外科休克双

外科休克 Surgical shock,HUYIN,2006-12-11,第一节 概 论,休克 SHOCK: 机体有效循环血容量减少、组织灌注不足，细胞代谢紊乱和功能受损的综合征,本质：氧供障碍需求增加 恢复有效供氧,HUYIN,2006-12-11,现代的观念,序贯性事件亚临床的灌注不足 多器官功能障碍(MODS)或衰竭(MOF),HUYIN,2006-12-11,Definition,Shock is a severe condition that occurs when not enough blood flows through the body, causing very low blood pressure, a lack of urine, and cell and tissue damage. This can damage multiple organs. Shock requires IMMEDIATE medical treatment and can get worse very rapidly.,HUYIN,2006-12-11,分类,心源性休克 Cardiogenic shock低血容量性休克 Hypovolemic shock感染中毒性休克 Toxic shock过敏性休克 Allergic shock神经性休克 Nervous shock,HUYIN,2006-12-11,Considerations,Major classes of shock include:Cardiogenic shock (associated with heart problems) Hypovolemic shock (caused by inadequate blood volume) Anaphylactic shock (caused by allergic reaction) Septic shock (associated with infections) Neurogenic shock (caused by damage to the nervous system),HUYIN,2006-12-11,Causes,Heart problems (such as heart attack or heart failure) Low blood volume (as with heavy bleeding or dehydration) Changes in blood vessels (as with infection or severe allergic reactions) Shock is often associated with heavy external or internal bleeding from a serious injury. Spinal injuries can also cause shock.Toxic shock syndrome is an example of a type of shock from an infection.,HUYIN,2006-12-11,病理生理 微循环变化,微循环收缩期 period of microcirculatory contraction 微循环扩张期 microcirculatory expanding period 微循环衰竭期 microcirculatory failure,HUYIN,2006-12-11,病理生理 微循环收缩期,神经内分泌反应主动脉弓和颈动脉窦交感-肾上腺素/儿茶酚胺球旁小体 肾素-血管紧张素心跳加快、心排出量增加,HUYIN,2006-12-11,病理生理 微循环收缩期,选择性血管收缩血流重新分配小动、静脉血管平滑肌/毛细血管前括约肌毛细血管后括约肌回心血量下降迷走神经抑制的降低渗透压升高 抗利尿激素增加垂体 肾上腺皮质激素 醛固酮分解代谢,HUYIN,2006-12-11,微循环三条通道,动静脉短路,直捷通道,营养通路,儿茶酚胺,乳酸、丙酮酸,儿茶酚胺,微血栓DIC,HUYIN,2006-12-11,病理生理 微循环扩张期,缺氧动静脉短路/直捷通道 开放组织灌注下降更缺氧炎性物质血液滞留 血浆外渗休克加重,HUYIN,2006-12-11,病理生理 微循环衰竭期,血液滞留酸性环境高凝状态DIC缺氧 缺能溶酶体破裂 酶释放 细胞自溶器官功能受损,HUYIN,2006-12-11,病理生理 代谢改变,无氧代谢乳酸盐/丙酮酸盐代谢性酸中毒能量代谢障碍应急儿茶酚胺/肾上腺皮质激素蛋白分解糖异生 血糖升高,HUYIN,2006-12-11,病理生理 介 质,体液因子神经内分泌因子补体系统激肽系统前列腺素类细胞因子炎性介质（白介素、肿瘤坏死因子氧自由基,HUYIN,2006-12-11,炎症介质释放和缺血再灌注损伤;release of mediators of inflammationreperfusion injury,HUYIN,2006-12-11,病理生理 细胞与器官,内脏器官的继发性损害 微循环障碍1O小时 多系统器官衰竭,MSOFMultiple System Organ Failure,HUYIN,2006-12-11,肺 内皮细胞肺间质水肿 肺泡上皮细胞局限性肺不张 ARDS肾 抗利尿激素醛固酮水钠潴留 肾皮质肾小管坏死肾衰心 冠脉血流少心肌损害脑、胃肠道、肝,HUYIN,2006-12-11,细胞的变化,膜线粒体内质网溶酶体,HUYIN,2006-12-11,临床表现 Clinical Manifestation,休克代偿期 Compensatory Stage of Shock 早期休克pre-shock stage烦燥 口渴 面色苍白呼吸增快 心率 80120次/分收缩压 9.3312kPa(7090mmH)脉压2.64.0kPa尿量正常减少(25次/分 脉博细速 140次/分 收缩压 6.679.33kPa(5070mmH) 呼吸窘迫 脉压缩小 收缩压06.6kPa 尿量减少1525ml/h 比重增高 尿量015ml/h 中心静脉压(CVP)1.96kPa,HUYIN,2006-12-11,Symptoms,A person in shock has extremely low blood pressure. Depending on the specific cause and type of shock, symptoms will include one or more of the following:,HUYIN,2006-12-11,Anxiety or agitation Confusion Pale, cool, clammy skin,HUYIN,2006-12-11,Low or no urine output Bluish lips and fingernails Dizziness, light-headedness, or faintness,HUYIN,2006-12-11,Profuse sweating, moist skin Rapid but weak pulse Shallow breathing Chest pain Unconsciousness,HUYIN,2006-12-11,诊断 diagnosis,病史 case history临床表现 clinical situation,HUYIN,2006-12-11,一般监测 genera monitoring,意识 呼吸 脑血流灌注/脑血氧 皮温 色泽 末梢血循环 脉率 血压 血容量平均动脉压 = 舒张压 + 1/3脉压 120.6kPa 休克指数 = 脉率收缩压(mmHg) 尿量 肾灌流血容量,HUYIN,2006-12-11,一般监测 genera monitoring,精神状态 mental status皮肤温度色泽 skin temperature colour血压 blood pressure脉率 pulse rate尿量 urinary volume,HUYIN,2006-12-11,特殊监测 special monitoring,中心静脉压 回心血量右心搏出量 肺毛细血管楔压 心排出量 (CO) 心脏指数(CI) 血气分析 动脉血乳酸盐 DIC的检测 胃肠黏膜内pH值,HUYIN,2006-12-11,First Aid,Call 911 for immediate medical help. Check the persons airway, breathing, and circulation. If necessary, begin rescue breathing and CPR.,HUYIN,2006-12-11,First Aid,Even if the person is able to breathe on his or her own, continue to check rate of breathing at least every 5 minutes until help arrives.,HUYIN,2006-12-11,First Aid,If the person is conscious and DOES NOT have an injury to the head, leg, neck, or spine, place the person in the shock position. Lay the person on the back and elevate the legs about 12 inches. DO NOT elevate the head. If raising the legs will cause pain or potential harm, leave the person lying flat.,HUYIN,2006-12-11,First Aid,Give appropriate first aid for any wounds, injuries, or illnesses. Keep the person warm and comfortable. Loosen tight clothing.,HUYIN,2006-12-11,First Aid,IF THE PERSON VOMITS OR DROOLS Turn the head to one side so he or she will not choke. Do this as long as there is NO suspicion of spinal injury. If a spinal injury is suspected, log roll him or her instead. Keep the persons head, neck and back in line and roll him or her as a unit.,HUYIN,2006-12-11,治疗 treatment;,一般紧急治疗体位：躯干抬高1O一15 下肢抬高2O一30呼吸道通畅 吸氧 保温防暑 急救,HUYIN,2006-12-11,HUYIN,2006-12-11,Do Not,DO NOT give the person anything by mouth, including anything to eat or drink. DO NOT move the person with a known or suspected spinal injury. DO NOT wait for milder shock symptoms to worsen before calling for emergency medical help.,HUYIN,2006-12-11,治 疗 补充血容量,恢复有效循环血量量: 丧失量 补充量(扩大的毛细血管床质: 晶 体 (等渗液、平衡液) 胶 体 (全血、血浆、白蛋白)补液恢复的标准 ( CVP 脉博、血压、尿量、皮温、神志 ),HUYIN,2006-12-11,治 疗,积极处理原发病,HUYIN,2006-12-11,治 疗 纠正酸碱失衡,低碳酸血症高乳酸血症高碳酸血症,碳酸氢钠的应用,HUYIN,2006-12-11,治 疗 血管活性物质的应用,vasoactive drugs血管收缩药 大计量多巴胺 多巴酚丁胺去 甲肾上腺素 间羟安 血管扩张药 酚妥拉明 阿托品 硝普钠 小计量多巴胺强心药 西地兰 ,HUYIN,2006-12-11,治 疗,治疗DIC改变微循环 （肝素 / 氨甲苯酸 / 阿司匹林）皮质类固醇（五大作用）其他,HUYIN,2006-12-11,治 疗,维护重要器官的功能防治感染 粘膜屏障- 肠菌移位,HUYIN,2006-12-11,第二节 低血容量性休克 Hypovolemic shock,定义: 短时间内丢失大量全血、血浆或其它液体，超过机体的代偿限度即导致休克综合征,HUYIN,2006-12-11,Hypovolemic shock,Hypovolemic shock is an emergency condition in which severe blood and fluid loss makes the heart unable to pump enough blood to the body. This type of shock can cause many organs to stop working.,HUYIN,2006-12-11,包括:,失血性休克 (20%总血量) 静脉曲张出血、肝癌破裂、宫外孕失液性休克 肠梗阻、烧伤损伤性休克,HUYIN,2006-12-11,Causes, incidence, and risk factors,Losing about 1/5 or more of the normal amount of blood in your body causes hypovolemic shock.Blood loss can be due to bleeding from cuts or other injury or internal bleeding such as gastrointestinal tract bleeding. The amount of blood in your body may drop when you lose too many other body fluids, which can happen with diarrhea, vomiting, burns, and other conditions.,HUYIN,2006-12-11,The greater and more rapid the blood loss, the more severe the shock symptoms.,HUYIN,2006-12-11,病 理,血容量骤减 神经内分泌 心搏加强加快外周/内脏血管收缩 保持心脑血供肾 水钠储留 口渴少尿,失液 细胞外液丢失 血液浓缩创伤感染,HUYIN,2006-12-11,Symptoms,Rapid pulse Pulse may be weak (thready) Rapid breathing Anxiety or agitation,HUYIN,2006-12-11,Cool, clammy skin Weakness Pale skin color (pallor) Sweating, moist skin,HUYIN,2006-12-11,Decreased or no urine output Low blood pressure Confusion Unconsciousness,HUYIN,2006-12-11,tests,CBC CT scan or an x-ray of suspected areas Endoscopy Echocardiogram (heart ultrasound) Right heart (Swan-Ganz) catheterization - can help tell the difference between hypovolemic and another type of shock called cardiogenic shock,HUYIN,2006-12-11,Gastric endoscopy,HUYIN,2006-12-11,Swan Ganz catheterization,HUYIN,2006-12-11,CBC (complete blood count ),The number of red blood cells (RBCs) The number of white blood cells (WBCs) The total amount of hemoglobin in the blood The fraction of the blood composed of red blood cells (hematocrit) MCV ( mean corpuscular volume ) - the size of the red blood cells MCH (mean corpuscular hemoglobin) MCHC (mean corpuscular hemoglobin concentration) platelet count,HUYIN,2006-12-11,一、失血性休克和失液性休克,治 疗一补充血容量 治 疗二药物治疗 治 疗三病因治疗,HUYIN,2006-12-11,Treatment,Get immediate medical help. In the meantime, follow these steps:Keep the person comfortable and warm (to avoid hypothermia). Have the person lie flat with the feet lifted up about 12 inches to increase circulation. However, if the person has from a head, neck, back, or leg injury, leave him or her in the position in which they were found unless doing so poses other immediate danger.,HUYIN,2006-12-11,Do not give fluids by mouth. If person is having an allergic reaction, treat the allergic reaction, if you know how. If the person must be carried, try to keep him or her flat, with the head down and feet lifted up. Stabilize the head and neck before moving a person with a suspected spinal injury.,HUYIN,2006-12-11,The goal of hospital treatment,to replace blood and fluids. Anintravenous (IV) line will be put into the persons arm to allow blood or blood products to be given.Medicines such asdopamine, dobutamine, epinephrine, and norepinephrine may be needed to increase blood pressure and the amount of blood pumped out of the heart (cardiac output).,HUYIN,2006-12-11,Other methods,that may be used Cardiac monitoring, including Swan-Ganz cathertization Urinary catheter to collect and monitor how much urine is produced,HUYIN,2006-12-11,补充血容量,依据休克的程度或休克指数(血压、 cvp)红细胞比积 (3O%)血清白蛋白 (白蛋白3gdl),HUYIN,2006-12-11,中心静脉压和动脉压变化的处理原则,HUYIN,2006-12-11,成人 (体重5070公斤),45分钟内平衡盐液(等渗盐水)10001500ml中分子右旋糖酐、羟乙基淀粉 (38 OR 90 次/分呼吸急促20次/分PaCO212*109 /L Systemic Inflammatory Response Syndrome,HUYIN,2006-12-11,Risk factors for septic shock include,Diabetes Diseases that weaken the immune system such as AIDS Lymphoma Leukemia Diseases of the genitourinary system, biliary system, or intestinal system Recent infection Long-term use ofantibiotics Recent surgeryor medical procedure.,HUYIN,2006-12-11,Symptoms,High or very low temperature, chills Lightheadedness Shortness of breath Palpitations Cool, pale extremities Restlessness, agitation, lethargy, or confusion Rapid heart rate Low blood pressure, especially when standing Low urine output (due to kidney failure),HUYIN,2006-12-11,临床表现,原有的感染病变 (败血症)休克表现 冷休克 低排高阻型 热休克 高排低阻型并发系统器官衰竭 (DIC、ARDS),HUYIN,2006-12-11,临床表现,HUYIN,2006-12-11,Signs and tests,Blood gases revealing low oxygen concentration and acidosis Blood cultures or blood count detecting infection Low blood pressure Chest