外科学休克pblppt课件

1、外科休克ShockTerm “choc” French for “push” or impact was first published in 1743 by the physician LeDranAbout myselfName: 费 健Email: feijianhotmailMobile:137-0176-9798开始了大家要专心啊一个例子八大问题 A 22 year old man was driving drunk and without his seatbelt fastened when he was involved in a single-vehicle automobil

2、e accident. When attended by EMT（abbr. emergency medical technician 急诊医士） personnel, no information was available about the time of the accident. He was found agitated and complaining of abdominal pain. His airway was patent. At the scene, he was breathing at 20 per minute with a blood pressure of 9

3、0/60 and a pulse of 130. He was placed 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 abdomen is markedly distended. His hands and feet are cold, his legs mottled. A nasogastric tube rev

4、eals green liquid. A urinary catheter reveals dark yellow urine. His hemoglobin is 7. His abdominal lavage（灌洗）reveals gross blood. Study Questions 1:What type of shock does this patient exhibit? At the scene, he was breathing at 20 per minute with a blood pressure of 90/60 and a pulse of 130. Upon a

5、rrival 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 7. His abdominal lavage（灌洗）reveals gross blood.

6、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）低血容量性休克失血性休克损伤性休克感染性休克 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Study Questions 2: What alterations in oxygen delivery are present? At the scene, he was

7、 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 hands and feet are cold, his legs mottled. A nasogastric tube reveals green liquid. A urinary catheter reveals

8、dark yellow urine. His hemoglobin is 7. His abdominal lavage（灌洗）reveals gross blood. 单位时间内通过心血管系统进行循环的血量- 有效循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Section 2. Local feedback regulation of capillary perfusion： Constriction of

9、Pre-capillary Decreased blood Local accumulation of sphincter 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 o

10、f pre-capillary metabolic products true capillary net sphincter and post-arteriole Constriction Relaxation 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 少灌少流

11、灌少于流 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（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 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

12、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%Study Questions 3: What acid/base category would be expected? At the scene, he was breathing at 20 per minute with a bloo

13、d 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 7.

14、 His abdominal lavage（灌洗）reveals gross blood. 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 组织功能降低 MODSStudy Questions 4:What is the effect of this kind of shock on the kidneys, the heart, the lungs, the brain, the intestine? At the scene, he was breathing at 20 per minute

15、 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 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. 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内脏器官的继发性损害肺： 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）。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