外科学休克pbl课件

1、About myselfName: 费 健Email: feijianhotmailMobile:137-0176-9798About myselfName: 费 健开始了大家要专心啊开始了一个例子八大问题 一个例子八大问题 A 22 year old man was driving drunk and without his seatbelt fastened when he was involved in a single-vehicle automobile accident. When attended by EMT（abbr. emergency medical technician

2、 急诊医士） personnel, no information was available about the time of the accident. He was found agitated and complaining of abdominal pain. A 22 year old man was driving His airway was patent. At the scene, he was breathing at 20 per minute with a blood pressure of 90/60 and a pulse of 130. He was place

3、d in a hard cervical collar and on a back board and transported to your emergency room. Upon arrival his vital signs are the same, with a temperature of 36oC. His airway was patent. At theHis abdomen is markedly distended. His hands and feet are cold, his legs mottled. A nasogastric tube reveals gre

4、en liquid. A urinary catheter reveals dark yellow urine. His hemoglobin is 7. His abdominal lavage（灌洗）reveals gross blood. His abdomen is markedly distenStudy Questions 1:What type of shock does this patient exhibit? Study Questions 1:What typeAt the scene, he was breathing at 20 per minute with a b

5、lood pressure of 90/60 and a pulse of 130. Upon arrival his vital signs are the same, with a temperature of 36oC. His abdomen is markedly distended. His hands and feet are cold, his legs mottled. A nasogastric tube reveals green liquid. A urinary catheter reveals dark yellow urine. His hemoglobin is

6、 7. His abdominal lavage（灌洗）reveals gross blood. At the scene, he was breathing休克的原因和分类按病因学分类一、失血失液性休克:二、创伤性休克：三、感染性休克：四、心源性休克：五、过敏性休克：六、神经源性休克：大出血，腹泻，剧烈呕吐等疼痛和失血内毒素大面积心肌梗死，心包填塞青霉素，血清制剂或疫苗高位脊髓麻醉或损伤休克的原因和分类按病因学分类大出血，腹泻，剧烈呕吐等疼痛和失按血流动力学的特点低排高阻型休克（低动力型休克，冷休克）高排低阻型休克（高动力型休克，暖休克）按血流动力学的特点低血容量性休克失血性休克损伤性休克感

7、染性休克 心源性休克神经源性休克过敏性休克休克的分类外科休克低血容量性休克休克的分类外科休克Study Questions 2: What alterations in oxygen delivery are present? Study Questions 2: What altAt the scene, he was breathing at 20 per minute with a blood pressure of 90/60 and a pulse of 130. Upon arrival his vital signs are the same, with a temperatur

8、e of 36oC. His abdomen is markedly distended. His hands and feet are cold, his legs mottled. A nasogastric tube reveals green liquid. A urinary catheter reveals dark yellow urine. His hemoglobin is 7. His abdominal lavage（灌洗）reveals gross blood. At the scene, he was breathing单位时间内通过心血管系统进行循环的血量- 有效循

9、环血量不包括贮存在肝、脾、淋巴血窦、淤滞于毛细血管中的血量单位时间内通过心血管系统进行循环的血量-依赖于充足的血容量有效的心排量良好的周围血管张力有效循环血量休 克代谢障碍细胞受损组织血液灌注不足有效循环血量锐减依赖于有效循环血量休 克代谢障碍细胞受损组织血微循环障碍微循环收缩期微循环扩张期DIC期休克的病理生理微循环障碍休克的病理生理Section 2. Local feedback regulation of capillary perfusion： Constriction of Pre-capillary Decreased blood Local accumulation of sp

10、hincter and Post-arteriole flow of products and histamine true capillary net Increased response Decreased response of SMC to of SMC to Vasoconstrictive agents Vasoconstrictive agents Increased blood Clearance of histamine and flow of Relaxation of pre-capillary metabolic products true capillary net

11、sphincter and post-arteriole Constriction Relaxation Section 2. Local feedback r真毛细血管开放调节示意图后微动脉与毛细血管前括约肌收缩真毛细血管血流量减少局部组织激肽,组胺,乳酸,腺苷增多平滑肌对缩血管物质反应性升高后微动脉与毛细血管前括约肌舒张局部组织激肽,组胺,乳酸,腺苷减少真毛细血管血流量增多平滑肌对缩血管物质反应性降低真毛细血管开放调节示意图后微动脉与毛细血管前括约肌收缩真毛细休克期 （缺血性缺氧期） 微循环变化： 微血管、毛细血管前括约肌痉挛性 收缩,毛细血管缺血、缺氧,动-静 脉短路、直捷通路开放 少灌

12、少流 灌少于流 休克期 （缺血性缺氧期）外科学休克pbl课件休克期（淤血性缺氧期） 微循环变化： 微血管扩张，毛细血管前括约肌 松弛，静脉内血流缓慢、淤滞， 毛细血管淤血、缺氧 多灌少流，灌大于流 休克期（淤血性缺氧期）外科学休克pbl课件休克期（微循环衰竭期、DIC期） 微循环变化： 微血管麻痹性扩张，毛细血管内 血流停滞，出现大量的微血栓。 不灌不流 休克期（微循环衰竭期、DIC期）外科学休克pbl课件 氧代谢动力学监测1.全身氧代谢：氧输送、氧耗量、氧摄取及混合静脉血 氧分压氧输送(DO2)：单位时间内心脏泵血提供给组织细胞的氧量。受三个因素影响，呼吸功能(动脉血氧饱和度和氧分压)、血红

13、蛋白、心脏指数。正常值，500-600ml/min.m2氧耗量(VO2):单位时间内组织器官所消耗的氧量。 160-220ml/min.m2。氧摄取率(O2ER):单位时间内组织的氧耗量占氧输送 的比率，正常20-30%.氧 需: 机体单位时间内维持组织细胞正常代谢 所需的氧量。 氧代谢动力学监测1.全身氧代谢：氧输送、 氧债：机体的氧耗量不能满足正常代谢，即氧需与氧耗量的差值。血乳酸浓度：血乳酸越高，表示微循环障碍越重。混合静脉血氧饱和度(SvO2)或血氧分压(PvO2):正常值65%和 40mmHg经皮动脉血氧饱和度(SaO2):94% 氧债：机体的氧耗量不能满足正常代谢，即氧需与氧耗量的

14、差Study Questions 3: What acid/base category would be expected? Study Questions 3: What aciAt the scene, he was breathing at 20 per minute with a blood pressure of 90/60 and a pulse of 130. Upon arrival his vital signs are the same, with a temperature of 36oC. His abdomen is markedly distended. His h

15、ands and feet are cold, his legs mottled. A nasogastric tube reveals green liquid. A urinary catheter reveals dark yellow urine. His hemoglobin is 7. His abdominal lavage（灌洗）reveals gross blood. At the scene, he was breathing氧代谢障碍组织细胞缺氧是休克的本质问题缺氧无氧代谢增加 ATP生成减少 肝功能下降 乳酸大量产生 乳酸代谢降低 代谢性酸中毒 组织细胞器功能降低 组织

16、功能降低 MODS氧代谢障碍组织细胞缺氧是休克的本质问题Study Questions 4:What is the effect of this kind of shock on the kidneys, the heart, the lungs, the brain, the intestine? Study Questions 4:What is tAt the scene, he was breathing at 20 per minute with a blood pressure of 90/60 and a pulse of 130. Upon arrival his vital

17、signs are the same, with a temperature of 36oC. His abdomen is markedly distended. His hands and feet are cold, his legs mottled. A nasogastric tube reveals green liquid. A urinary catheter reveals dark yellow urine. His hemoglobin is 7. His abdominal lavage（灌洗）reveals gross blood. At the scene, he

18、was breathing内脏器官损伤休克失代偿 内脏缺血、缺氧 内脏血管内皮细胞受损全身炎症反应综合征 MODS内脏器官损伤休克失代偿内脏器官的继发性损害肺： 内脏器官的继发性损害肾：休克时由于肾血管收缩、血流量减少、引起急性肾衰竭，表现少尿（每日尿量400ml）严重者无尿（每日尿量100ml）。肾：休克时由于肾血管收缩、血流量减少、引起急性肾衰竭，表现心：由于冠脉灌流量的80发生于舒张期，当心率过快而舒张期过短或舒张期压力下降时，冠状动脉的血流减少，由此引起的缺氧和酸中毒可导致心肌损害。当心肌微循环内血栓形成，还可引起心脏局灶性坏死，此外，电解质的失衡也将加重心脏损害 。心：由于冠脉灌流量的80