis is not The pathogenesis of hyperthyroidism crisis is not clearly defined. The possible key factors may clearly defined. The possible key factors may include:include: 甲亢危象发病机制尚不清楚，可能相关的主要因素包括：甲亢危象发病机制尚不清楚，可能相关的主要因素包括： 1.1. Massive thyroid hormone releasing into blood Massive thyroid hormone releasing into blood 大量大量甲状腺素释放入血甲状腺素释放入血 2.2. Blood concentration of free thyroid hormone Blood concentration of free thyroid hormone increasing.increasing.血游离甲状腺素浓度增加血游离甲状腺素浓度增加 3 3 Activation of adrenaling increasing Activation of adrenaling increasing 肾上腺素活力增加肾上腺素活力增加 二、病情评估二、病情评估 Assessment Assessment 1.1. Primary hyperthyroidism aggravated. Primary hyperthyroidism aggravated. 原有甲状腺功能亢进进一步加重原有甲状腺功能亢进进一步加重 2.2. Systemic symptoms Systemic symptoms 全身症状全身症状 The body temperature increases sharply. A lethal high fever The body temperature increases sharply. A lethal high fever may develop within 2428 hours. Skin presents red and moist may develop within 2428 hours. Skin presents red and moist accompanied by massive perspiration, then turns to no sweat.accompanied by massive perspiration, then turns to no sweat. It is followed by obviously dehydration or collapse, dyspnea or It is followed by obviously dehydration or collapse, dyspnea or even shock.even shock. 高热、皮肤潮湿红润、大汗、明显脱水、呼吸困难、休克高热、皮肤潮湿红润、大汗、明显脱水、呼吸困难、休克 3. CNS symptoms 3. CNS symptoms 中枢神经系统症状中枢神经系统症状 It manifests as anxiety, indifferent expression, It manifests as anxiety, indifferent expression, restless, and even coma.restless, and even coma. 焦虑、表情淡漠、躁动不安、昏迷。焦虑、表情淡漠、躁动不安、昏迷。 二、病情评估二、病情评估 Assessment Assessment 4. Cardiovascular system symptoms 4. Cardiovascular system symptoms 心血管症状心血管症状 5.5. Digestive system symptomsDigestive system symptoms 消化系统症状：厌食、恶心、呕吐、腹泻消化系统症状：厌食、恶心、呕吐、腹泻 6.6. Water and electrolyte imbalance Water and electrolyte imbalance 水与电解质紊乱：代谢性酸中毒、低血钠。水与电解质紊乱：代谢性酸中毒、低血钠。 7.7. Other manifestationsOther manifestations 胸痛、呼吸急促、后期可出现呼吸窘迫综合征胸痛、呼吸急促、后期可出现呼吸窘迫综合征 三、救治与护理三、救治与护理 First Aid CareFirst Aid Care i. Monitoring i. Monitoring changes of the level of consciousness , changes of the level of consciousness , body temperature, pulse, breath, blood body temperature, pulse, breath, blood pressure , blood oxygen saturation.pressure , blood oxygen saturation. 严密观察严密观察 患者神志、体温、脉搏、呼吸、血压、血氧饱和度患者神志、体温、脉搏、呼吸、血压、血氧饱和度 三、救治与护理三、救治与护理 First Aid CareFirst Aid Care （二）急救措施（二）急救措施 1 1、原则、原则维持基本生命维持基本生命 迅速降温迅速降温 补充体液补充体液 消除诱因消除诱因 治疗病因对症处理治疗病因对症处理 2 2、措施：、措施： 降低血循环中甲状腺素的浓度降低血循环中甲状腺素的浓度抑制甲状腺素的合成抑制甲状腺素的合成- -丙硫丙硫 氧嘧啶（氧嘧啶（PTUPTU）抑制甲状腺素的释放。抑制甲状腺素的释放。 PTU+PTU+碘液碘液 降低组织对甲状腺素降低组织对甲状腺素- -儿茶酚胺的反应儿茶酚胺的反应 普萘洛尔普萘洛尔利血平各胍乙啶利血平各胍乙啶氢化可的松氢化可的松 糖皮质激素的应用糖皮质激素的应用 降温降温 其它对症处理其它对症处理 （三）加强基础护理（三）加强基础护理 Strengthen Primary Nursing CareStrengthen Primary Nursing Care 1.1. Absolute bed rest; maintain a quiet and Absolute bed rest; maintain a quiet and comfortable environment. comfortable environment. 绝对卧床休息绝对卧床休息 2.2. Provide primary nursing care: offer high energy, Provide primary nursing care: offer high energy, high protein , and high vitamin diet; encourage the high protein , and high vitamin diet; encourage the patient to drink more waterpatient to drink more water . . 做好生活护理做好生活护理 3.3. Psychological care Psychological care 精神护理精神护理 Concern and comfort the patient; eliminate the Concern and comfort the patient; eliminate the fear and encourage confidence to confront the fear and encourage confidence to confront the disease.disease. （四）对症护理（四）对症护理 Symptomatic CareSymptomatic Care 1.1. Administer sedative such as diazepam Administer sedative such as diazepam to the manicto the manic（狂躁）（狂躁） patientpatient . . 镇静镇静 2.2. Keep various rescue equipment ready; Keep various rescue equipment ready; prevent complications such as aspiration prevent complications such as aspiration pneumonia etc. pneumonia etc. 做好各种抢救准备，预防吸入性肺炎做好各种抢救准备，预防吸入性肺炎 第四节第四节 高血糖危象高血糖危象 Hyperglycemic Crisis Hyperglycemic Crisis 概念及特征概念及特征 概念：高血糖危象指糖尿病昏迷概念：高血糖危象指糖尿病昏迷diabetic comadiabetic coma 基本病理生理变化基本病理生理变化 胰岛素分泌不足至胰岛素分泌不足至 糖代谢紊乱糖代谢紊乱 特征性病理改变：高血糖、高酮血症、代谢性酸特征性病理改变：高血糖、高酮血症、代谢性酸 中毒中毒 hyperglycemic, hyperketonemia and metabolic hyperglycemic, hyperketonemia and metabolic acidosis. acidosis. 分类：酮症酸中毒昏迷、高渗性非酮症昏迷分类：酮症酸中毒昏迷、高渗性非酮症昏迷 Ketoacidosis coma Ketoacidosis coma 、 hyperosmolar nonketotic coma hyperosmolar nonketotic coma 一、糖尿病酮症酸中毒一、糖尿病酮症酸中毒 概概 述述 是糖尿病急性并发症之一是糖尿病急性并发症之一 可作为糖尿病首发表现可作为糖尿病首发表现 由于胰岛素绝对或相对缺乏引起由于胰岛素绝对或相对缺乏引起 以高血糖（以高血糖（ hyperglycemiahyperglycemia） 、高酮血症、高酮血症 （hyperketonemiahyperketonemia ）、代谢性酸中毒（）、代谢性酸中毒（ metabolic metabolic acidosisacidosis ）为特征）为特征, ,三联征。三联征。 英文（英文（DKA Diabetic ketoacidosisDKA Diabetic ketoacidosis ） （一）诱因与发病机制（一）诱因与发病机制 Precipitants and PathogenesisPrecipitants and Pathogenesis 1 1、引起糖升高的因素：、引起糖升高的因素： 感染：最常见，占一半以上，泌尿道、肺部感染。最常见感染：最常见，占一半以上，泌尿道、肺部感染。最常见 胰岛素治疗中断或不适当减量。胰岛素治疗中断或不适当减量。 应激状态：心肌梗死、外伤、手术、妊娠分娩、精神刺激应激状态：心肌梗死、外伤、手术、妊娠分娩、精神刺激 。 各种引起糖升高的药物各种引起糖升高的药物 2 2、引起失水、脱水的因素、引起失水、脱水的因素 利尿药物、水摄入不足、透析、利尿药物、水摄入不足、透析、 大面积烧伤大面积烧伤 3 3、肾功能不全、肾功能不全 高血糖 胰岛素绝对或相对不足 胰岛素对抗性调节激素升高 脂肪分解蛋白质分解葡萄糖利用 游离脂肪酸甘油 酮体 碱储备 酮症酸中毒 氨基酸 糖异生 渗透性利尿 水电解质丢失 脱水高渗 DKA发病机制 ( (二二) )、病情评估面、病情评估面 AssessmentAssessment 1 1、症状、症状SymptomsSymptoms：原有糖尿病症状加重；极度软：原有糖尿病症状加重；极度软 弱无力，意识改变弱无力，意识改变 2 2、体征、体征SignsSigns：体征：失水征、呼吸深而速有酮：体征：失水征、呼吸深而速有酮 味，血压下降、休克味，血压下降、休克 3 3、实验室检查、实验室检查 Laboratory investigationsLaboratory investigations ： 血血: :血糖明显升高，血糖明显升高， 16-33.3mmol/L CO2CP16-33.3mmol/L CO2CP降低，血降低，血PHPH降低降低, ,代谢性代谢性 酸中毒酸中毒 尿：尿糖、尿酮体阳性尿：尿糖、尿酮体阳性 临床表现临床表现 ( (三三) )救治与护理救治与护理 First Aid CareFirst Aid Care 1.1.严密观察病情严密观察病情 Monitoring Monitoring (1)(1) Strictly observe for the changes of Strictly observe for the changes of temperature, pulse, breathing, BP and temperature, pulse, breathing, BP and consciousness; consciousness; (2)(2) Promptly draw blood sample and take Promptly draw blood sample and take urine sampleurine sample (3)(3) Accurately record the intake and output Accurately record the intake and output of 24 hours.of 24 hours. ( (三三) )救治与护理救治与护理 First Aid CareFirst Aid Care 2 2、补液，纠正电解质及酸碱失衡：、补液，纠正电解质及酸碱失衡： Fluid resuscitation and correction of Fluid resuscitation and correction of electrolytes or acid-base imbalanceelectrolytes or acid-base imbalance 补液：首选生理盐水补液：首选生理盐水1000ml/1000ml/第第1 1小时纠正电解质及酸小时纠正电解质及酸 碱失衡碱失衡 胰岛素应用：小剂量胰岛素治疗，根据血糖、尿糖调胰岛素应用：小剂量胰岛素治疗，根据血糖、尿糖调 节剂量节剂量 治疗中避免血糖下降过快、过低，以免发生脑水肿治疗中避免血糖下降过快、过低，以免发生脑水肿 一般护理：加强生活护理一般护理：加强生活护理。 二、糖尿病高渗性非酮症昏迷二、糖尿病高渗性非酮症昏迷 Hyperosmolar Nonketotic DiabeticHyperosmolar Nonketotic Diabetic ComaComa 是糖尿病另外一种急性并发症是糖尿病另外一种急性并发症 特点：重度高血糖，、高渗性脱水、进行性意识特点：重度高血糖，、高渗性脱水、进行性意识 障碍为特点。无明显酮症酸中毒多见老年人，约障碍为特点。无明显酮症酸中毒多见老年人，约 2/32/3病人发病前无糖尿病史或仅有轻症（不多食、病人发病前无糖尿病史或仅有轻症（不多食、 不消瘦）不消瘦） (HNDC) is another acute complication of diabetic. (HNDC) is another acute complication of diabetic. It is a clinical syndrome characterized by severe It is a clinical syndrome characterized by severe hyperglycemia, hypertonic dehydration, and hyperglycemia, hypertonic dehydration, and progressively mental gressively mental disorder. HNDC is a medical emergency with a high morbidity HNDC is a medical emergency with a high morbidity and mortalityand mortality （一）诱因与发病机制（一）诱因与发病机制 Precipitants and PathogenesisPrecipitants and Pathogenesis 发病机制发病机制 PathogenesisPathogenesis 患者已存在不同程度的糖代谢障碍，在诱因的作用下患者已存在不同程度的糖代谢障碍，在诱因的作用下 加重原有糖代谢障碍，导致严重高血糖加重原有糖代谢障碍，导致严重高血糖, ,但血酮增加不但血酮增加不 明显。明显。 诱因诱因 Precipitants Precipitants 1 1、引起血糖增高的因素、引起血糖增高的因素 1 1）各种感染性并发症和应激因素）各种感染性并发症和应激因素 2 2）各种引起高血糖的药物）各种引起高血糖的药物 3 3）糖摄入过多）糖摄入过多 4 4）合并影响糖代谢的内分泌疾病）合并影响糖代谢的内分泌疾病 2 2、引起失水、脱水的因素、引起失水、脱水的因素 3 3、肾功能不全、肾功能不全 ( (二二) )病情病情评估评估 AssessmentAssessment 临床表现：临床表现： Clinical pres