SHOCK英语解读和应用

1、Western recordviolent impact or blow, 1743physiologic instability, 1815Eastern record厥脱，内闭外脱I. Historical Aspect Initial records of shockSHOCK英语解读和应用Initial Explanation of shockWesternThomas Latta, 1831Patients with CholeraInfusion of fluids improvementHypovolemiaEastern邪毒内陷气随血脱阴亏气脱气机郁闭阴绝阳脱SHOCK英语解读

2、和应用with the Rise of PhysiologyBurgeoning of Cardiovascular physiology in the end of 19CN, CrileCVP dropped after hemorrhageAnimal survival was increased after the infusion of salinethe Use of Cardiac CatheterizationBlood volume loss fall in Cardiac OutputSHOCK英语解读和应用with the Combination of Physiolog

3、y and BiochemistryToxin theory of shock, Cannon & Baylissimpairment of oxygen transportdevelopment of acidosistoxin in severe muscle injury loss of vasomotor tone venous sequestration of blood hypotensionSHOCK英语解读和应用Antedate the Era of Critical Care MedicineExtensive physiologic research of Wigger,

4、in early 1940sintegrating the Concepts of impaired oxygen deliveryoxygen debttissue injury / death the concept of irreversible shockprogressive systemic circulatory decompensationSHOCK英语解读和应用Controversy on Lung & KidneyARDS Introduction of the flow directed pulmonary artery catheter, in 1970 Noncard

5、iogenic nature Not due to volume overloadARF More prompt and aggressive resuscitationIncidence ATN happens: hypoperfusionARDS happens:Defects in Cell Membrane Function and Vascular Permeability Hypovolemia / Toxin /CytokineHypoxiaARDSSHOCK英语解读和应用A syndrome that results from inadequate perfusion of t

6、issues insufficient to meet metabolic demandlead to cellular dysfunction, elaboration of inflammatory mediators, and celluar injury which may be limited, or widespread A continuum, ranging from subclinical deficits in perfusion to MODS or frank organ failure.Tissue hypoxia due to hypoperfusionDefect

7、sInjuryII. Definition of shock SHOCK英语解读和应用 A. 组织低灌注所致细胞缺氧B. 低血压C. 酸中毒D. 心功能不全E. 以上都不对休克的根本问题是:SHOCK英语解读和应用Impaired tissue perfusion Wider spectrum of shock presentations Ranging from occult tissue hypoxia to full-blown cardiovascular collapse or Multiple organ dysfunctionImplication alarm earliertr

8、eat earlierExplanationSHOCK英语解读和应用Tissue hypoperfusiontissue hypoxiaanaerobic metabolism, acidosisinflammatory mediaterscirculatory redistributionearly involvement of splanchnic circulationcellular injuryseptic complicationsMODS ExplanationSHOCK英语解读和应用O2 DebtWhether DO2crit is increased in ARDS, or

9、sepsis ?Delivery -dependent oxygen uptake = Hypoxiacause MODSsupranormal levels supply of O2prevent the progression of MODS ?Providing opportunity for interventionProviding time for the disease to subsider Oxygen consumption(vO )2Oxygen delivery(DO2)O2 DebtExplanationSHOCK英语解读和应用Circulatory redistri

10、butionConceptHomeostatic response to hypoperfusion to preserve oxygen delivery to heart and brain by selective diverting bloodMechanismcatechols, angiotension II, Vasopressin, endothelin,TXA2 ConsequenceCellular and organ derangement MODS Breakdown of the intestinal epithelial barrierbacterial and t

11、oxin translocation SIRSMODSExplanationSHOCK英语解读和应用intrinsic obstruction of cap. Bedlow-flow states, hypothermia, and increased viscositycap. Sludging: intravascular coagulation, platelet aggregation, other intraluminal debrispreventing RBC from reaching the tissues extrinsic obstruction of cap. Bedl

12、ocal tissue inflammation, edema, or hemorrhage, ACSvessel wall permeability deficitThe changes in Microcirculatary LevelExplanationSHOCK英语解读和应用Hypovolemic ShockHemorrhage -Plasma losses -Cardiogenic ShockIntrinsic - ExtrinsicCompressive -Obstructive -III. Classificaion of Shock TraumaGI BleedingRupt

13、ured aneurysmsBurnBowel obstructionMyocardial infarctionCardiomyopathyValvular Heart DiseaseCardiac Rhythm disturbanceMyocardial depression Tension pneumothoraxPericardial tamponadeHigh level of positive-pressure ventilationPulmonary embolismSurgical Shock 1SHOCK英语解读和应用Neurogenic Shocke.g. Vasogenic

14、 ShockSIRS, toxin Septic despite adequate fluid resucitationTraumatic Anaphylactic and AnaphylactoidHypoadrenalSpinal cord injurySevere head injurySpinal cord anesthesiaSurgical Shock 2SHOCK英语解读和应用The othersThere may be a “ ” to be filled. but “cellular shock”, such as poisoning, hypoxia, hypoglycem

15、ia, is not the syndrome, continuum, or tissue hypoxia due to hypoperfusion, may be excluded from the category of shock.SHOCK英语解读和应用各型休克的共同特点是： A. 血压下降B. 中心静脉压下降C. 脉压缩小D. 尿量减少E. 有效循环血量锐减SHOCK英语解读和应用Secondary visceral impairement Microcirculatory changes Metabolic changesIV. Pathophysiologic staging o

16、f shockSHOCK英语解读和应用 Microcirculatory StagingMicrocirculatory constrictive phaseMicrocirculatory dilatation phaseMicrocirculatory failure phaseSHOCK英语解读和应用后微A微V前括约肌AV吻合支微动脉微静脉加重过程 只出不进/只过不进只进不出/进多出少Microcirculatory StructureSHOCK英语解读和应用 Metabolic Changesenergy metabolic abnormality无氧糖酵解，产能减少metabolic

17、 acidosis引起微血管扩张，等barrier function defects of membrane 累及基底膜，细胞膜，溶酶体膜SHOCK英语解读和应用 Secondary Visceral ImpairmentHeart Kidney LungBrainGastrointestinal tractLiverSHOCK英语解读和应用Clinical StagingShock compensatory stagenervous, restless, agitation, cool, pale, thirsty, tachycardia, short of breathBP normal

18、 or increased, pulse pressure decreased, urinary output normal or decreasedBlood loss 20% ，20% ，800mlSHOCK英语解读和应用 关于休克代偿期微循环改变， 下列那一项是错误的： A. 动静脉短路开放B. 直捷通道开放C. 微动脉收缩D. 微静脉收缩E. 毛细血管内血液淤积SHOCK英语解读和应用V. Diagnosis and patient monitoringCauses and PredictionConventional monitoringMental statusSkin tempe

19、ratureBlood pressure, Pulse rateUrinary output (30ml/hr)Special monitoringCVP (15, 20)Blood routine test/Arterial blood gas analysis/ElectrolytesPCWP(615mmHg)CO CISerum lactate concentrationArterial blood gas analysisDIC: PLT/FDPSHOCK英语解读和应用VI. Measurement of Shock一般紧急处理Urgent measurement补充血容量Resusc

20、itation积极处理原发病Treat inciting cause of shock纠正酸碱平衡失调Control electrolytes, and acid base derangement血管活性药物的应用Inotropic agent治疗DIC，改善微循环 Treat DIC, improve microcirculation皮质类固醇和其它药物的应用 Corticosteroids心理支持与呵护SHOCK英语解读和应用PCWPCVP15, Volume expansion10cmH2O18, Consider volume 18 Diurese 14 Reestablishment

21、 of urinary outputto a rate of 0.5-1.0ml per kg. Per hourA normal heart rate and blood pressureAdequate capillary refillNormal sensoriumNormal CVP and PWCPi. Volume Resuscitation & Initial end-pointsFluid resuscitation End-point reachingSHOCK英语解读和应用Optimize Oxygen DeliveryKeep SaO290% Optimize Cardi

22、ac Index Optimize HbSupply supplemental O2 Early hemodynamic monitoring 11-13 g/dlVentilator, if necessary Assess volume status(preload) ReassessKeep: PCWP15-18 mmHg, MAP 60-80mmHg, Delivery independent O2 consumptionGoal meet Goal not meetTreat inciting cause of shockControl SIRSNutritional support

23、 Inotropic support beta agonismGoal meetGoal not meetConsider Vasodilator, alpha agonistInitial resuscitation of patients in ShockPCWP15, Volume expansion18 DiureseSHOCK英语解读和应用 A. 心功能不全B. 血容量不足C. 血容量过多D. 血管张力升高E. 以上都不是 休克病人经补液后，血压仍低。5 10 min内经静脉注入等渗盐水250ml，如血压上升，而中心静脉压不变，提示：SHOCK英语解读和应用ShockMODSDist

24、urbanceDeath? Timing & Strategy!Effort & Effectii. Current Strategy for Shock Solution SHOCK英语解读和应用Prevention, early Identification, early and specific treatment for Shock and MODS感染创伤烧伤SAPSIRS代谢紊乱低氧乏氧代谢休克复苏失败痊愈MODS好转MODS第二次打击心源性、神经源性因素低血容量血管源性PrimarySecondary（感染）(24h)死亡SHOCK英语解读和应用1. Hypovolemic sh

25、ockSymptoma decrease in pulse pressuretachycarida and hypotensionurine output fallsnormal skin turgor is lostmental status changes - in a progressive fashion apprehension, anxiety, complete obtundationCVP decreaseTreatmentResuscitation & Control the inciting cause of shockSpecificSHOCK英语解读和应用2. Trau

26、matic shockTypeVasogenic shock that begins as hypovolemic shockCharacter - refractory to fluid replacement therapyLarger volume losses, greater fluid sequestrationMore intense activation of inflammatory mediatorsDevelopment of SIRSDevastating soft tissue injuriesMachanismincreasing microvascular per

27、meability, Excessive fluid requirement Frequently Require mechanical ventilation, Pulmonary artery catheter monitoringCardiovascular supportOperationSpecificSHOCK英语解读和应用 3. Septic shockTypeVasogenic shock, Refractory to fluid replacement therapyDefinitionSepsis with hypotension despite adequate flui

28、d resuscitationalong with the presence of manifestations of hypoperfutionsuch as lactic acidosis, obliguria, or acute alteration in mental statusMechanism CytokinesVasodilatation, Increasing microvascular permeability, Excessive fluid requirement SpecificSHOCK英语解读和应用 Treatment of Septic shockResusci

29、tationControl infectionNormalization of electrolytes, acid base dearangementInotropic agentCorticosteroidsNutritional support, deal with DIC, organ function support SpecificSHOCK英语解读和应用4. Anaphylactic and Anaphylactoid shockMechanismInflammatory mediatorsC3a, C5a, Histamine, Kinnins, Prostaglandinss

30、ymptomsVasodilatation, increased capillary permeabilitybronchospasm, airway edema, circulatory collapseTreatment缩血管Aminophylline CorticosteroidsAntihistamineImmunologically Mediated: byIgE antibodyNot Immunologically Mediated: Radiographic contrast dyes, narcoticsSpecificSHOCK英语解读和应用5. Cardiogenic ShockSymptomWeak or slow pulse ratetachycarida or