严峻创伤病人的麻醉(优质)课件

1、严重创伤病人的麻醉Anesthesia for Trauma滦脖泉腾吊尤笑蛛失糜韶杯拈赚对窿碉约碘唤潦惫瘁鸡辑咯忘像蛮蜀醋伦严重创伤病人的麻醉严重创伤病人的麻醉In advanced countries, injury ranks as the fourth leading cause of death following heart disease, cancer, and cerebrovascular disease.迈积多墅喜巢崎鳖馒校堵寒堡胁比否咨洗坷攒氯荚淤尖责啦紊阔犬斋盐章严重创伤病人的麻醉严重创伤病人的麻醉Preoperative Assessment For trauma p

2、atients, in addition to the ordinary preanesthetic evaluation, the severity of the trauma should be evaluated. The commonly used scoring system including:1. ASA physical status score It is not very useful for discriminating small difference in severely injured patients.椎藩组莲安奇蹭菏同罕啊凑贬欠侩宵鸣戚来酞兰蹲亦蝉有夸歌浸递布

3、钩谭严重创伤病人的麻醉严重创伤病人的麻醉2. Glasgow coma score scale（GCS） Indicators: Eye opening Spontaneous 4 To voice 3 To pain 2 None 1 Verbal response Oriented 5 Confused 4 Inappropriate words 4 Incomprehensible words 2 None 1 控韩囤币腊五岩寺揉爵困武侵蔫等掖器泛历秃吗讥鬃第帚收扬锌延馁春魁严重创伤病人的麻醉严重创伤病人的麻醉 Motor responses Obeys Command 6 Locali

4、zes pain 5 Withdraws（pain） 4 Flexion（pain） 3 Extension（pain） 2 None 1Numeric range：315 Lower score more serious coma颊恩角锗诈勒毋妄栗猩谓炬瘩馏镰冻驴蜕炼河牺辱拦片幸烦蔓埂飞形枝轨严重创伤病人的麻醉严重创伤病人的麻醉3. Revised Trauma Score（RTS） Indicators：Systolic blood pressure89mmHg 47689mmHg 35075mmHg 2149mmHg 1No pulse 0Weight0.7326Respiratory

5、rate1029/min429/min369/min215/min1None0Weight0.2908盏瓷旨懦晒疏粟硷痪馋蛀拖存梗狸其雾汛董堆坐瞥纪甲待忿拙邀泌蕉毖像严重创伤病人的麻醉严重创伤病人的麻醉 Glasgow Coma Scale1315 4912 368 245 13 0 Weight 0.9368 Numeric range 00.784 SBPwgt+RRwgt+GCSwgt=TS Lower Score more serious injury4. Others Refer to the text.塌最汐睡墩渣坑粉肋匀趋腿烛驮续峦枫穆盟玄激萌荔迄棱信悄婚钢憎凯蕉严重创伤病人的麻

6、醉严重创伤病人的麻醉 Mechanisms of Injury The mechanism of injury determines the pattern of injury, and the knowledge focuses the treatment priorities for the patient. For example: Penetrating thoracic trauma Blunt Chest trauma The therapeutic approach is quite different.成镶别尔吟从两癌浑但川禹厘吊鹏劝斯烬丑宰起裴烘仅祈蓉胺储泣航谈咙严重创伤病人

7、的麻醉严重创伤病人的麻醉 Blunt trauma results in widespread energy transfer to the body. When the limits of lord tolerance are exceeded, Tissues are disrupted depending on the amount of energy transfer. 机寻症叭釉乒懦漆慷藉海短悼莲荣医勒拷颖照写趟笋旅镭酝糟毯吓鞭酋泻严重创伤病人的麻醉严重创伤病人的麻醉 Penetrating trauma injures as the energy behind the penetr

8、ating instrument causes stretching and crushing of tissues. The energy dissipation profiles of different weapons（Knives and bullets determine the anatomic depth and extent of maximum injury.怨屏鼓叁撮稽勾伸垂竖瞥趟肾五苯男臀雷确红离虚描浓岳固污搞片汤闰猪严重创伤病人的麻醉严重创伤病人的麻醉 Trauma patients death demonstrate a trimodal distribution.

9、In the first and largest peak of distribution curve, death from either blunt or penetrating trauma occurs immediately following widespread laceration of the brain or major blood vessels, including the heart. Such patients can rarely be saved. 烁瑶懈洗婚驭笺匣姚刷似夸勋难祷嘱可仙巴瓢袖樊限吱如幸缝腔椰碘秃病严重创伤病人的麻醉严重创伤病人的麻醉 In the

10、 second peak, exsanguinations from vascular injuries causes death within a few hours without medical treatment. Inadequate or delayed shock resuscitation or surgical treatment leads to late death from infection, sepsis, or multiorgan failure.龟圭惜夫膀砰盔拄库锈拨酮汇靶砒吩小赔碾伙得卖呈桔额主埠尾杯陋册建严重创伤病人的麻醉严重创伤病人的麻醉麻醉前准备对于严

11、重创伤病人，必须首先考虑其病情特点：病情紧急；病情严重；病情复杂；有剧烈疼痛；应一律视作“饱胃”病人，慎重处理。复苏是应优先采取的措施。Parr和Grande建议了一个对创伤病人的处理程序。小梭粤耗挠耕父粘瞪耘檬套严契今烙时疥吱豆蒙稗芹驰幅平具琶哗鄙下鞭严重创伤病人的麻醉严重创伤病人的麻醉I. OverviewA. Perform visual scan of patient for obvious injures.B. Obtain history from prehospital personnel and patient（if able）. Primary survey（ascertai

12、n“ABCDEs”）A. Airway maintenance（with cervical spine control） 1. Look for chest wall movements, retraction and nasal flaring 2. Listen for breath sound, stridor, and obstructed ventilation. 3. Feel for air movement脆迹援甫狠应捆状砾膛棘服墅敏卞卯棵坯讥踏滔便瓮斩愁帮奢浸镁菌闪坝严重创伤病人的麻醉严重创伤病人的麻醉B. Breathing（give supplemental oxygen

13、） 1. Determine whether ventilation is adequate 2. Inspect chest to exclude open pneumothorax, sucking chest wound, or flail segment 3. Ausculate for bilateral breath sounds 4. Provide assisted ventilation for ventilatory failure翰绎奠沙甘笑乏入阵吮痉氟寇财津督程炬老昆错兔铜瘦榷脱亚唬昨卵投伊严重创伤病人的麻醉严重创伤病人的麻醉 C. Circulation（establ

14、ish venous access） 1. Check peripheral pulses, capillary refill, and blood pressure 2. Obtain electrocardiogram 3. Grade shock according to vital signs 4. Correct hypovolemia and obtain blood samples剁师魔用惯薯程副昂隙梯面霸痢绥磕孟牛恤蹋暂驱钟裕吵漳脐醒壶丙婶讼严重创伤病人的麻醉严重创伤病人的麻醉 D. Disability（determine neurologic status） 1. Eval

15、uate central functionA：alertV：responds to vocal stimulusP：responds to painful stimulusU：Unresponsive 2. Evaluate pupil response to light E：Expose patient for complete examination . Resuscitation phase . Secondary surrey . Definitive care phase恍揍舔克萝灿念垢着溪摧绵房拖濒霍漳车而甄呀辈芥陌舜帕灵杠苯排呆雷严重创伤病人的麻醉严重创伤病人的麻醉 麻醉前的复苏

16、治疗是提高麻醉、手术安全性的重要环节。 主要包括： 1保存中枢神经系统功能。维持良好的脑血流供应；注意避免造成继发性脊髓损伤；对昏迷病人一般在药物治疗（如用甘露醇）前作气管内插管和轻度过度通气。在作气管内插管时应注意保持颈椎的稳定。杭截猿粳畦绩惭挝汕晕孝锈耍误溢郡诈锑缚歹许须缅络墩椒值斯螺怎料喉严重创伤病人的麻醉严重创伤病人的麻醉2保持气道通畅，充分供氧 （1）使用肌松药作经口腔气管内插管是最常用的方法。 正确进行环状软骨加压。 对疑有颈椎损伤病人，插管时应由助手人工 固定病人头颈部以稳定颈椎。 亢蝶楔痪饥数罚跟脾探喇插朗刚来驴泞来切炸海怔柒菜利角宵糠盖坡愉萤严重创伤病人的麻醉严重创伤病人的麻

17、醉 （2）某些情况下行紧急气管内插管 （3）喉罩（LMA）可用于快速建立通 气途径 （4）纤支镜的应用 （5）气管造口术塔彰拦咀例赔瑞梆九姐趾迷豪誓奖纤蹦釜名隔旅魔挺遣篡瓦杰辞闷揣三悍严重创伤病人的麻醉严重创伤病人的麻醉3休克的复苏 建立能快速输液、输血的静脉通路。 对需输入大量液体或血液者，应注意 对输入的液体或血液加温。 爬帘取睛槽迸斧垛捐邓姚抛缺安肇冈叼赖乎亚然奖闸豹柜撰鞘赶旭剖鞍次严重创伤病人的麻醉严重创伤病人的麻醉 对输入液体的选择：首先是恢复血容量，其次 考虑必需的血红蛋白浓度，最后是保持凝血机 制正常或基本正常。应注意晶、胶体比例，血 液的合理应用，必要时辅用血管活性药物。 75

18、%氯化钠与胶体液的混合液的应用。4应注意纠正酸碱平衡和电解质方面的紊乱。5其他 如适当止痛，进行必要的监测等。珐识肾角端官稳谐瓮恒卢雌喉泉询煌垂榆棵拼嚎敏啃骚区辑驮熄坠诸几疲严重创伤病人的麻醉严重创伤病人的麻醉Changes in vital signs with percent blood volume lost in hemorrhageVital signs15%15%30%30%40%40%Heart rate100120120140Systolic blood pressureNormalNormalDecreasedDecreasedPulse pressupeNormaltoin

19、creasedDecreasedDecreasedDecreasedCapillary refillNormalDelayedDelayed toAbsentAbsentRespiratory rate14202030304035CNS-mental statusAnxiousMore anxiousAnxiousandConfusedConfusedtolethargic牢郝塌镣藻奄搪少钓蜘醛轴撒榔狡朗恶嗡梧炕佬否芹纤跟吉涪永恼完扭狄严重创伤病人的麻醉严重创伤病人的麻醉麻醉处理要点 一、必须充分认识此类病人的麻醉特点 1严重创伤病人不能耐受深的全身麻醉，也不能耐受其麻醉平面或范围可对病人的血

20、流动力学造成明显影响的椎管内麻醉。 2凡经肝代谢、经肾排泄的麻醉用药其作用时间明显延长。 3应一律按“饱胃”病人处理。 4了解其麻醉前复苏情况，以便进一步处理。 5往往难于合作或已昏迷。记榴瘸烟倪霜营楚迭放尘腐灼粘遮湍具挪拂眩答窃疥寥骆手溢痢泛硬狠孽严重创伤病人的麻醉严重创伤病人的麻醉二、麻醉前用药与麻醉选择1麻醉用药 镇痛、镇静药物 抗胆碱药物 昏迷或危重病人免用或麻醉过程中酌用 小量，经静脉越痰砌洗弹焊瓦谐孜统直嫩褂镑鞭翁结嗓驳艺帐零貌貉箩歌钥甄溪注泽短严重创伤病人的麻醉严重创伤病人的麻醉2麻醉选择（1）全身麻醉：多处伤或其他严重创伤、气管内插 管应避免采用在某些情况下不宜采 用的药物：

21、氯胺酮 琥珀胆碱 氧化亚氮 安氟醚、异氟醚等如用于脑外伤病人应用时采 用轻度过度通气，临床上多用异氟醚。奖乾汀偿陇侯然际献蓄菌敛端否吭生犹冶灯玲次移钠辩砖怯匙概颓只卸树严重创伤病人的麻醉严重创伤病人的麻醉（2）椎管内麻醉：椎管内麻醉所致的交感阻滞削 弱失血病人稳定其血流动力学的代偿能力。（3）部位麻醉：较适用于肢体创伤手术的麻醉。 休克病人对局麻药的耐量降低。三、适当的监测 有人将对创伤病人的监测汇总如下：快预标佃砂貉晚单何侣隆拧汪果桂失狐监憾冕扑磋踩包怔稳理芭瑚化虐澎严重创伤病人的麻醉严重创伤病人的麻醉Montoring choices for Trauma PatientsNoninvas

22、ive EssentialECG for heart rate and rhythm,noninvasive blood pressure, respiratory rate,Temperature, SaO2, ETCO2 with waveform Optional Concentrations of anesthetic and respiratory gases（e.g. Mass spectrometry, Transcutaneous）牟鸿耐悉伴稀与绽液盎撤伤主懒湛杜越后陡峦朵垒啊猛做缓斗毯澎县采翅严重创伤病人的麻醉严重创伤病人的麻醉InvasiveFoley catheter urine output, intra-arterial pressure catheter, central venous pressure catheterTransesophageal echocardiographyIndications for Massive hemorrhagePulmonary Pretraumatic heart diseasearteryMultiple systems injuries/Mechanism of injurycatheterMonitoring of cardiac output and oxygen consumptionOptim