严重创伤病人的麻醉课件

1、严重创伤病人的麻醉严重创伤病人的麻醉1严重创伤病人的麻醉严重创伤病人的麻醉1overviewIn advanced countries, injury ranks as the third leading cause of death following heart disease and cancer.严重创伤病人的麻醉2overviewIn advanced countriesTreatment principle to critically ill patients Assessment to organ function and disease states Preoperative

2、treatment Selection to anesthesia way and anesthetics Close intra-operative monitoring and correction to abnormality of pathophysiological state Positive prevention and treatment toPostoperative complications 严重创伤病人的麻醉3Treatment principle to critiPreoperative Assessment For trauma patients, in addit

3、ion to the ordinary preanesthetic evaluation, the severity of the trauma should be evaluated. The commonly used scoring system including:严重创伤病人的麻醉4Preoperative Assessment严重创伤病人的1.ASA physical status classification system It is divided into 5 levels According to medical history, Physical examination

4、and laboratory examination Level 1 and Level 2 :normal organ function Level 3: compensation, need sufficient preoperative preparation Level 4 decompensation, High mortality Level 5 dying严重创伤病人的麻醉51.ASA physical status classifi2. Glasgow coma score scale（GCS） Indicators: Eye opening Spontaneous 4 To

5、voice 3 To pain 2 None 1 Verbal response Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible words 2 None 1 严重创伤病人的麻醉62. Glasgow coma score scale（GC Motor responses Obeys Command 6 Localizes pain 5 Withdraws（pain） 4 Flexion（pain） 3 Extension（pain） 2 None 1严重创伤病人的麻醉7 Motor responses严重创伤病人的麻醉

6、 Injury classificationLight : 1315 Consciousness obstacle in 20min Medium: 912 Consciousness obstacle between 20min and 6hSevere: 38 Coma more than 6 hours or the second coma in 24h严重创伤病人的麻醉8 Injury classification严重创3. Revised Trauma Score（RTS） Indicators：Systolic blood pressure89mmHg 47689mmHg 3507

7、5mmHg 2149mmHg 1No pulse 0Weight0.7326Respiratory rate1029/min429/min369/min215/min1None0Weight0.2908严重创伤病人的麻醉93. Revised Trauma Score（RTS）严重 Glasgow Coma Scale1315 4912 368 245 13 0 Weight 0.9368 Numeric range 07.84 SBPwgt+RRwgt+GCSwgt=TS Lower Score more serious injury严重创伤病人的麻醉10严重创伤病人的麻醉104 CRAMS

8、 Score CRAMS is constituted by five words including Circulation ,Rspiration,Abdomen,Motor and SpeakIt is a comprehensive according to physiological indexes and traumatic parts Score7 minor injurie mortality 0.15%Score6 serious injury mortality 62%sensitivity 83%91.7%, higher than TS严重创伤病人的麻醉114 CRAM

9、S Score严重创伤病人的麻醉115Assessment to organ function5.1 cardiac function:performance After activity ,Breathless test 5.2 pulmonary function:Measuring chest diameter method Blowing matches testblcod gas analysis and Pulmonary function test5.3 Liver functionSerum bilirubin , transaminase , albumin ,PT,APTT

10、5.4 renal functionUrine , Urea nitrogen , creatinine 严重创伤病人的麻醉125Assessment to organ function严心功能分级及意义级 别 屏气 临 床 表 现 临床意义 麻醉 试验I级 30s 能耐受日常体力活动 心功能正常 耐受力 活动后无心慌 良好 气短等不适II级 2030s 日常体力活动有一定不适， 心功能较差 如处理适当 自行控制活动量， 耐受仍好 不能作跑步或用力的工作III级 1020s 轻度或一般体力活动后 心功能不全 麻醉前应充分准备 心悸、气短明显， 应避免增加心脏负担 只能胜任极轻微的体力 活动或静

11、息IV级 10s以内 不能耐受任何体力活动， 心功能衰竭 极差，一般需推迟 静息时也感气短，不能平卧， 有端坐呼吸、心动过速等表现严重创伤病人的麻醉13心功能分级及意义严重创伤病人的麻醉135.5 Assess to blood loss of damage in different parts Estimation to blood loss （ml） Position Moderate damage Severe damage Upper limb 500 1000Calf 500 2000Thigh 1000 3500 Pelvis 1000 4000Abdomen 1000 5000

12、Chest 1000 4000严重创伤病人的麻醉145.5 Assess to blood loss of da严重创伤病人的麻醉15严重创伤病人的麻醉15Characteristics of severe trauma patients condition 1 病情紧急 注意检查和治疗的矛盾 2病情严重 失血性休克发生率可达95% 3病情复杂 复合伤居多 4疼痛剧烈 5饱胃 急诊病人一律视为饱胃病人 严重创伤病人的麻醉16Characteristics of severe trauanesthesia characteristics of Severe trauma patients 1不能

13、耐受深麻醉2难以配合麻醉3难于避免呕吐误吸4麻醉药作用时间明显延长5常伴有不同程度脱水、酸中毒6常需支持循环功能 疼痛剧烈 病情严重病情复杂病情严重病情复杂病情紧急饱胃病情严重严重创伤病人的麻醉17anesthesia characteristics of First aid and treatment before anesthesia 原则 积极准备而不延误手术时机确保呼吸道通畅及充分供氧 导致缺氧的原因通常有： 呼吸道梗阻：神志不清、昏迷、舌后坠、分泌物、呕吐 中枢性呼吸抑制：颅脑损伤 胸外伤处理方法： 通畅呼吸道：吸引、口咽通气道、气管插管、气管切开 充分供氧：鼻导管、面罩、机械通气

14、多发伤病人应假定有颈椎损伤而做颈椎固定严重创伤病人的麻醉18First aid and treatment before严重创伤病人的麻醉19严重创伤病人的麻醉19 快速补充血容量建立输液通道： 常需穿刺中心静脉输液种类 平衡液 右旋糖酐、羟乙基淀粉万汶、血定安输血 ：成份输血或全血纠正代谢性酸中毒 5%NaHCO2解除病人疼痛 度冷丁5075mg监测 呼吸、循环、体温、出凝血监测等严重创伤病人的麻醉20 快速补充血容量严重创伤病人的麻醉20Principles of anesthesiaPremedicationAnalgesic ，Sedative ，Anticholinergics Me

15、thod of anesthesia 1. local anesthesia-it is suitable to Superficial surgery and doses should be noted intravertebral anesthesia-Caution！general anesthesia -Common ，Light anesthesia is appropriate严重创伤病人的麻醉21Principles of anesthesiaPremedMethod of general anesthesia 1 anesthesia induction 1.1 Prevent

16、ive measures of reflux and aspiration Large diameter of gastric tube Antacids :Cemitidine200400mgAwake tracheal intubation after topical anesthesiaCricoid pressure before intubationInflate endotracheal tube cuff Appropriate dose anti-cholinergic drugsInjecte non-depolarizing muscle relaxants before

17、Succinylcholin 严重创伤病人的麻醉22Method of general anesthesia 严2 drugs of anesthesia Induction2.1 intravenous anestheticdrugs of little effect on blood pressure are usually selected ,such asetomidateMidazolamgamma OH） Ketamine it is suitable to hypotension2.2 muscle relaxantnot directly lower blood pressur

18、e，Succinylcholine banned from large areas of contusion in patients with renal dysfunction 严重创伤病人的麻醉232 drugs of anesthesia Inductio3 keep of general anesthesia 3.1 superficial anesthesia3.2 balanced anesthesia3.3 inhalation anestheticEnfluorine,isoflurane sevenflurane and nitrous oxide3.4intravenous

19、 anesthesiagive priority to ketamine , fentanyl and Sufentanil3.5 muscle relaxant Pancuronium, vecuronium, atracurium and cisatracurium严重创伤病人的麻醉243 keep of general anesthesia 严4 Anesthesia Monitoring objective: understand patients condition and guide treatment 4.1Blood pressure and pulse Pressure de

20、pend on arterial puncture4.2 urine volume4.3 central venous pressure,CVP)and (pulmonary capillary wedge pressure，PCWP)4.4Temperature monitoring 4.5Hematocrit 2530%4.6 arterial blood Lactic Acid4.7blood gas and electrolure严重创伤病人的麻醉254 Anesthesia Monitoring objec5Circulation and respiratory management

21、 during anesthesia5.1Circulation management5.1.1maintain blood pressure blood volume supplement:Crystalloid, colloid, blood, plasmaVasoactive drugs: dopamine315g/kg/min严重创伤病人的麻醉265Circulation and respiratory m5.1.2AntiarrhythmicDrugs slow down the heart rate after ensuring ventilation and oxygen sup

22、ply,and eliminating low blood volume5.1.3 heart function Cedilanid5.1.4Microcirculation Dextran, scopolamine ,654-2, corticosteroids, etc. 严重创伤病人的麻醉275.1.2Antiarrhythmic严重创伤病人的麻醉275.2 Respiratory management General principles: to maintain airway patency and adequate oxygen supply Monitoring SpO2PaO2

23、PETCO2PACO2PaCO2严重创伤病人的麻醉28严重创伤病人的麻醉28胸部创伤病人的麻醉处理危险因素及处理1气胸: 麻醉前需胸腔闭式引流2大血管破裂:导致休克或死亡3心包填塞:麻醉前宜心包穿刺4严重缺氧:可因反常呼吸、气胸、合并颅脑损伤、肺挫伤及低血压等引起-对肺挫伤者，应严格控制输血输液严重创伤病人的麻醉29胸部创伤病人的麻醉处理危险因素及处理严重创伤病人的麻醉29严重创伤病人的麻醉30严重创伤病人的麻醉30Prevention of postoperative complications 1 disseminated inravascular coagulation1.1Diagnosis 1.1.1Have the cause of DIC, such as shock, infection, trauma, etc. 1.1.2 Multiple bleeding tendency 严重创伤病人的麻醉31Preve