小儿急症.ppt

TheSickChild,BeverlyYoung,MD2010TheWarrenAlpertMedicalSchoolofBrownUniversity,1,.,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,andwhatdidnt?哪些治疗有效，哪些无效？,2,.,Childrendiein2ways:儿童死亡的两个原因：,Respiratoryfailure呼吸衰竭Inadequatetissueperfusion体液丢失,3,.,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,4,.,Majorcausesofchilddeath儿童死亡的主要原因:,5,.,ChildrensRespiratoryRate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Ifasickchildsrespiratoryratedrops,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。,6,.,IdentifyingRespiratoryDistress判断呼吸窘迫,Increasedrespiratoryrate呼吸频率加快Nasalflaring鼻翼扇动Retractionsabovethesternalnotch,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Sometimesthereisanobviouscausechoking,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,7,.,IdentifyingInadequatePerfusion辨认体液不足,8,.,ChildrensHeartRates儿童心率,Theyoungerthechild,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。,9,.,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Capillaryrefilltime2seconds毛细充盈时间大于2秒Mottlingandpallor(peripheralbeforecentral)斑影与苍白（先周围，后中央）,10,.,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(6hours婴儿（小于1岁）：无尿超过6小时Olderchildren(1year):nourinefor12hours稍大的儿童（大于1岁）：无尿超过12小时,11,.,ChildrensBloodPressure儿童血压,Theolderthechild,thehigherthebloodpressure孩子越大，血压越高Approximatesystolicbloodpressureforchildren110yearsold:90mmHg+(2ageinyears)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,12,.,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,13,.,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Peripheralcapillaryrefill2seconds末梢回血时间大于2秒Infants:sunkenfontanel婴儿：前囟凹陷Decreasedurineoutput尿量减少6hours小于1岁的孩子：超过6小时无尿1yearold:nourinefor12hours大于1岁的孩子：超过12小时无尿,14,.,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）,15,.,Majorcausesofchilddeath儿童死亡的主要原因:,16,.,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,17,.,TreatingInadequatePerfusion治疗体液不足,Giveoxygen,ifavailable如有可能，吸氧GetIVaccessusealarge-boreneedle静脉输液用大号针3.Give20ml/kgofnormalsalineasfastaspossible:over510minutes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,18,.,TreatingInadequatePerfusion治疗体液不足,5.Ifthesearestillabnormal:repeat20ml/kgnormalsaline+reassessmentasmanytimesasneeded!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,19,.,#1,A5yearoldboycomestoyouwith2daysofsorethroatandrunnynose.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。,20,.,#1,A5yearoldboycomestoyouwith2daysofsorethroatandrunnynose.Todayhehadafeverto38degreesinthemorning.Hehasbeenabitsleepyandcrankysincehehashadthefever.Hismothergavehimparacetamol2hoursagoanditbroughthisfeverdownandhehasbeenactingnormalsincethen.Hisheartrateis110（60140）andhisrespiratoryrateis23（2025）.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（60140），呼吸频率是23次/分（2025），食纳可，二便正常。,21,.,2,A1yearoldgirlcomestoyouwith2daysofrunnynoseandcongestionandcough.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。,22,.,2,A1yearoldgirlcomestoyouwith2daysofrunnynoseandcongestionandcough.Thismorningshehasbeenwheezingabit.Sheisfebrileto38.4degrees,herheartrateis190（100190）,andherrespiratoryrateis60（2040）.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。,23,.,3,A7yearoldboycomestoyouwith5daysofvomitinganddiarrhea.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。,24,.,3,A7yearoldboycomestoyouwith5daysofvomitinganddiarrhea.Hehashadafeverto38degreesfor2days.Hisheartrateis120（60140）andhisrespiratoryrateis24（2025）.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（60140），呼吸频率24次/分（2025），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,A4yearoldgirlcomestoyouwith4daysofdiarrhea.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。,26,.,4,A4yearoldgirlcomestoyouwith4daysofdiarrhea.Shehasnothadafeverandhasbeeneatinganddrinkingasusual.Herheartrateis100（60140）andherrespiratoryrateis21（2025）.Sheisalertandplayfulandherlipsappearmoist.Shehasbeenurinatingasusual.4岁女孩，腹泻4天，不发热，吃喝正常，心率100次/分（60140），呼吸频率21次/分（202