严重创伤病人的麻醉1

1,严重创伤病人的麻醉,Anaesthesia for Critical Trauma Patients,2,几个概念,创伤多发伤多部位伤复合伤,轻伤中等伤重伤,严重创伤,3,Why should we learn trauma anesthesia?,Anesthesiologists are being faced with anesthetizing an increasing number of trauma patientAll anesthesiologists will likely have significant and unpredictable exposure to trauma patients,4,In 1993, approximately 90,000 individuals in the U.S died of accidental injuries , for a rate of 34.9 deaths per 100, 000 population, the second lowest accidental death rate on record,5,In the same year there were an estimated 18,200,000 disabling accidental injuries, or about 2,080 injuries every hour, and the 90,000 accidental deaths amounted to 1 every 6 minutes-and these numbers excluded the rising level of intentional injuries caused by attempted or successful suicides and homicides,6,Injury ranks as the fourth leading cause of death in the U.S.Currently, for American younger than 40 years, trauma is the most common cause of death, following heart disease, cancer, and cerebrovascular disease,7,Potential roles of the anesthesiologist in this area,Trauma team memberTrauma team leaderAnesthesiologistCritical care physician,8,病情评估,9,病情评估,评分系统（scoring system)创伤机制 (mechanisms of injury),10,Scoring system,ASAPSGCS: a useful prognostic tool for patient with acute head injuriesTS, RTS(revised trauma score) and PTS(pediatric trauma score): used to predict outcome and direct patients to appropriate facilities.CRAMS Score,ASA分级,12,GCS（Glasgow coma score),Eye opening (41)Verbal responses (51)Motor responses (61),轻型：1315分，意识障碍20min以内中型：912分，意识障碍20min 6h重型：38分，伤后昏迷至少6h以上或伤后24h内情况再次恶化者,13,Eye opening,Spontaneous- 4To voice- 3To pain- 2To none- 1,14,Verbal reponses,Oriented- - 5Confused- 4Inappropriate- 3Incomprehensive words- 2None- 1,15,Motor response,Obeys command- 6Localizes pain- 5Withdraws(pain)- 4Flexion(pain)- 3Extension(pain)- 2None- 1,16,创伤机制,虽然创伤的原因多种多样，但各种创伤导致的损伤机制是相同的，因此可以用创伤性疾病（traumatic disease)来概括各种创伤导致的机体损害了解创伤的损伤机制是创伤治疗的前提钝性损伤与穿透性损伤颈部与气道创伤胸部创伤闭合性头部损伤与开放性股骨骨折,18,严重创伤病人的病情特点,病情紧急，伤情复杂生理紊乱重，并发症多，死亡率高疼痛剧烈饱胃,19,严重创伤病人的麻醉处理特点,不能耐受深麻醉难以配合局部麻醉麻醉药物作用时间明显延长容易误吸常需支持循环功能,20,术前准备,Preoperative Preparation,21,原则,按步骤获取病史、体检、诊断和治疗的程序不适用于创伤病人在经过3045s的病情判断后应立即开始创伤救治经过初期复苏治疗后，应除外一切可能的隐匿损伤,22,程序（sequence of management of trauma patients),OverviewPerform visual scan of patient for obvious injuriesObtain history from prehospital personnel and patient(if able)Primary survey(ascertain “ABCDEs”)Airway maintenance (with cervical spine control)Look for chest wall movements, retraction ,and nasal flaringListen for breath sounds, stridor, and obstucted ventilationFeel for air movement,23,Primary survey(ascertain “ABCDEs”)Breathing (give supplemental oxygen)Determine whether ventilation is adequateInspect chest to exclude open pneumothoraxAuscultate for bilateral breath soundsProvide assisted ventilation for ventilatory failureCirculation (establish venous access)Check peripheral pulses, capillary refill, and blood pressureObtain electrocardiogramGrade shock according to vital signsCorrect hypovolemia and obtain blood samples,24,Primary survey(ascertain “ABCDEs”)Disability (determine neurologic status)Evaluate central functionA: alertV: responds to vocal stimulusP: responds to painful stimulusU: unresponsiveEvaluate pupil response to lightExpose patient for complete examinationResuscitation phase Secondary surveyDefinitive care phase,25,气管插管术,需要立即行气管插管的适应症GCS 30%或出血继续，应输胶体和血，另外再加13倍的晶体液（根据临床表现和监测判断），这部分病人同时需要纯氧通气以增加氧向组织中的释放，直至血红蛋白恢复 失血量40%，立即输入浓缩红细胞，再加胶体和晶体液 初期复苏完成后，应结合监测及病人对治疗的反应进行进一步液体治疗,休克复苏输液方案,38,不同程度失血引起的生命体征改变,39,麻醉前病史获取,病史的获取对象包括目击者和病人本人，需要了解创伤发生的场景以判断可能的隐匿性损伤了解既往疾病史、过敏史、手术史和药物服用史虽然所有创伤病人都应视为饱胃状态，但仍应尽可能了解进食时间、量和种类以了解胃内容物性质注意酗酒、药物成瘾可能,40,麻醉前检诊,同其他外科手术病人一样需要体检和实验室检查，但应特别注意呼吸、循环和神经系统检查意识状态（GCS）瞳孔对光反应肢体运动未插管病人应评估气管插管的困难程度注意是否存在颈椎骨折及是否固定是否存在气胸、心肌挫伤、心包填塞失血量评估（根据生命体征）血气、血红蛋白计数、血球压积、血糖、血肌酐、ECG、颈椎X线等,41,创伤病人的监测项目,42,术中管理,Intraoperative Management,43,麻醉选择,全身麻醉是多发伤病人的第一选择严重创伤病人需要气管插管和呼吸支持长时间手术过程中病人不能始终安静合作不会影响出血引起的代偿机制局部麻醉有其特殊的吸引力，但通常只适用于单一肢体的创伤对心血管功能影响较小，避免了建立气道可能的困难,44,麻醉计划（Anesthesia Plan),选择对心血管抑制较小同时不引起颅内压升高的药物小剂量的硫喷妥钠、依托米酯、舒芬太尼肌松药的剂量通常并不减少通常静脉应用极小剂量的药物就能达到需要的药效血容量的减少可能使结合于脑内药物作用部位的药物浓度增加肝脏血流量的减少使药物的清除时间延长,45,麻醉计划（Anesthesia Plan),药物禁忌氯胺酮禁忌使用于颅脑损伤的病人琥珀胆碱禁忌使用于急性上运动神经元（脊髓）损害、烧伤急性期笑气禁忌用于有闭合气腔形成可能的病人气胸、气脑、肠道积气患者绝对禁用是否禁用于颅脑损伤尚有争议检查并联接好麻醉设备,46,术中常见问题,手术时间长多发伤手术时间往往较长，需要麻醉医师制定长时间的麻醉计划麻醉医师应将手术室作为ICU调整病人的内环境（如电解质、酸碱平衡等）低温温度与创伤评分成反比所有非手术区域皮肤应覆盖保持室温在22以上，输入液体加温 ，吸入气体加温、湿化、体腔温盐水灌洗等,47,术中常见问题,大量输血（massive blood transfusion)稀释性血小板减少，凝血时间延长，短暂的钙离子浓度凝血障碍可补充凝血因子、维持正常体温补充由于枸橼酸螯合作用（citrate chelation)导致的离子钙浓度下降，但应当有离子钙浓度监测证实颌面部损伤（maxilofacial injuries)气道困难，常需直接喉镜或纤支镜插管常常难以面罩供氧通气、合并脑、颈髓损伤，因此气管切开是最安全的插管途径由于颌面部手术后面部长需内固定或敷料包扎，应防止气管导管脱出,48,术中常见问题,恶性高热（malignant hyperthermia，MH)疼痛、骨折等可以在没有使用麻醉药的情况下触发MH，手术室应备好充足的丹曲洛林(dantrolene)热损伤（thermal injury)烧伤：静脉通道建立困难，水电失衡，非去机化肌松药需要量增加，体热散失,49,术中常见问题,缺氧（hypoxia)气胸？脂肪栓塞综合证？心跳停止（cardiac arrest)创伤后由于心肌挫伤和失血性休克所造成的心跳骤停难以预测由于有效灌注降低所造成的心跳骤停通常已有全身其他器官的缺血改变深低温通常是心跳停止的预兆，同时也可能是大片心肌细胞坏死和心跳骤停的原因,50,术后管理,Postoperative Management,51,麻醉后监护室(Postanesthetic Care Unit）,问题：苏醒过程中的呕吐、误吸，苏醒延迟，苏醒期躁动处理：特别注意气管导管拔除时机由于术前可能未对病人进行仔细检查，需要在苏醒期排除其他创伤和药物成瘾可能,52,重症监护病房（Critical Care Unit),用以收治创伤后最不稳定的病人败血症（sepsis）和多脏器功能衰竭（MOF）是创伤后最常见的死亡原因代谢和营养支持、心肺功能维护是减少上述病人死亡率的重要手段快速、完全地复苏有助于预防ARDS、败血症、多脏器功能衰竭,53,小结(summary),Trauma care is becoming an increasingly important part of modern medical practice as advances in care reduce the mortality from other diseasesThe goal of treatment is to prov