特殊情况的处理 PPT课件.ppt

SpecialConsiderations Objectives UnderstandmanagementprinciplesofseveregastrointestinalhemorrhageDiscussdiagnosisandmanagementofpulmonaryembolismReviewrecognitionandmanagementofaorticdissectionListprinciplesofpoisoningmanagementIdentifymanagementprinciplesoftemperature relatedinjury A49 yr oldmaleisadmittedafterbloodyemesis Hehasahistoryofheavyalcoholuse Bloodpressure90 40mmHgHeartrate116beats minHematocrit24 Heisconfusedanddiaphoretic SevereGIHemorrhage ManagementPrinciples AssessadequacyofairwayIntravenousaccessPromptinitialresuscitationMonitoravailabilityofbloodproductsMonitorforsecondaryconsequencesofhypotensionandanemiaRapiddiagnosticevaluation surgicalconsultation transfer SevereUpperGIHemorrhage EndoscopyafterlavagetoestablishdiagnosisEndoscopictherapyVaricealbleedingEndoscopictherapyVasopressinOctreotide SevereLowerGIBleeding RectalexaminationConsiderupperGIsourceEndoscopyAngiography embolizationSurgery SPC6 PediatricConsiderations GIHemorrhage UpperGIbleedingrareCausesoflowerGIbleeding1mo 1yr Meckel sdiverticulum1 2yrs intussusception2 12yrs polyps childabuse inflammatoryboweldisease PulmonaryEmbolism Anobesediabeticpatientisatbedrestwithlowerextremitycellulitis Shehadthesuddenonsetofdyspneaandpalpitations SheisenroutetotheED SPC8 RiskFactorsforPulmonaryEmbolism HeartfailureAdvancedageTraumaObesityEstrogens pregnancy RiskFactorsforPulmonaryEmbolism MalignancySurgeryImmobility paralysisPriorembolism thrombosisHypercoagulabledisorders PulmonaryEmbolism Diagnosis Nonspecificsigns symptomsNonspecificchestradiographECGnonspecificHypoxemiacommonbutnormalPaO2possibleLevelofclinicalsuspicionimportant SPC11 DiagnosisofPulmonaryEmbolism SuspectPE Anticoagulate unlesscontraindicationorhighriskforbleedingcomplication V Qscan WhenV Qscanningunavailableorlogisticallydifficult considerpulmonaryangiogram spiralCTorechocardiography DiagnosisofPulmonaryEmbolism V Qscan Anticoagulation IVCfilter WhenclinicalsuspicionforPEislow despitehigh probabilitylungscan alegstudyand orpulmonaryangiogrammaybeindicated Highprobability No No Yes Yes Contra indicationtoanticoagulation DiagnosisofPulmonaryEmbolism DVT Anticoagulation IVCfilter Iflegstudiesnotavailable pulmonaryangiogramorspiralCTshouldbeconsidered Intermediateprobability No Yes Yes Contra indicationtoanticoagulation DVT Legstudies No PulmonaryangiogramorspiralCT DiagnosisofPulmonaryEmbolism Anticoagulation IVCfilter Yes Contra indicationtoanticoagulation DVT No PulmonaryangiogramorspiralCT Positive Negative EndevaluationforPE DiagnosisofPulmonaryEmbolism DVT Anticoagulation IVCfilter Incircumstancesofhighclinicalsuspicionofpulmonaryembolism pulmonaryangiogramorspiralCTmaybeindicated Lowprobability No Yes Yes Contra indicationtoanticoagulation DVT Legstudies No EndofevaluationforPE DiagnosisofPulmonaryEmbolism EndevaluationforPE Normalperfusionscan Yes PulmonaryEmbolism TherapyHeparinfollowedbywarfarinThrombolysisSurgeryInferiorvenacavafilterindicationsContraindicationtoanticoagulationEmbolidespiteanticoagulationBleedingwithanticoagulation AorticDissection ClinicalfindingsHypertensionChestpain back epigastricpainAsymmetricpulsesWidemediastinumDiagnosisAngiographyCTscanTransesophagealechocardiography AorticDissection BloodpressureandheartratecontrolSodiumnitroprusside b blockerLabetalolGoal systolicpressure100 120mmHgSurgicalconsultation PoisoningandOverdose AirwaysupportasrequiredIntravenousaccessMonitoringConsider50 dextrose thiamine naloxoneObtaininformation laboratorystudiesConsidermethodstolimitdrugabsorptionEarlyadministrationofactivatedcharcoalSpecificantidotesorinterventions HeatStroke ProtectairwayandsupplyoxygenAdministerivfluidsCorrectelectrolyteabnormalitiesCoolingEvaporativemethodIcepacks soaksAnticipatecomplications Hypothermia ProtectairwayInstituteCPRifnoperfusionAvoidexcessivemanipulationWarmintravenousfluidsRectal esophagealprobeOrogastrictubeInitiaterewarm