临床医学休克 (英文)

临床医学院

Shock休克2023/2/151Notthese2023/2/152Contents1.Definition2.Etiology3.Pathophysiology4.Manifestation5.Diagnosis6.Management2023/2/153AskquestrionsHowtoaskquestions?Howtoasksmartquestions?Howtogetgoodanswers.2023/2/154Case1.Drunkandcrash2023/2/155Case1OnenightofChinesenewyearfestival.a44-year-oldman.drunkamotorvehiclecollision6hoursago.Beforehisadmission,hewastransfers2differenthospitals,nothinghasbedone.2023/2/156Case1T

36.1℃，P140bpm,BP70/40mmHg,R30bpmPale,slumber,thirstySlightabdominaltenderness.PelvicmalformationNourineafterFoleycatheter.HGB60g/L2023/2/157case1Whatdoyouwanttodonow?A.BloodsamplingB.ivfluid.C.bloodtransfusion.D.CTscan.E.Ultrasonic.F.Analgesic2023/2/158Case1DiagnosisMotorvehiclecollisionTrauma（liver，bone…..）Shock2023/2/159Case1:HowtoexplainthesignsandsymptomBPlow,HRhighSlumberThirstPaleOliguria2023/2/1510Case1Howtotreathim?What,Howandwhy?2023/2/1511Case22023/2/1512Case2

hypotensionafterValvereplacement33yearsoldwomanIntermittentdyspneafor2yearsRheumaticheartdiseaseAorticvalveandmitralvalvestenosisValvereplacement2hoursago2023/2/15132023/2/15142HourslaterT37.8℃，P135bpm，BP60/40mmHg，R16bpmWhatdoyouwanttodonowandnext?Why?2023/2/1515Case3yellowandfeverMale，65years,single,Skinyellowstainandabdominalpainfor1week,feverfor3days.T38.0℃，P126BPM，BP75/40mmHg，R35bpm，lethargy,jaundice,tendernessupperabdomen.WBC62.42*10^9/L，N94.8%，HGB150g/L，PLT85*10^9/L。BUN27.16mmol/L，CRE

530.2umol/L，TBIL230umol/L，DBIL187.3umol/L，ALB23.3g/L，PH7.12PCO220mmHg，PO2238mmHg，BE-20.9mmol/L,Lac10.7mmol/L。2023/2/1516AnyQuestions?acuteobstructivesuppurativecholangitisCharcot'scholangitistriadrightupperquadrantpain,jaundice,fever.Reynolds'pentad(additionaltwo):HypotensionConfusion2023/2/151714dayslaterweaningforventilationAfter17

daysrenalfunctionrecover1.Definition**Shockistheclinicalsyndromethatresultsfrominadequatetissueperfusion.hypoperfusion-inducedimbalancebetweenthedeliveryofandrequirementsforoxygenandsubstrateleadstocellulardysfunction.Longo,D.,A.Fauci,D.Kasper,S.Hauser,J.JamesonandJ.Loscalzo(2011).Harrison'sPrinciplesofInternalMedicine,18thEdition,Mcgraw-hill.2023/2/1519deliveryrequirements2023/2/1520WhatisNOTshock?hypotensionLostofconsciousness.Adisease.Asymptom.2023/2/1521Contents1.Definition2.Etiology3.Pathophysiology4.Manifestation5.Diagnosis6.Management2023/2/15222.EtiologyPumptankpipes2023/2/15232023/2/15242.1HypovolemicshockHemorrhageVolumedepletionInternalleak2023/2/15252.2CardiogenicshockMyopathicMechanicalArrhythmic2023/2/15262.3ObstructiveshockPericardialtamponadeMassivepulmonaryembolismTensionpneumothorax2023/2/15272.4DistributiveshockSepsisToxicoverdosesAnaphylaxisNeurogenicEndocrinologic2023/2/1528Typesofshock**2023/2/15292023/2/1530Typesofshock2023/2/1531Contents1.Definition2.Etiology3.Pathophysiology4.Manifestation5.Diagnosis6.Management2023/2/15323.PathophysiologyCardiovascularResponseNeuroendocrineResponseHormonalresponsesMicrocirculationCellularResponsesInflammatoryResponse2023/2/15333.1CardiovascularResponse2023/2/15343.2NeuroendocrineResponse2023/2/15353.3Hormonalresponse2023/2/15363.4Microcirculation2023/2/1537SublingualMicrocirculationinaHealthyVolunteer(A)andaPatientwithSepticShock(B).densityofthecapillariesisdiminished,manyofthecapillarieshavestoppedorintermittentflow(PanelB,arrows).Vincent,J.L.andD.DeBacker(2013)."Circulatoryshock."NEnglJMed

369(18):1726-1734.2023/2/15382023/2/15393.5Cellularresponse2023/2/15403.6Inflammatoryresponse2023/2/1541Contents1.Definition2.Etiology3.Pathophysiology4.Manifestation5.Diagnosis6.Management2023/2/15424.Manifestation4.1HemodynamicParameters4.2OxygenTransportMonitoring4.3Cardinalfindings4.4Stagesofshock2023/2/15434.1HemodynamicParameters2023/2/1544Hagen–Poiseuilleequation\DeltaPisthepressurelossListhelengthofpipe\muisthedynamicviscosityQisthevolumetricflowrateristheradiusdisthediameter\piisthemathematicalconstantPi2023/2/1545SystemictissueperfusionSystemictissueperfusionisdeterminedbythecardiacoutput(CO)andsystemicvascularresistance(SVR)MAP=COxSVR2023/2/15464.1HemodynamicParametersBSA,bodysurfacearea;HR,heartrate;MAP,meanarterialpressure;PAPm,pulmonaryarterypressure—mean;PCWP,pulmonarycapillarywedgepressure;RAP,rightatrialpressure.2023/2/15472023/2/15484.2OxygenTransportThemajorfunctionoftheheart,lungsandcirculationistheprovisionofoxygenandothernutrientstothevariousorgansandtissuesofthebody.Duringthisprocesscarbondioxideandtheotherwasteproductsofmetabolismareremoved.2023/2/1549Balancerateofsupplyrateofcomsumption2023/2/1550CaO2 arterialO2content动脉氧气含量（pao2inmmHg)=(HbxSaO2x1.34)+(PaO2x0.0031)DO2 oxygendeliveryQT cardiacoutputOER oxygenextractionratioVO2 oxygenconsumption2023/2/15512023/2/1552Transportofoxygenfrominspiredgastothecell,demonstratingthe'oxygencascade',Valuesinparenthesesforanormal70kgindividual(bodysurfacearea:1.67m2)breathingair(FiO2:0.21)atstandardatmosphericpressure(PB:101kPa).PartialpressuresofO2,CO2inkPa;saturationin%;contents(CaO2,CvO2)inml/litre;Hbing/l;blood/gasflows(QT,Vi/e)inlitre/min;oxygentransport(DO2,O2R),VO2andVCO2inml/min.ToconvertkPatommHg,multiplyby7.5.2023/2/1553Therelationshipbetweenoxygentension(PO2)andpercentagesaturationofhaemoglobinwithoxygen(SO2).Thedottedlineillustratestherightwardshiftofthecurve(i.e.P50increases)causedbyincreasesintemperature,PaCO2,metabolicacidosisand2,3diphosphoglycerate(DPG).2023/2/1554Theeffectsofchangingoxygendeliveryonconsumption.Thesolidline(ABC)representsthenormalrelationshipandthedottedline(DEF)thealteredrelationshipbelievedtoexistinsepsis.2023/2/15554.3cardinalfindingsCardinalfindings

hypotensionabnormalmentalstatusoliguriametabolicacidosiscoolandclammyskin2023/2/15564.3.1HypotensionAbsolutehypotension(systolicbloodpressure<90mmHg)Relativehypotension(adropinsystolicbloodpressure>40mmHg)2023/2/15574.3.2Abnormalmentalstatusagitationconfusionordeliriumcoma2023/2/15584.3.3oliguria2023/2/15594.3.4Metabolicacidosis2023/2/15604.4STAGESOFSHOCK1.Preshock

(compensatedshock)asymptomaticdespitea10percentreductionintotalbloodvolume.Tachycardia,peripheralvasoconstriction,andeitheramodestincreaseordecreaseinsystemicbloodpressure2.Shock

(decompensatedshock)20to25percentreductionineffectivearterialbloodvolumeinhypovolemicshock,afallinthecardiacindextolessthan2.5

L/min/m2

incardiogenicshockorgandysfunctionappear.(tachycardia,dyspnea,restlessness,diaphoresis,metabolicacidosis,oliguria,andcoolclammyskin.)3.End-organdysfunction

—

Progressiveend-organdysfunctionleadstoirreversibleorgandamageandpatientdeath.

2023/2/1561CellularResponsestoInjuryIftoolate…soyoushould…IrreversiblecellinjuryNecrosisofthecentralportionofaliverlobuleinseverecirculatoryshock.(CourtesyDr.J.W.Crowell.)RobbinsandCotranPathologicBasisofDisease,Chapter2,31-685.DiagnosisCardinalsymptomsandsignsofshock,Additionalfindingsfromthehistory,physicalexamination,laboratorystudiesthatsuggestaparticulartypeofshock.2023/2/1565Properpositioningoftheultrasoundprobeforparasternal(A)andsubxiphoid(B)viewsoftheheart.Step1:Evaluatetheheart(the“pump”).Step2:Assessintravascularvolumestatus(the“tank”).Step3:Evaluatethemajorvascularstructures(the“pipes”）2023/2/1567HypovolemicshockHistory:Hematemesis,hematochezia,melena,vomiting,diarrhea,orabdominalpain.Bluntorpenetratingtrauma.Postoperative.Physicalmanifestations:dryskin,drytongue,ordryoralmucosa.posturalhypotension.2023/2/15682023/2/1569CardiogenicshockDyspnea,chestpain,orpalpitations.Historyofcardiovasculardisease.Lungexaminationmayrevealdiffusecracklesandcardiacexaminationmayrevealanewmurmur,gallops,orsoftheartsounds.Thejugularvenouspressureandcentralvenouspressuremaybeincreased,whilethedistalarterialpulsesmaybediminished.2023/2/1570DistributiveshockDyspnea,productivecough,dysuria,hematuria,chills,rashes,fatigue,headache,pain,fever,tachypnea,tachycardia,leukocytosis,anabnormalmentalstatus,orflushing.2023/2/15716.Management**6.1Tank:Fluidand/orblood6.2Pipes:Vasopressors6.3Pump:Inotropicagents,machines6.4Treattheunderlinedisease2023/2/1572EmanuelRiversandEGDT2023/2/1573GoaldirectedtherapyRivers,E.,B.Nguyen,S.Havstad,J.Ressler,A.Muzzin,B.Knoblich,E.PetersonandM.Tomlanovich(2001)."Earlygoal-directedtherapyinthetreatmentofseveresepsisandsepticshock."NEnglJMed

345(19):1368-1377.2023/2/15742023/2/1575Earlygoal-directedtherapytargets**Meanarterialpressure(MAP)≥65mmHg(MAP=[(2xdiastolic)+

systolic]/3)Urineoutput≥0.5

mL/kg/hourStaticordynamicpredictorsoffluidresponsiveness,eg,centralvenouspressure(CVP)8to12mmHgCentralvenous(superiorvenacava)oxyhemoglobinsaturation(ScvO2)≥70percentormixedvenousoxyhemoglobinsaturation(SvO2)≥65percent2023/2/1576SURVIVINGSEPSISCAMPAIGNBUNDLES（2013）TOBECOMPLETEDWITHIN3HOURS:1)Measurelactatelevel2)Obtainbloodculturespriortoadministrationofantibiotics3)Administerbroadspectrumantibiotics4)Administer30mL/kgcrystalloidforhypotensionorlactate4mmol/LTOBECOMPLETEDWITHIN6HOURS:5)Applyvasopressors(forhypotensionthatdoesnotrespondtoinitialfluidresuscitation)tomaintainameanarterialpressure(MAP)65mmHg6)Intheeventofpersistentarterialhypotensiondespitevolumeresuscitation(septicshock)orinitiallactate4mmol/L(36mg/dL):-Measurecentralvenouspressure(CVP)*-Measurecentralvenousoxygensaturation(ScvO2)*7)Remeasurelactateifinitiallactatewaselevated**TargetsforquantitativeresuscitationincludedintheguidelinesareCVPof8mmHg,ScvO2of70%,andnormalizationoflactate.Dellinger,R.P.,etal.(2013)."Survivingsepsiscampaign:internationalguidelinesformanagementofseveresepsisandsepticshock:2012."CritCareMed

41(2):580-637.2023/2/15776.1Fluid(Tank)Fluidsshouldbeadministeredwiththesamecautionthatisusedwithanyintravenousdrug.Considerthetype,dose,indications,contraindications,potentialfortoxicity,andcost.Fluidresuscitationisacomponentofacomplexphysiologicalprocess.Identifythefluidthatismostlikelytobelostandreplacethefluidlostinequivalentvolumes.Considerserumsodium,osmolarity,andacid–basestatuswhenselectingaresuscitationfluid.Fluidrequirementschangeovertimeincriticallyillpatients.2023/2/15782023/2/15796.2Vasoactiveagents（pipes）DrugEffectonheartrateEffectoncontractilityArterialconstrictioneffectsDobutamine++++-(dilates)Dopamine++++++Epinephrine++++++++Norepinephrine+++++++Phenylephrine00+++Amrinone++++--(dilates)2023/2/1580NorepinephrineisbetterNS50ml+NEP0.3*kg1-20ml/h(0.1-2ug/kg.min)

DeBacker,D.,etal.(2010)."Comparisonofdopamineandnorepinephrineinthetreatmentofshock."NEnglJMed

362:779-789.

2023/2/15816.3Pump:Inotropicagents（Dobutamine，Dopamine）Machines2023/2/1582Intra-aorticballoonpump（IABP）2023/2/1583IABP2023/2/1584ECMO(Extracorporealmembraneoxygenation)2023/2/1585体外膜肺氧合（ECMO）Case1Howtomanagehim?Dopamine?NS？Albumin？Blood？Machine？Surgery?2023/2/1587Case1NoUrineHemofiltrationfor10days.AbdominalpainstillNosurgeonwantstodooperationonhim.2023/2/1588Endofcase110dayslaterSuddenabdominalpain.SuddenabdominaldistensionUnclottingBloodonabdominocentesisDeadin10min2023/2/15896.4Treattheunderlinedisease**Trauma:stopbleedingMI:percutaneouscoronaryintervention/ThrombolysisSepticshock:antibiotics2023/2/1590KeypointsShockistheclinicalsyndromethatresultsfrominadequatetissueperfusion.hypoperfusion-inducedimbalancebetweenthedeliveryofandrequirementsforoxygenandsubstrateleadstocellulardysfunction.2023/2/1591Typesofshock**2023/2/15922023/2/1593Cardinalfindingsofshock

hypotensionabnormalmentalstatusoliguriametabolicacidosis2023/2/1594Earlygoal-directedtherapytargets**Meanarterialpressure(MAP)≥65mmHg(MAP=[(2xdiastolic)+

systolic]/3)Urineoutput