ChapterShockSC

Chapter 8Shock Evaluation and Management,Shock Evaluation and Management休克的评估及处理,Overview概要,Four vascular system components of perfusionProgression of shock signs and symptoms休克征状之改变Three common clinical shock syndromes常见休克种类之征状Hemorrhagic and neurogenic shock pathophysiology 出血性及神经性休克之病理生理,2,Shock -,Overview概要,Controllable and uncontrollable hemorrhage, nonhemorrhagic shock syndromesHemostatic agents凝血剂Current indications for fluid administration 补充体液的指标,3,Shock -,Shock休克,Shock -,4,Perfusion of tissues with oxygen(组织灌注, electrolytes (电解质),glucose(血糖份), and fluid(体液) becomes inadequate.,Prepared by Harris Lam (A&E Training Centre, R&TSKH),5,“Fick” Principle,空气中的氧气注入人体细胞可用 ”Fick Principle”说明如下：畅通的气道Airway 足够的呼吸Breathing 有效的血循环Circulation红血球释放氧气到各细胞,On load Oxygen,Delivery Oxygen,Off load Oxygen,“Steady state” activity,Normal Perfusion正常的灌注,6,Shock -,气体交挽,心脏,血管网络,液量,Normal Perfusion,Shock -,7,Heart Rate x Stroke Volume = Cardiac Output 心跳x每次收缩的输出量=心输出量Cardiac Output x PVR = Blood Pressure心输出量x血管阻力 =血压,Perfusion Preservation保存灌注,Basic rules of shock management:Maintain airway维持气道畅通Maintain oxygenation and ventilation 维持足够供气及换气Control bleeding where possible制止出血Maintain circulation维持足够血液循环Adequate heart rate and intravascular volume 足够之心跳及血量,8,Shock -,Shock Progression休克进程,Shock -,9,Begins with injury, spreads throughout body, multisystem insult to major organs开始时身体受伤,继而影响全身,导致各器官受伤害,Shock Progression休克进程,10,Shock -,灌注不足,无氧呼吸,加速缺氧,细胞死亡,肾上腺分泌增加,红血球减少,Shock,Shock is a continuum.休克一开始后持续发生Signs and symptoms are progressive. 征状会慢慢演变出来Many symptoms due to catecholamines. 大部征状是因肾上腺素泌造成Cellular process has clinical manifestations.当细胞受影响时会有明显临床征状,11,Shock -,Shock,Compensated and decompensated补尝期及非保尝期:Older, hypertensive, and/or head injury cannot tolerate hypotension for even short time年老,血压高及/或头部受伤者都不能短暂处于血压低,12,Shock -,Prepared by Harris Lam (A&E Training Centre, R&TSKH),13,Hypovolemic Shock,Compensated progression补尝期进程Weakness and lightheadedness软弱及头晕Thirst口渴Pallor苍白Tachycardia心跳加速Diaphoresis皮肤浅湿泠Tachypnea呼吸加速Urinary output decreased尿量减少Peripheral pulses weakened周围脉搏减弱,14,Shock -,Shock Progression,Compensated to decompensated由补尝期到非保尝期Initial rise in blood pressure due to shunting血压升高Initial narrowing of pulse pressure脉搏压收窄Diastolic raised more than systolic收缩压上升较舒张压上怏Prolonged hypoxia leads to worsening acidosis酸中毒Ultimate loss of catecholamine response对肾上腺无返应Compensated shock suddenly “crashes”补尝失败,15,Shock -,Hypovolemic Shock,Decompensated progression非保尝期进程Hypotension血压低Hypovolemia and/or diminished cardiac outputAltered mental status意识紊乱Decreased cerebral perfusion脑组织灌注, acidosis, hypoxia, catecholamine stimulationCardiac arrest心跳停止Critical organ failureSecondary to blood or fluid loss, hypoxia (缺氧), arrhythmia (心律不齐),16,Shock -,Classic Shock Pattern,Early shock早期休克,1525% blood volume失血15-20%Tachycardia心跳加速Pallor苍白Narrowed pulse pressure脉搏压收窄Thirst口渴Weakness软弱Delayed capillary refill 毛细管再充时问延迟,Late shock后早期休克,17,Shock -,3045% blood volume失血130-45%Hypotension血压下降First sign of “late shock”后早期休克时最早出现征状Weak orno peripheral pulse 周围脉搏变弱或丧失Prolonged capillary refill毛细管再充时问进一步延迟长,Capillary Refill毛细管再充时问进一步延迟长,18,Shock -,Capillary Refill,19,Shock -,Tachycardia心跳加速,Early sign of illnessmost common最见的疾患早期征状:Transient rise with anxiety, quickly to normal间歇性Determine underlying causeEarly sign of shock为早期休克征状:Suspect hemorrhage怀疑出血: sustained rate 100Red flag for shock休克的危俭状态:pulse rate 120No tachycardia does not rule out shock.无脉搏加速并不能排徐休克“Relative bradycardia”相对性心跳过慢,20,Shock -,Capnography,Level ofexhaled CO2 as waveform (EtCO2)呼气CO2 含量Typically 3540 mmHgFalling EtCO2 Hyperventilation呼吸过速 or decreased oxygenationEtCO2 75% with penetrating cardiac injury“Becks triad”Shock, muffled heart tones, distended neck veinsManagementRapid safe transport to appropriate facilityCardiac arrest can occur in minutesFluid administration by local medical direction,38,Shock -,Mechanical Shock Causes,Myocardial contusionHeart muscle injury and/or cardiac dysrhythmiasRarely causes shock; mostly little or no signsSevere may cause acute heart failure急性心脏衰竭ManagementRapid safe transportCardiac arrest may occur in 510 minutesCardiac monitoring and treat arrhythmiasFluid administration may worsen condition,39,Shock -,Special Situations,Severe head injury hypovolemic shockGlasgow Coma Score of 8 or lessFluid administrationBP of 120 mmHg systolic to maintain cerebral perfusion pressure of at least 60 mmHg 非出血性的血溶积减少性休克Nonhemorrhagic hypovolemic shockGeneral management same as controllableFluid administration for volume replacement,40,Shock -,Summary,Knowledge about pathophysiology and treat