急诊医学教学课件：Critical care Medicine1

TheSecondAffiliatedHospitalofNanjingMedicalUniversityTheSecondClinicalMedicalSchoolofNanjingMedicalUniversityCriticalcareMedicineWewilldiscussCriticalcareMedicineMultiplyorgandysfunctionsyndromeAcuterespiratorydistresssyndromeMechanicalventilationShockPoisoningASKQUESTIONS!/art/305163Halfofwhatyouaretaughtinmedicalschoolwillbewrongin10years’time.Andthetroubleisnoneofyourteachersknowwhichhalf.CharlesSidneyBurwell(1893-1967)(aformerdeanofHarvardmedicalschool)Evidence-basedmedicineEBMrequirestheintegrationofthebestresearchevidencewithourclinicalexpertiseandourpatient’suniquevaluesandcircumstances.HowdowepracticeEBM?Thefull-blownpracticeofEBMcomprisesfivesteps:Step1:convertingtheneedforinformation(aboutprevention,diagnosis,prognosis,therapy,etc.)intoananswerablequestion.Step2:trackingdownthebestevidencewithwhichtoanswerthatquestion.Step3:criticallyappraisingthatevidenceforitsvalidityStep4:integratingthecriticalappraisalwithourclinicalexpertiseandwithourpatient’suniquebiology,values,andcircumstancesStep5:evaluatingoureffectivenessandefficiencyinexecutingsteps1–4andseekingwaystoimprovethembothfornexttimeWherecanIfindananswer?KnowingandactingACaseCase:PresentationofCaseA64-year-oldwomanpresentedtotheemergencydepartmentwiththoracicandabdominalpainfor1hour.Pain:Abruptonsetofthoracicandabdominalpainwithasharp,tearingcharacterHermedicalhistoryincludedhypertension.Case:Intheemergencydepartment,T36.8℃，P125bpm，BP220/100mmHg,R30bpm.CLINICALEXAMINATIONOFTHECRITICALLYILLPATIENTRECOGNISINGTHECRITICALLYILLPATIENTWhatdoyouwanttodothemost?ComputedtomographicscanBloodroutinetestPainpillsIVnitroprusside,Ivbeta-blockersOralpillstocontrolbloodpressure.CASECTscanCTofabdominalaortashowsintimalflap(darkline-redarrow)

withtruelumenanteriorlyandfalselumenposteriorlyWhatisthediagnosis?Aorticdissections.hypertensiveurgencyhypertensiveemergencyhypertensivecrisisClassificationManagementTypeAdissections:emergentsurgerytopreventruptureorpericardialeffusion.(morethan50%mortalitywithmedicaltherapy)TypeBdissections:medicaltreatment,unlesscomplicated.Mortalityrateforuntreatedpatientsisreportedtobe1-3%/hourduringthefirst48hoursafterdevelopmentofsymptoms.CASEWheredoyouwhattoputthispatient？Thispatientshadaaortareplacement(10hoursofoperationwith2hoursofCardiopulmonarybypass

)Afterthesurgerywheredoyouwhattoputthispatient？ICUorfloor?1.IntensiveCareUnit2.CriticalCaremonitoring1.IntensiveCareUnit1.1IntroductionIntensivecareunits(ICUs)areforthecareofveryillpatientswithpotentialorestablishedorganfailure.1.2HistoryFlorenceNightingale(1820-1920)wroteabouttheadvantagesofestablishingaseparateareaofthehospitalforpatientsrecoveringfromsurgery.

BjørnAageIbsen(1915–2007)1952poliomyelitisoutbreakinDenmark,2722patientsin6month,with316sufferingrespiratoryparalysis.Positivepressureventilation,enlisting200medicalstudentstomanuallypumpairintothelungs.Criticalcareisayoungspecialtythatisgenerallyconsideredtohavedevelopedfromthesuccessfuluseofinvasiveventilationduringthe1952polioepidemicinCopenhagen.

Ibsen,B."TheAnaesthetist'sViewpointontheTreatmentofRespiratoryComplicationsinPoliomyelitisDuringtheEpidemicinCopenhagen,1952."ProcRSocMed47,no.1(1954):72-4.Themanualartificialrespirationwasdonewithato-and-froabsorbersystem……..Sincewehadtousemedicalstudents,itwasfeltthatthissystemhadsomebuffereffect:In2005,

critical

care

medicinecosts（$81.7billion）represented13.4%ofhospitalcosts,4.1%ofnationalhealthexpenditures,

and0.65%ofthegrossdomesticproduct（GDP）.1.3ClassificationNeonatalIntensiveCareUnit(NICU)PediatricIntensiveCareUnit(PICU)CoronaryCareUnit(CCU)(acuteMI)SurgicalIntensivecareUnit(SICU)(multiplytrauma,majorsurgery)MedicalIntensiveCareUnit(MICU)HighDependencyUnit(HDU)1.4HowtoworkIntegratedplanofmanagement1.5Indicationrequiringorlikelytorequiremechanicalventilatorysupportrequiringsupportoftwoormoreorgansystems(e.g.inotropesandhemofiltration)requiresupportforacutereversiblefailureoforgansystem1.6ContraindicationTerminalcancerPermanentbraindamageTerminalillnessorirreversible1.7DischargeIntheUnitedStates,29.2%ofpatientshadbeentreatedinanICUduringthelastmonthoftheirlives.Currently,mostdeathsinICUsareexpected.DNR,DNI.

stabilizeddeteriorated2.CriticalCaremonitoringNoteverythingthatcountscanbecounted.Andnoteverythingthatcanbecountedcounts.AlbertEinstein2.0MonitoringprinciplesSimplephysicalsignsarejustasimportantasexpensivemonitors.Changesandtrendsaremoreimportantthananysinglemeasurement.Alwaysask'Isitnecessary?',andceasemonitoringassoonaspossible.2.1Neural2.1.1Clinicalmonitor(consciousness,pupilsizeandreactiontolight,reflection,tension)2.1.2Glasgowcomascale2.1.3Intracranialpressure2.1.4Electroencephalography(EEG)2.1.2.Glasgowcomascale**2.1.3Intracranialpressure2.1.4Electroencephalography(EEG)CaseNoresponseaftersurgerySmallPupilDoyouworryaboutthis?CASEAfter4hoursthepatientwasalertandcanfollowedyourordertomoveherfingersandtoes.Butherbloodpressureincreasedfrom110/60mmHgto170/90mmHg，heartrateincreasedfrom80to140beat/minnow.Whatdoyouwanttodo?2.2CirculationMonitoring2.2.1ArterialBloodPressureMonitoring2.2.2CentralVenousPressure2.2.3PulmonaryArteryCatheters2.2.1ArterialBloodPressureMonitoringOnly3%ofthegeneralpractitionersand2%ofthenursesobtainedbloodpressuremeasurementsthatwerereliable

VillegasI,AriasIC,BorteroA,EscobarA.Evaluationofthetechniqueusedbyhealth-careworkersfortakingbloodpressure.Hypertension1995;26:1204–1206.NoninvasiveArterialBloodPressureMonitoringAcceptablevalueinmostsituations.Advantages:lowcost,andsimplicity.Ifthebladderistoosmallforthesizeofthearm,thepressuremeasurementswillbefalselyelevated.Optimalrelationshipsbetweenthewidth(W)andlength(L)ofthecuffbladderandthecircumference(C)oftheupperarm.DirectInvasiveBloodPressureMeasurementDirectbloodpressuremeasurementisperformedwithanintra-arterialcatheter.Real-time:heartbeat-to-heartbeatmeasurementNoneedforKorotkoffsoundsDonotrequirerepeatedinflationanddeflationofacuff.EasyaccessforbloodsamplingCaseYouaskthepatientifshefeelpain.Shenoddedherhead.Yourgive5mgofmorphine.BP80/40mmHg,HR

110/minWhatdoyouwanttodonow?CheckCVPorPCWPDopamine?Fluid?2.2.2CentralVenousPressureReflectstherightventricularfillingpressure.Theabilityoftherightsideofthehearttoacceptandpumpblood.CVP2.2.3PulmonaryArteryCathetersIndicationsforPAcatheter*•Acuteheartfailure•Complexcirculatoryandfluidconditions(massiveresuscitation)•Shock•Diagnosisofpericardialtamponade•Intraoperativemanagement(majorsurgery)•ComplicatedMINormalPulmonaryArteryMeasurementsParameter RangeRightatrialpressure 1–7mmHgRightventricularpressureSystolic 15–25mmHgDiastolic 0–8mmHgPAPSystolic 15–25mmHgDiastolic 8–15mmHgMean 10–20mmHgPCWP(PAOP) 6–12mmHgCardiacoutput 3.5–5.5L/minCardiacindex 2.8–3.2L/min/m2MixedvenousO2saturation(SvO2) 70–80%Rightventricularejectionfraction 80–120mLAbbreviations:PAP=pulmonaryarterypressure;PAOP=pulmonaryarteryocclusionpressure;PCWP=pulmonarycapillarywedgepressure.CaseCVP2mmHg4–10mmHgPCWP5mmHg 6–12mmHgCardiacoutput4L/min 3.5–5.5L/min

Yougive100mloffluidin10minuteandherbloodpressureincreasesto110/60mmHg.NowyoufindSpo2is90%.Whatdoyouwanttodonow?Doabloodgastest.X-rayPhysicalexaminationChecktheventilator.IncreasetheFiO2inventilator.2.3RespiratoryMonitoring2.3.1Oxygensaturation(SpO2)2.3.2Arterialbloodgases2.3.3OxygenTransport2.3.1Oxygensaturation(SpO2)aprobe,attachedtoafingerorearlobe.Spectrophotometricanalysisisusedtodeterminetherelativeproportionsofsaturatedanddesaturatedhemoglobin.2.3.2ArterialbloodgasesPaO2andPaCO2.Acid-basebalanceBloodgas.1pH7.287.350～7.4502PCO265.035.0～45.0mmHg3PO275.080.0～110.0mmHg4BE4-2.0～3.0mmol/L5TCO22422.0～29.0mmol/L7spo289%90-100%CaseNorespiratorysoundintheleftlung.Ventilator:Mode：IPPV

FIO21.0，Tidevolume：200ml，PEEP5cmH2O，Frequency12/minX-ray:atelectasisYouchecktheoralendotrachealtubefinditistoodeepinthemouth.Youpullitouttonormaldepth.Spo2increaseto98%,Pao2350mmHg(FIO20.8).DoyoulikethisPaO2?2.3.3OxygenTransportThemajorfunctionoftheheart,lungsandcirculationistheprovisionofoxygenandothernutrientstothevariousorgansandtissuesofthebody.carbondioxideandtheotherwasteproductsofmetabolismareremoved.Therateofsupplyandremovalshouldmatchthespecificmetabolicrequirementsoftheindividualtissues.Doeslifelikeoxygen？HyperoxiaincreasemortalityKilgannon,J.H.etal.JAMA2010;303:2165-2171Figure.In-HospitalDeathBetweenHyperoxiaandNormoxiaKilgannon,J.H.etal.JAMA2010;303:2165-2171Rincon,F.,J.Kang,M.Maltenfort,M.Vibbert,J.Urtecho,M.K.Athar,J.Jallo,C.C.Pineda,D.Tzeng,W.McBrideandR.Bell."AssociationbetweenHyperoxiaandMortalityafterStroke:AMulticenterCohortStudy."CritCareMed42,no.2(2014):387-96.Case2dayslaterthePaO2decreasesto70mmHgatFIO20.8anditisstill70mmHgatFIO21.0Whatisyourdiagnosis?DiagnosticCriteriaforARDS(2012)*Abbreviations:CPAP,continuouspositiveairwaypressure;FIO2,fractionofinspiredoxygen;PaO2,partialpressureofarterialoxygen;PEEP,positiveend-expiratorypressure.aChestradiographorcomputedtomographyscan.bIfaltitudeishigherthan1000m,thecorrectionfactorshouldbecalculatedasfollows:[PaO2/FIO2(barometricpressure/760)].cThismaybedeliverednoninvasivelyinthemildacuterespiratorydistresssyndromegroup.4weekslaterspo2andBPdropssuddenly,norespiratorysoundinleftlung.FibroticPhasePneumothoraxYouseebubblesinthechesttube.CaseAfter5weeks,tracheostomyatbedside.WhenyoudothetracheostomySuddenlossofresponsivenessECGshowsCardiacarrest.Whatdoyouwanttodo?PleasememorizetheminyourlifetimeCompressionFrequency:atleast100/minCompressiondepth:atleast5cmCompressiontobreathratio30:2,3:1(neonatal)After10minCPR,spontaneouscirculationcomesback.Butshehasnoconsciousness.Whatdoyouwanttodotoresuscitatethebrain?Coolcalmglucoseetc.2.3TemperaturemonitoringCorebodytemperature36.5–37.5°CNormal30%<36.8℃32%>37.6℃38%Coolpatients32°Cto34°C,TheHypothermiaAfterCardiacArrestStudygroup.Mildtherapeutichypo-thermiatoimprovetheneurologicoutcomeaftercardiacarrest.NEnglJMed2002;346:549–556.CaseAfter1day,thispatientisconsciousagain,butshehaveaabdominalpain,andyoufindtheNGtubedrainageiscoffeecolor.Occultbloodtestispositive.2.4Gastricandintestinalmonitoring1.clinicalsignsandsymptoms(bowelsound,occultblood)2.PHofthegastricjuice3.PHofthegastricmucous(pHi)pHi<7.35ischemiaDonotusetoomuchofProton-pumpinhibitor!Youdoabloodroutinetest:WBC20*109/L,band20%HGBis90g/LPLT80*109/L2.5hematologicmonitoring1.bloodroutinetest(RBC,WBC,PLT)2.bloodcoagulationtest(PT,APTT,D-dimmer,fibrinogendegradationproduct)WBCandSystemicinflammatoryresponsesyndromeCase:Doessheneedbloodtransfusion?Restrictivestrategy(transfusionwhenthehemoglobinlevelfellbelow70/L)Liberalstrategy(transfusionwhenthehemoglobinfellbelow90/L).Dateofdownload:4/23/2014Copyright