荟萃10休克课件

Ourgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime休克OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?各种强烈的致病因子作用于机体引起的微循环血液灌流量急剧减少导致机体重要器官血液灌流减少和细胞器官功能障碍而引起的全身性危重病理过程。一、概念OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime休克的分类---原因分类脱水性休克烧伤性休克创伤性休克失血性休克感染性休克过敏性休克心源性休克神经源性休克OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime病因和分类?一、病因分类?失血性休克(Hemorrhagicshock)?外伤、消化道溃疡等疾病引起的急性大失血等。?体液大量丢失使有效循环血量锐减，也可导致休克。常见于剧烈呕吐、腹泻、肠梗阻、大量出汗等。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?休克的发生与否取决于机体血容量丢失的速度和程度，一般15分钟内失血少于全血量的10%时，机体能够通过代偿保持血压和组织血液灌流量处于稳定状态，但若迅速失血超过总血量的20%左右，即可引起休克，超过总血量的50%则往往迅速导致死亡。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?脱水性休克：由于呕吐、腹泻、肠梗阻、大出汗导致丢失体液，引起有效循环血量锐减。微循环灌注减少。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?创伤性休克(Traumaticshock)?严重创伤可导致创伤性休克，这种休克的发生与疼痛和失血有关。?烧伤性休克(Burnshock)?大面积烧伤伴有血浆大量渗出时可引起烧伤性休克。此型休克的发生与血容量减少及疼痛有关。晚期若合并感染,可发展为败血症性休克。?以上四种休克的共同环节都有血容量降低，可统称为低血容量性休克。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?感染性休克(Infectiousshock)?严重感染引起的休克称为感染性休克。最常见的致病原因为革兰氏阴性菌感染，约占感染性休克病因的70－80%。细菌内毒素在此型休克中具有重要作用，故又称内毒素性休克（endotoxicshock）。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?心源性休克(Cardiogenicshock)?大面积急性心肌梗塞、弥漫性心肌炎、心包填塞、严重心律失常等疾病均可使心泵功能严重障碍，心输出量急剧减少，有效循环血量和组织灌流量下降而引起休克，称为心源性休克。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?过敏性休克(Anaphylacticshock)?某些药物（如青霉素）、血清制剂或疫苗等过敏可引起过敏性休克，属I型变态反应。发病机制与IgE及抗原在肥大细胞表面结合，引起组胺和缓激肽等血管活性物质入血，造成血管床容积扩张，毛细血管通透性增加有关OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?神经源性休克(Neurogenicshock)?高位脊髓麻醉或损伤、剧烈疼痛，通过影响交感神经的缩血管功能，降低血管紧张性，使外周血管扩张、血管容量增加、循环血量相对不足，从而引起神经源性休克。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime二、按休克发生的始动环节分类血容量充足心泵功能正常血管容量正常正常血液循环OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime三、按休克发生的始动环节分类血容量??低血容量性休克心泵功能障碍心源性休克血管容量??血管源性休克休克失血、失液、烧伤、创伤、大出汗、腹泻、呕吐等，血容量剧减，静脉回流减少，心输出量减少，血压降低，交感兴奋，外周血管收缩，组织灌流更少。急性心肌梗死、心肌缺血再灌注损伤，心外科手术等心泵功能失常，灌注锐减血管活性物质扩张血管，外周血不能回流，有效循环下降，组织灌流不足OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime休克的发病过程和机制休克时微循环的变化休克发生的机制OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime休克早期(缺血缺氧期)休克期(淤血缺氧期)休克晚期(微循环衰竭期)休克的分期和微循环的变化(Thestagesandmechanismsofmicrocirculatorydisorderofshock)OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime(一)缺血缺氧期(Ischemichypoxicstage)OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime1.缺血缺氧期微循环变化(thealterationofmicrocirculation)?微循环小血管持续收缩?毛细血管前阻力↑↑>后阻力↑?关闭的毛细血管增多?血液经动–静脉短路和直捷通路迅速流入微静脉?灌流特点：少灌少流、灌少于流OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.ThemostcertainwaytosucceedisalwaystotryjustonemoretimeOurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime2.微循环缺血缺氧的机制(themechanismofmicrocirculatoryischemichypoxia)OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime失血、创伤等交感-肾上腺髓质系统兴奋微血管显著收缩v皮肤、骨骼肌、腹腔内脏微血管的α受体动-静脉短路的β受体动-静脉短路开放vCA大量释放OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime3.微循环缺血缺氧对机体的影响theeffectofMicrocirculatoryischemichypoxiaOurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime①回心血量↑自身输血:儿茶酚胺等缩血管物质大量释放，使微静脉、小静脉等容量血管收缩，迅速而短暂地增加回心血量，以利于维持动脉血压。自身输液:由于毛细血管前阻力比后阻力增加显著，使毛细血管内压降低，因而就有较多的组织间液进入毛细血管，致使回心血量增加(1)有利于维持动脉BP醛固酮和ADH↑:肾小管重吸收钠水↑OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?②心输出量↑(心源性休克除外)?心率↑，收缩力↑，回心血量↑③外周阻力↑OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime(2)有利于心脑血供①脑血管:交感缩血管纤维分布稀疏；α受体密度低②冠状动脉:β受体兴奋→扩血管效应强于α受体兴奋→缩血管效应③BP维持正常OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime4.微循环缺血期的主要表现(manifestationsofmicrocirculatoryischemiastage)OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime交感-肾上腺髓质系统兴奋儿茶酚胺↑出冷汗腹腔内脏、皮肤小血管收缩皮肤缺血汗腺分泌↑中枢神经系统兴奋外周阻力↑BP(–)脉搏细速脉压差↓肾缺血少尿面色苍白四肢冰冷烦躁不安心率↑心肌收缩力↑OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?此期时抢救的最好时期，如能及时采取输血、输液等措施，则休克可停止发展，逐渐恢复。但由于此期血压不降，容易麻痹，如得不到有效治疗，则很快发展进入休克期。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime(二)淤血缺氧期(Stagnanthypoxicstage)OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime1.淤血期微循环变化?前阻力血管扩张，微静脉持续收缩?前阻力小于后阻力?毛细血管开放数目增多灌流特点:灌而少流，灌大于流OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.ThemostcertainwaytosucceedisalwaystotryjustonemoretimeOurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime2.微循环淤血的机制(themechanismofmicrocirculatorystasis)OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?酸中毒?局部扩血管物质堆积?内毒素的作用?血细胞黏附、聚集加重，血黏度↑OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime酸中毒?在休克早期，由于微动脉、后微动脉、毛细血管前括约肌强烈收缩，致使组织微循环持续缺血缺氧，因此这些部位细胞无氧酵解增强，乳酸大量堆积，引起代谢性酸中毒。?在酸性环境中，微动脉、后微动脉和毛细血管前扩约肌的耐受性较差，对儿茶酚胺的反应性降低，以致收缩逐渐减弱,甚或扩张。与前阻力血管的变化相比，微静脉在酸性环境中的耐受性较强，因而继续收缩，于是毛细血管网大量开放，血液淤滞在微循环中。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime内毒素?除感染性休克外，其它类型休克患者肠道细菌产生的内毒素可通过缺血的肠黏膜而被吸收入血。内毒素通过激活激肽系统，间接引起血管扩张、血管壁通透性增高；同时，内毒素又能激活补体系统，促使肥大细胞、血小板、白细胞等释放组胺，促进微循环淤血的发生。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime血液流变学的改变?休克期白细胞贴壁，黏附于内皮细胞上，加大了毛细血管的后阻力，同时，红细胞发生聚集，血小板粘附聚集，加之血浆外渗，血液粘滞性增加，都造成微循环血流缓慢，泥化、淤滞，使毛细血管后阻力明显增加，加剧微循环的淤血状态。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime扩张血管物质堆积?如组胺、激肽、NO、内啡肽、TNF等OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime3.微循环淤血对机体的影响(theeffectofmicrocirculatorystasis)OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?血液淤滞在微循环?血浆外渗至组织间隙?血细胞黏附、聚集、血液浓缩(1)有效循环血量进行性↓(2)血流阻力进行性增大↑OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?有效循环血量↓?外周阻力↓(3)BP进行性↓(4)重要器官供血↓、功能障碍?心肌舒缩功能障碍，心输出量↓OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime4.微循环淤血期的主要表现(thesymptomofmicrocirculatorystagnantstage)OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime微循环淤血肾血流量↓心输出量↓回心血量↓BP↓脑缺血神志淡漠肾淤血发绀、花斑皮肤淤血少尿、无尿OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?休克期微循环的变化仍然处于可逆性阶段，只要得到及时正确的救治，病人仍可康复。否则，病情进一步恶化进入休克晚期。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime(Microcirculationfailurestage)(三)微循环衰竭期OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime1.衰竭期微循环变化(thealterationofmicrocirculationfailureofshock)?微循环血管麻痹扩张?血细胞黏附聚集加重，微血栓形成?灌流特点:不灌不流，灌流停止OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.ThemostcertainwaytosucceedisalwaystotryjustonemoretimeOurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?１.休克晚期由于血液进一步浓缩，血液粘滞性升高，红细胞聚集，血液处于高凝状态，加之血流速度缓慢，极易导致DIC。２.缺氧、酸中毒和内毒素都可使血管内皮细胞损伤，通过激活XII，启动内源性凝血系统导致DIC的发生。2.微循环衰竭的发生机制(themechanismsofmicrocirculationfailure)OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?３.烧伤、创伤等原因引起的休克，由于组织受损释放出大量组织因子，可激活外源性凝血系统导致DIC。?４.异型输血等情况所致的休克中，红细胞大量破坏，释放出磷脂和二磷酸腺苷(ADP)，促进凝血过程。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?５.休克时，体内生成大量促凝物质，如血小板活化因子、血栓素(TXA2)等，可促进血小板和红细胞聚集，加速DIC形成。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime3.微循环衰竭对机体的影响(theeffectofmicrocirculationfailure)?１.微血栓形成阻塞微循环通道，进一步减少回心血量。?２.DIC时由于大量凝血因子的消耗及继发性纤溶亢进，患者易发生出血，使血容量减少，加重微循环障碍。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime３.凝血和纤溶过程的某些产物如纤维蛋白降解产物和某些补体成分，增加了血管通透性，加重了微血管舒缩功能紊乱。４.器官栓塞、梗死，加重了器官功能障碍，甚至发生多器官功能衰竭。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime4.微循环衰竭期的临床表现(manifestationsofmicrocirculationfailure)休克期症状进一步加重，可出现DIC的表现，如皮下出血和重要脏器功能衰竭。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime三、重要器官功能衰竭（一）休克肾shockkidney?休克早期，由于肾血管收缩，肾血流量减少，肾小球滤过率降低，可发生功能性肾功能衰竭(functionalrenalfailure)，不伴有肾小管坏死，表现为少尿、无尿，氮质血症等。?休克后期，肾小管持续缺血、缺氧而发生坏死，肾小球、肾间质毛细血管中由于微血栓形成而滤过功能严重障碍，从而发生器质性肾功能衰竭(parenchymalrenalfailure)，出现严重的内环境紊乱，使休克进一步恶化。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime（二）急性呼吸衰竭——休克肺shocklung1、典型病理变化：肺充血、水肿、血栓形成及肺不张、肺透明膜形成。2、机制：肺泡-毛细血管膜损伤→弥散障碍和通气血流比例（V/Q）失调3、典型临床表现：进行性低氧血症和呼吸困难。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime（三）心功能障碍1、早期：心功能无明显影响2、中晚期：心功能下降，并可发生心肌局灶性出血和心内膜下出血。机制：①冠状动脉血流量减少②酸中毒和高血钾使心肌收缩力减弱③心肌抑制因子MDF的作用④心肌内DIC⑤细菌毒素对心功能的抑制OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime（四）脑功能障碍休克早期，血液重新分布使脑血流量基本正常，但由于交感神经兴奋，患者表现为烦躁不安。随着休克的发展，血压的进行性下降，脑内DIC形成，患者可因脑血流量减少而出现神智淡漠、反应迟钝，嗜睡、甚至昏迷。严重者由于脑能量代谢障碍，可出现脑水肿和颅内高压。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime（五）消化道和肝功能障碍肠屏障功能削弱，可引起肠源性感染内毒素血症肝淤血缺血→肝功能障碍→肝解毒功能下降糖异生能力↓乳酸利用↓加重酸中毒OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?（六）多器官功能衰竭(multipleorganfailure,MOF)是指在严重感染、失血、创伤或休克过程中,在短时间内出现两个或两个以上的重要器官功能衰竭。休克晚期常并发MOF。MOF是休克致死的重要原因，而且衰竭的器官越多，死亡率也越高。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime休克的防治原则一、病因学防治二、发病学治疗?1、纠正酸中毒：原因：（1）影响血管活性药物的疗效（2）影响心肌收缩力（3）引起高血钾OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?2、扩充血容量：补充血容量是治疗休克的根本措施。补液的原则：需多少，补多少补液量应等于：失液量+血管床容积增加量+血浆外渗量休克1期：及时的补液就可纠正休克。休克2期：在补液的同时应注意血管活性药物的应用OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?3、合理使用血管活性药物扩血管药物：在充分扩容的基础上使用，适用于低血容量性休克、低排高阻型感染性休克和心源性休克。缩血管药物：适用于过敏性休克和神经源性休克，及高排低阻型感染性休克。当血压过低时，扩容又不能及时进行，应使用缩血管药物升压。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?4、细胞损伤的防治（1）极化液：葡萄糖-胰岛素-氯化钾（GIK）液（2）糖皮质激素：此外消炎痛可抑制环氧化酶，保护膜磷脂。（3）ATP-MgCL2：促进细胞摄取ATP?5、体液因子拮抗剂的使用?6、防止器官功能衰竭OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime休克OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?各种强烈的致病因子作用于机体引起的微循环血液灌流量急剧减少导致机体重要器官血液灌流减少和细胞器官功能障碍而引起的全身性危重病理过程。一、概念OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime休克的分类---原因分类脱水性休克烧伤性休克创伤性休克失血性休克感染性休克过敏性休克心源性休克神经源性休克OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime病因和分类?一、病因分类?失血性休克(Hemorrhagicshock)?外伤、消化道溃疡等疾病引起的急性大失血等。?体液大量丢失使有效循环血量锐减，也可导致休克。常见于剧烈呕吐、腹泻、肠梗阻、大量出汗等。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?休克的发生与否取决于机体血容量丢失的速度和程度，一般15分钟内失血少于全血量的10%时，机体能够通过代偿保持血压和组织血液灌流量处于稳定状态，但若迅速失血超过总血量的20%左右，即可引起休克，超过总血量的50%则往往迅速导致死亡。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?脱水性休克：由于呕吐、腹泻、肠梗阻、大出汗导致丢失体液，引起有效循环血量锐减。微循环灌注减少。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?创伤性休克(Traumaticshock)?严重创伤可导致创伤性休克，这种休克的发生与疼痛和失血有关。?烧伤性休克(Burnshock)?大面积烧伤伴有血浆大量渗出时可引起烧伤性休克。此型休克的发生与血容量减少及疼痛有关。晚期若合并感染,可发展为败血症性休克。?以上四种休克的共同环节都有血容量降低，可统称为低血容量性休克。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?感染性休克(Infectiousshock)?严重感染引起的休克称为感染性休克。最常见的致病原因为革兰氏阴性菌感染，约占感染性休克病因的70－80%。细菌内毒素在此型休克中具有重要作用，故又称内毒素性休克（endotoxicshock）。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?心源性休克(Cardiogenicshock)?大面积急性心肌梗塞、弥漫性心肌炎、心包填塞、严重心律失常等疾病均可使心泵功能严重障碍，心输出量急剧减少，有效循环血量和组织灌流量下降而引起休克，称为心源性休克。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?过敏性休克(Anaphylacticshock)?某些药物（如青霉素）、血清制剂或疫苗等过敏可引起过敏性休克，属I型变态反应。发病机制与IgE及抗原在肥大细胞表面结合，引起组胺和缓激肽等血管活性物质入血，造成血管床容积扩张，毛细血管通透性增加有关OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?神经源性休克(Neurogenicshock)?高位脊髓麻醉或损伤、剧烈疼痛，通过影响交感神经的缩血管功能，降低血管紧张性，使外周血管扩张、血管容量增加、循环血量相对不足，从而引起神经源性休克。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime二、按休克发生的始动环节分类血容量充足心泵功能正常血管容量正常正常血液循环OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime三、按休克发生的始动环节分类血容量??低血容量性休克心泵功能障碍心源性休克血管容量??血管源性休克休克失血、失液、烧伤、创伤、大出汗、腹泻、呕吐等，血容量剧减，静脉回流减少，心输出量减少，血压降低，交感兴奋，外周血管收缩，组织灌流更少。急性心肌梗死、心肌缺血再灌注损伤，心外科手术等心泵功能失常，灌注锐减血管活性物质扩张血管，外周血不能回流，有效循环下降，组织灌流不足OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime休克的发病过程和机制休克时微循环的变化休克发生的机制OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime休克早期(缺血缺氧期)休克期(淤血缺氧期)休克晚期(微循环衰竭期)休克的分期和微循环的变化(Thestagesandmechanismsofmicrocirculatorydisorderofshock)OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime(一)缺血缺氧期(Ischemichypoxicstage)OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime1.缺血缺氧期微循环变化(thealterationofmicrocirculation)?微循环小血管持续收缩?毛细血管前阻力↑↑>后阻力↑?关闭的毛细血管增多?血液经动–静脉短路和直捷通路迅速流入微静脉?灌流特点：少灌少流、灌少于流OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.ThemostcertainwaytosucceedisalwaystotryjustonemoretimeOurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime2.微循环缺血缺氧的机制(themechanismofmicrocirculatoryischemichypoxia)OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime失血、创伤等交感-肾上腺髓质系统兴奋微血管显著收缩v皮肤、骨骼肌、腹腔内脏微血管的α受体动-静脉短路的β受体动-静脉短路开放vCA大量释放OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime3.微循环缺血缺氧对机体的影响theeffectofMicrocirculatoryischemichypoxiaOurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime①回心血量↑自身输血:儿茶酚胺等缩血管物质大量释放，使微静脉、小静脉等容量血管收缩，迅速而短暂地增加回心血量，以利于维持动脉血压。自身输液:由于毛细血管前阻力比后阻力增加显著，使毛细血管内压降低，因而就有较多的组织间液进入毛细血管，致使回心血量增加(1)有利于维持动脉BP醛固酮和ADH↑:肾小管重吸收钠水↑OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?②心输出量↑(心源性休克除外)?心率↑，收缩力↑，回心血量↑③外周阻力↑OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime(2)有利于心脑血供①脑血管:交感缩血管纤维分布稀疏；α受体密度低②冠状动脉:β受体兴奋→扩血管效应强于α受体兴奋→缩血管效应③BP维持正常OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime4.微循环缺血期的主要表现(manifestationsofmicrocirculatoryischemiastage)OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime交感-肾上腺髓质系统兴奋儿茶酚胺↑出冷汗腹腔内脏、皮肤小血管收缩皮肤缺血汗腺分泌↑中枢神经系统兴奋外周阻力↑BP(–)脉搏细速脉压差↓肾缺血少尿面色苍白四肢冰冷烦躁不安心率↑心肌收缩力↑OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?此期时抢救的最好时期，如能及时采取输血、输液等措施，则休克可停止发展，逐渐恢复。但由于此期血压不降，容易麻痹，如得不到有效治疗，则很快发展进入休克期。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime(二)淤血缺氧期(Stagnanthypoxicstage)OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime1.淤血期微循环变化?前阻力血管扩张，微静脉持续收缩?前阻力小于后阻力?毛细血管开放数目增多灌流特点:灌而少流，灌大于流OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.ThemostcertainwaytosucceedisalwaystotryjustonemoretimeOurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime2.微循环淤血的机制(themechanismofmicrocirculatorystasis)OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?酸中毒?局部扩血管物质堆积?内毒素的作用?血细胞黏附、聚集加重，血黏度↑OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime酸中毒?在休克早期，由于微动脉、后微动脉、毛细血管前括约肌强烈收缩，致使组织微循环持续缺血缺氧，因此这些部位细胞无氧酵解增强，乳酸大量堆积，引起代谢性酸中毒。?在酸性环境中，微动脉、后微动脉和毛细血管前扩约肌的耐受性较差，对儿茶酚胺的反应性降低，以致收缩逐渐减弱,甚或扩张。与前阻力血管的变化相比，微静脉在酸性环境中的耐受性较强，因而继续收缩，于是毛细血管网大量开放，血液淤滞在微循环中。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime内毒素?除感染性休克外，其它类型休克患者肠道细菌产生的内毒素可通过缺血的肠黏膜而被吸收入血。内毒素通过激活激肽系统，间接引起血管扩张、血管壁通透性增高；同时，内毒素又能激活补体系统，促使肥大细胞、血小板、白细胞等释放组胺，促进微循环淤血的发生。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime血液流变学的改变?休克期白细胞贴壁，黏附于内皮细胞上，加大了毛细血管的后阻力，同时，红细胞发生聚集，血小板粘附聚集，加之血浆外渗，血液粘滞性增加，都造成微循环血流缓慢，泥化、淤滞，使毛细血管后阻力明显增加，加剧微循环的淤血状态。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime扩张血管物质堆积?如组胺、激肽、NO、内啡肽、TNF等OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime3.微循环淤血对机体的影响(theeffectofmicrocirculatorystasis)OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?血液淤滞在微循环?血浆外渗至组织间隙?血细胞黏附、聚集、血液浓缩(1)有效循环血量进行性↓(2)血流阻力进行性增大↑OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?有效循环血量↓?外周阻力↓(3)BP进行性↓(4)重要器官供血↓、功能障碍?心肌舒缩功能障碍，心输出量↓OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime4.微循环淤血期的主要表现(thesymptomofmicrocirculatorystagnantstage)OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime微循环淤血肾血流量↓心输出量↓回心血量↓BP↓脑缺血神志淡漠肾淤血发绀、花斑皮肤淤血少尿、无尿OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?休克期微循环的变化仍然处于可逆性阶段，只要得到及时正确的救治，病人仍可康复。否则，病情进一步恶化进入休克晚期。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime(Microcirculationfailurestage)(三)微循环衰竭期OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime1.衰竭期微循环变化(thealterationofmicrocirculationfailureofshock)?微循环血管麻痹扩张?血细胞黏附聚集加重，微血栓形成?灌流特点:不灌不流，灌流停止OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.ThemostcertainwaytosucceedisalwaystotryjustonemoretimeOurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?１.休克晚期由于血液进一步浓缩，血液粘滞性升高，红细胞聚集，血液处于高凝状态，加之血流速度缓慢，极易导致DIC。２.缺氧、酸中毒和内毒素都可使血管内皮细胞损伤，通过激活XII，启动内源性凝血系统导致DIC的发生。2.微循环衰竭的发生机制(themechanismsofmicrocirculationfailure)OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?３.烧伤、创伤等原因引起的休克，由于组织受损释放出大量组织因子，可激活外源性凝血系统导致DIC。?４.异型输血等情况所致的休克中，红细胞大量破坏，释放出磷脂和二磷酸腺苷(ADP)，促进凝血过程。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime?５.休克时，体内生成大量促凝物质，如血小板活化因子、血栓素(TXA2)等，可促进血小板和红细胞聚集，加速DIC形成。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime3.微循环衰竭对机体的影响(theeffectofmicrocirculationfailure)?１.微血栓形成阻塞微循环通道，进一步减少回心血量。?２.DIC时由于大量凝血因子的消耗及继发性纤溶亢进，患者易发生出血，使血容量减少，加重微循环障碍。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemoretime３.凝血和纤溶过程的某些产物如纤维蛋白降解产物和某些补体成分，增加了血管通透性，加重了微血管舒缩功能紊乱。４.器官栓塞、梗死，加重了器官功能障碍，甚至发生多器官功能衰竭。OurgreatestweaknessliesinOurgreatestweaknessliesingivingup.Themostcertainwaytosucceedisalwaystotryjustonemore