外科休克(双)课件

外科休克

Surgicalshock2006-12-11HUYIN第一节概论休克SHOCK:

机体有效循环血容量减少、组织灌注不足，细胞代谢紊乱和功能受损的综合征本质：氧供障碍\需求增加→恢复有效供氧2006-12-11HUYIN现代的观念序贯性事件亚临床的灌注不足——￫多器官功能障碍(MODS)或衰竭(MOF)2006-12-11HUYIN分类心源性休克Cardiogenicshock低血容量性休克Hypovolemicshock感染中毒性休克Toxicshock过敏性休克Allergicshock神经性休克Nervousshock2006-12-11HUYINConsiderations

Majorclassesofshockinclude:Cardiogenicshock

(associatedwithheartproblems)Hypovolemicshock

(causedbyinadequatebloodvolume)Anaphylacticshock

(causedbyallergicreaction)Septicshock

(associatedwithinfections)Neurogenicshock

(causedbydamagetothenervoussystem)2006-12-11HUYINCauses

Heartproblems(suchasheartattackorheartfailure)Lowbloodvolume(aswithheavybleedingordehydration)Changesinbloodvessels(aswithinfectionorsevereallergicreactions)Shockisoftenassociatedwithheavyexternalorinternalbleedingfromaseriousinjury.Spinalinjuriescanalsocauseshock.Toxicshocksyndromeisanexampleofatypeofshockfromaninfection.2006-12-11HUYIN病理生理

微循环变化

微循环收缩期

periodofmicrocirculatorycontraction微循环扩张期

microcirculatoryexpandingperiod微循环衰竭期

microcirculatoryfailure2006-12-11HUYIN病理生理

微循环收缩期选择性血管收缩血流重新分配小动、静脉血管平滑肌/毛细血管前括约肌毛细血管后括约肌回心血量下降迷走神经抑制的降低渗透压升高抗利尿激素增加垂体肾上腺皮质激素醛固酮分解代谢2006-12-11HUYIN病理生理

微循环扩张期缺氧动静脉短路/直捷通道开放组织灌注下降更缺氧炎性物质血液滞留血浆外渗休克加重2006-12-11HUYIN病理生理

代谢改变无氧代谢→乳酸盐/丙酮酸盐→代谢性酸中毒能量代谢障碍应急→儿茶酚胺/肾上腺皮质激素→蛋白分解→糖异生血糖升高2006-12-11HUYIN病理生理

介质体液因子神经内分泌因子补体系统激肽系统前列腺素类细胞因子炎性介质（白介素、肿瘤坏死因子氧自由基2006-12-11HUYIN炎症介质释放和缺血再灌注损伤;releaseofmediatorsofinflammationreperfusioninjury2006-12-11HUYIN病理生理

细胞与器官内脏器官的继发性损害

微循环障碍＞1O小时

多系统器官衰竭MSOFMultipleSystemOrganFailure2006-12-11HUYIN肺

内皮细胞—肺间质水肿肺泡上皮细胞——局限性肺不张—————ARDS肾

抗利尿激素\醛固酮——水钠潴留肾皮质肾小管坏死——肾衰心

冠脉血流少——心肌损害脑、胃肠道、肝2006-12-11HUYIN临床表现ClinicalManifestation

休克代偿期

CompensatoryStageofShock﹝早期休克pre-shockstage﹞烦燥口渴面色苍白呼吸增快心率80～120次/分收缩压9.33～12kPa(70～90mmH)脉压2.6～4.0kPa尿量正常\减少(<25ml/h)比重增高中心静脉压(CVP)0.5～10kPa2006-12-11HUYIN临床表现休克抑制期

inhibitorystageofshock

烦渴面色苍黄肢体凉湿\\意识模糊昏迷紫绀心率100～140次/分呼吸>25次/分\\脉博细速>140次/分收缩压6.67～9.33kPa(50～70mmH)\\呼吸窘迫脉压缩小\\收缩压0～6.6kPa尿量减少15～25ml/h比重增高\\尿量0～15ml/h中心静脉压(CVP)<0.49kPa\\或>1.96kPa

2006-12-11HUYINAnxietyoragitationConfusion

Pale,cool,clammyskin2006-12-11HUYINLowornourineoutput

Bluishlipsandfingernails

Dizziness,light-headedness,orfaintness

2006-12-11HUYIN诊断diagnosis病史casehistory临床表现clinicalsituation2006-12-11HUYIN一般监测generamonitoring

意识呼吸脑血流灌注/脑血氧皮温色泽末梢血循环

脉率血压血容量平均动脉压=舒张压+1/3脉压12±0.6kPa休克指数=脉率÷收缩压(mmHg)尿量肾灌流\血容量

2006-12-11HUYIN一般监测generamonitoring精神状态mentalstatus皮肤温度\色泽skintemperature\colour血压bloodpressure脉率pulserate尿量urinaryvolume2006-12-11HUYINFirstAid

Call911forimmediatemedicalhelp.Checktheperson'sairway,breathing,andcirculation.Ifnecessary,beginrescuebreathingandCPR.2006-12-11HUYINFirstAidEvenifthepersonisabletobreatheonhisorherown,continuetocheckrateofbreathingatleastevery5minutesuntilhelparrives.2006-12-11HUYINFirstAidIfthepersonisconsciousandDOESNOThaveaninjurytothehead,leg,neck,orspine,placethepersonintheshockposition.Laythepersononthebackandelevatethelegsabout12inches.DONOTelevatethehead.Ifraisingthelegswillcausepainorpotentialharm,leavethepersonlyingflat.2006-12-11HUYINFirstAidGiveappropriatefirstaidforanywounds,injuries,orillnesses.Keepthepersonwarmandcomfortable.Loosentightclothing.2006-12-11HUYINFirstAidIFTHEPERSONVOMITSORDROOLSTurntheheadtoonesidesoheorshewillnotchoke.DothisaslongasthereisNOsuspicionofspinalinjury.Ifaspinalinjuryissuspected,"logroll"himorherinstead.Keeptheperson'shead,neckandbackinlineandrollhimorherasaunit.2006-12-11HUYIN治疗treatment;一般紧急治疗体位：躯干抬高1O一15°下肢抬高2O一30°呼吸道通畅吸氧保温防暑急救2006-12-11HUYIN2006-12-11HUYINDoNot

DONOTgivethepersonanythingbymouth,includinganythingtoeatordrink.DONOTmovethepersonwithaknownorsuspectedspinalinjury.DONOTwaitformildershocksymptomstoworsenbeforecallingforemergencymedicalhelp.2006-12-11HUYIN治疗

补充血容量

恢复有效循环血量量:

丧失量＋补充量(扩大的毛细血管床质:

晶体

(等渗液、平衡液)

胶体

(全血、血浆、白蛋白)补液恢复的标准

(CVP

脉博、血压、尿量、皮温、神志)2006-12-11HUYIN治疗积极处理原发病2006-12-11HUYIN治疗纠正酸碱失衡低碳酸血症高乳酸血症高碳酸血症碳酸氢钠的应用2006-12-11HUYIN治疗

血管活性物质的应用vasoactivedrugs血管收缩药﹝大计量多巴胺多巴酚丁胺去甲肾上腺素

间羟安﹞血管扩张药﹝酚妥拉明阿托品硝普钠小计量多巴胺﹞强心药

﹝西地兰﹞2006-12-11HUYIN治疗治疗DIC改变微循环

（肝素/氨甲苯酸/阿司匹林）皮质类固醇（五大作用）其他

2006-12-11HUYIN治疗维护重要器官的功能防治感染粘膜屏障↓---→肠菌移位2006-12-11HUYIN第二节低血容量性休克

Hypovolemicshock

定义:

短时间内丢失大量全血、血浆或其它液体，超过机体的代偿限度即导致休克综合征2006-12-11HUYINHypovolemicshock

Hypovolemicshockisanemergencyconditioninwhichseverebloodandfluidlossmakestheheartunabletopumpenoughbloodtothebody.Thistypeofshockcancausemanyorganstostopworking.2006-12-11HUYIN包括:失血性休克(>20%总血量)

静脉曲张出血、肝癌破裂、宫外孕…失液性休克

肠梗阻、烧伤…损伤性休克2006-12-11HUYINCauses,incidence,andriskfactors

Losingabout1/5ormoreofthenormalamountofbloodinyourbodycauseshypovolemicshock.Bloodlosscanbeduetobleedingfromcutsorotherinjuryorinternalbleedingsuchasgastrointestinaltractbleeding.Theamountofbloodinyourbodymaydropwhenyoulosetoomanyotherbodyfluids,whichcanhappenwithdiarrhea,vomiting,burns,andotherconditions.2006-12-11HUYINThegreaterandmorerapidthebloodloss,themoreseveretheshocksymptoms.2006-12-11HUYIN病理血容量骤减神经内分泌心搏加强加快外周/内脏血管收缩保持心脑血供肾水钠储留口渴少尿失液→细胞外液丢失血液浓缩创伤感染2006-12-11HUYINSymptoms

Rapidpulse

Pulsemaybeweak(thready)Rapidbreathing

Anxietyoragitation2006-12-11HUYINCool,clammyskin

Weakness

Paleskincolor(pallor)Sweating,moistskin2006-12-11HUYINDecreasedornourineoutput

Lowbloodpressure

Confusion

Unconsciousness

2006-12-11HUYINtests

CBC

CTscanoranx-rayofsuspectedareasEndoscopy

Echocardiogram(heartultrasound)Rightheart(Swan-Ganz)catheterization--canhelptellthedifferencebetweenhypovolemicandanothertypeofshockcalledcardiogenicshock2006-12-11HUYINGastricendoscopy2006-12-11HUYINSwanGanzcatheterization

2006-12-11HUYINCBC(completebloodcount)Thenumberofredbloodcells(RBCs)Thenumberofwhitebloodcells(WBCs)ThetotalamountofhemoglobininthebloodThefractionofthebloodcomposedofredbloodcells(hematocrit)MCV(meancorpuscularvolume)--thesizeoftheredbloodcellsMCH(meancorpuscularhemoglobin)MCHC(meancorpuscularhemoglobinconcentration)plateletcount2006-12-11HUYIN一、失血性休克和失液性休克治疗﹙一﹚补充血容量

治疗﹙二﹚药物治疗

治疗﹙三﹚病因治疗

2006-12-11HUYINTreatment

Getimmediatemedicalhelp.Inthemeantime,followthesesteps:Keepthepersoncomfortableandwarm(toavoidhypothermia).Havethepersonlieflatwiththefeetliftedupabout12inchestoincreasecirculation.However,ifthepersonhasfromahead,neck,back,orleginjury,leavehimorherinthepositioninwhichtheywerefoundunlessdoingsoposesotherimmediatedanger.2006-12-11HUYINDonotgivefluidsbymouth.Ifpersonishavinganallergicreaction,treattheallergicreaction,ifyouknowhow.Ifthepersonmustbecarried,trytokeephimorherflat,withtheheaddownandfeetliftedup.Stabilizetheheadandneckbeforemovingapersonwithasuspectedspinalinjury.2006-12-11HUYINThegoalofhospitaltreatmenttoreplacebloodandfluids.Anintravenous(IV)linewillbeputintothepersonsarmtoallowbloodorbloodproductstobegiven.Medicinessuchasdopamine,dobutamine,epinephrine,andnorepinephrinemaybeneededtoincreasebloodpressureandtheamountofbloodpumpedoutoftheheart(cardiacoutput).2006-12-11HUYINOthermethodsthatmaybeusedCardiacmonitoring,includingSwan-GanzcathertizationUrinarycathetertocollectandmonitorhowmuchurineisproduced2006-12-11HUYIN补充血容量依据休克的程度或休克指数(血压、cvp)红细胞比积(3O%)血清白蛋白(白蛋白＜3g／dl)2006-12-11HUYIN中心静脉压和动脉压变化的处理原则2006-12-11HUYIN成人(体重50~70公斤)45分钟内平衡盐液(等渗盐水)1000~1500ml中分子右旋糖酐、羟乙基淀粉(<1000ml)血浆、白蛋白2006-12-11HUYIN补液方法:先晶体后胶体交替补液2006-12-11HUYIN药物应用5%碳酸氢钠→酸中毒1O%氯化钾→胃肠梗阻葡萄糖酸钙→大量输血血管活性药高渗盐水→“顽固性”休克5～7﹒5%氯化钠(50ml×8.v.q1/2h)

2006-12-11HUYIN病因治疗非手术止血法三腔管气囊口服硫酸高铁静滴垂体后叶素手术止血法2006-12-11HUYINExpectations(prognosis)

Hypovolemicshockisalwaysamedicalemergency,butthereiswidevariationinbothsymptomsandoutcomesdependingupontheamountofbloodvolumelost,therateofloss,theunderlyingillnessorinjurycausingtheloss,andotherfactors.2006-12-11HUYINIngeneral,patientswithmilderdegreesofshocktendtodobetterthanthosewithmoresevereshock.However,incasesofseverehypovolemicshock,deathispossibleevenwithimmediatemedicalattention.Theelderlyareatincreasedriskofhavingpooroutcomesfromshock.2006-12-11HUYIN二、创伤性休克

traumaticshock病因和预防急性出血炎性肿胀渗出挤压伤心血管功能障碍气胸心包填塞其它

脊瘫2006-12-11HUYIN治疗

输液输血/肺水肿纠正酸碱失衡药物治疗血管活性药利尿剂碳酸氢钠抗生素

创伤处理2006-12-11HUYIN第三节

感染性休克septicshock定义:急性严重感染引起的休克(革兰氏阴性菌革兰氏阳性菌霉菌、病毒)2006-12-11HUYINAlternativenames

Bacteremicshock;Endotoxicshock;Septicemicshock;Warmshock2006-12-11HUYINDefinitionSepticshockisaseriousconditionthatoccurswhenanoverwhelminginfectionleadstolowbloodpressureandlowbloodflow.Thebrain,heart,kidneys,andlivermaynotworkproperlyormayfail.2006-12-11HUYINCauses,incidence,andriskfactors

Septicshockoccursmostoftenintheveryoldandtheveryyoung.Italsooccursinpeoplewhohaveotherillnesses.2006-12-11HUYINCauses,incidence,andriskfactors

Anytypeofbacteriacancausesepticshock.Fungiand(rarely)virusesmayalsocausethecondition.Toxinsreleasedbythebacteriaorfungusmaycause

tissuedamage,andmayleadtolowbloodpressureandpoororganfunction.Manyresearchersbelievethatabnormalbloodclotsinsmallarteriescausethelackofbloodflowandpoororganfunction.2006-12-11HUYIN病理

G¯杆菌→内毒素━━━━━━━━━━┓↓←补体、抗体↓交感神经组胺激肽前列腺素↓↓血管痉挛内皮损伤炎性反应↓↓微循环障碍代谢紊乱器官功能障碍2006-12-11HUYINThetoxinsalsocauseastronginflammatoryresponsefromthebody,whichcontributestosepticshock.

2006-12-11HUYIN全身炎性反应综合征SIRS体温>38OR<36心率>90次/分呼吸急促>20次/分PaCO2<4.3kPa白细胞计数>12*109/L

SystemicInflammatoryResponseSyndrome

2006-12-11HUYINRiskfactorsforsepticshockincludeDiabetes

DiseasesthatweakentheimmunesystemsuchasAIDSLymphomaLeukemiaDiseasesofthegenitourinarysystem,biliarysystem,orintestinalsystemRecentinfectionLong-termuseof

antibioticsRecentsurgery

ormedicalprocedure.2006-12-11HUYINSymptomsHighorverylowtemperature,chillsLightheadednessShortnessofbreathPalpitationsCool,paleextremitiesRestlessness,agitation,lethargy,orconfusionRapidheartrateLowbloodpressure,especiallywhenstandingLowurineoutput(duetokidneyfailure)2006-12-11HUYIN临床表现原有的感染病变(败血症)休克表现冷休克低排高阻型热休克高排低阻型并发系统器官衰竭(DIC、ARDS)

2006-12-11HUYIN临床表现临床表现冷休克热休克神志躁动淡漠嗜睡清醒皮肤色泽苍白紫绀花斑淡红潮红皮肤温度湿冷冷汗温暧干燥毛细血管充盈时间延长1~2秒脉博细速慢博动清楚脉压(kpa)<4>4尿量/h<25