国际创伤生命支持ITLS-05-休克的评估及处理Chapter8-Shock-SC

Chapter8ShockEvaluationandManagementShockEvaluationandManagement

休克的评估及处理Overview概要FourvascularsystemcomponentsofperfusionProgressionofshocksignsandsymptoms休克征状之改变Threecommonclinicalshocksyndromes常见休克种类之征状Hemorrhagicandneurogenicshockpathophysiology

出血性及神经性休克之病理生理2Shock-Overview概要Controllableanduncontrollablehemorrhage,nonhemorrhagicshocksyndromesHemostaticagents凝血剂Currentindicationsforfluidadministration

补充体液的指标3Shock-Shock休克Shock-4Perfusionoftissueswithoxygen(组织灌注,electrolytes(电解质),glucose(血糖份),andfluid(体液)becomesinadequate.PreparedbyHarrisLam(A&ETrainingCentre,R&TSKH)5“Fick”Principle空气中的氧气注入人体细胞可用”FickPrinciple”说明如下：畅通的气道Airway

足够的呼吸Breathing

有效的血循环Circulation红血球释放氧气到各细胞OnloadOxygenDeliveryOxygenOffloadOxygen“Steadystate”activityNormalPerfusion正常的灌注6Shock-气体交挽心脏血管网络液量NormalPerfusionShock-7HeartRatexStrokeVolume=CardiacOutput

心跳x每次收缩的输出量=心输出量CardiacOutputxPVR=BloodPressure心输出量x血管阻力=血压PerfusionPreservation保存灌注Basicrulesofshockmanagement:Maintainairway维持气道畅通Maintainoxygenationandventilation

维持足够供气及换气Controlbleedingwherepossible制止出血Maintaincirculation维持足够血液循环Adequateheartrateandintravascularvolume

足够之心跳及血量8Shock-ShockProgression休克进程Shock-9Beginswithinjury,

spreadsthroughoutbody,

multisysteminsulttomajororgans开始时身体受伤,继而影响全身,导致各器官受伤害ShockProgression休克进程10Shock-灌注不足无氧呼吸加速缺氧细胞死亡肾上腺分泌增加红血球减少ShockShockisacontinuum.休克一开始后持续发生Signsandsymptomsareprogressive.

征状会慢慢演变出来Manysymptomsduetocatecholamines.

大部征状是因肾上腺素泌造成Cellularprocesshasclinicalmanifestations.当细胞受影响时会有明显临床征状11Shock-ShockCompensatedanddecompensated补尝期及非保尝期:Older,hypertensive,and/orheadinjurycannottoleratehypotensionforevenshorttime年老,血压高及/或头部受伤者都不能短暂处于血压低12Shock-PreparedbyHarrisLam(A&ETrainingCentre,R&TSKH)13HypovolemicShockCompensatedprogression补尝期进程Weaknessandlightheadedness软弱及头晕Thirst口渴Pallor苍白Tachycardia心跳加速Diaphoresis皮肤浅湿泠Tachypnea呼吸加速Urinaryoutputdecreased尿量减少Peripheralpulsesweakened周围脉搏减弱14Shock-ShockProgressionCompensatedtodecompensated由补尝期到非保尝期Initialriseinbloodpressureduetoshunting血压升高Initialnarrowingofpulsepressure脉搏压收窄Diastolicraisedmorethansystolic收缩压上升较舒张压上怏Prolongedhypoxialeadstoworseningacidosis酸中毒Ultimatelossofcatecholamineresponse对肾上腺无返应Compensatedshocksuddenly“crashes”补尝失败15Shock-HypovolemicShockDecompensatedprogression非保尝期进程Hypotension血压低Hypovolemiaand/ordiminishedcardiacoutputAlteredmentalstatus意识紊乱Decreasedcerebralperfusion脑组织灌注,

acidosis,hypoxia,catecholaminestimulationCardiacarrest心跳停止CriticalorganfailureSecondarytobloodorfluidloss,hypoxia(缺氧),arrhythmia(心律不齐)16Shock-ClassicShockPatternEarlyshock早期休克15–25%bloodvolume失血15-20%Tachycardia心跳加速Pallor苍白Narrowedpulsepressure脉搏压收窄Thirst口渴Weakness软弱Delayedcapillaryrefill

毛细管再充时问延迟Lateshock后早期休克17Shock-30–45%bloodvolume失血130-45%Hypotension血压下降Firstsignof“lateshock”后早期休克时最早出现征状Weakor

noperipheralpulse

周围脉搏变弱或丧失Prolongedcapillaryrefill毛细管再充时问进一步延迟长CapillaryRefill

毛细管再充时问进一步延迟长18Shock-CapillaryRefill19Shock-Tachycardia心跳加速Earlysignofillness—mostcommon最见的疾患早期征状:Transientrisewithanxiety,quicklytonormal间歇性DetermineunderlyingcauseEarlysignofshock为早期休克征状:Suspecthemorrhage怀疑出血:sustainedrate>100Redflagforshock休克的危俭状态:pulserate>120Notachycardiadoesnotruleoutshock.无脉搏加速并不能排徐休克“Relativebradycardia”相对性心跳过慢20Shock-CapnographyLevelofexhaledCO2aswaveform(EtCO2)呼气CO2含量Typically~35–40mmHgFallingEtCO2

Hyperventilation呼吸过速ordecreasedoxygenationEtCO2<20mmHgMayindicatecirculatorycollapse血循环失败Warningsignofworseningshock休克变差讯号21Shock-ShockSyndromesLow-volumeshock血溶积减少性休克AbsolutehypovolemiaHemorrhagic

orotherfluidlossMechanicalshock机械性休克22Shock-Obstructive阻塞性CardiactamponadeTensionpneumothoraxMassivepulmonaryembolismCardiogenic心原性MyocardialcontusionMyocardialinfarctionHigh-spaceshock容量增大性休克RelativehypovolemiaNeurogenicshock精神性VasovagalsyncopeSepsis毒血性Drugoverdose药物中毒Low-VolumeShockAbsolutehypovolemia血溶积减少Largevascularspace血管内容积Bloodvesselsholdmorethanactuallyflows.Catecholaminescausevasoconstriction血管收缩.Minorbloodloss:vasoconstrictionsufficientSeverebloodloss:vasoconstrictioninsufficientClinicalpresentation临床表现“Thready”pulse脉搏柔弱,tachycardia脉速,pale苍白,flatneckveins颈静脉扁平23Shock-High-SpaceShockRelativehypovolemia相对性低血溶量“Vasodilatoryshock”血管澎胀LargeintactvascularspaceInterruptionofsympatheticnervoussystem交感神经受阻Lossofnormalvasoconstriction失去血管收缩力;

vascularspacebecomesmuch“toolarge”血管内容量增大Clinicalpresentation临床表现Variesdependentontypeofhigh-spaceshock24Shock-High-SpaceShockTypesNeurogenicshock神经性休克Mosttypicallyafterinjurytospinalcord脊椎受伤Injurypreventsadditionalcatecholaminerelease阻碍肾上腺分泌CirculatingcatecholaminesmaybrieflypreserveSepsissyndrome细菌入血Drugoverdoses药物过量andchemicalexposures中毒Suchasnitroglycerin,calciumchannelblockers,antihypertensivemedications降血压药,cyanide山埃25Shock-High-SpaceShockNeurogenicshockHypotensionHeartratenormal

orslowSkinwarm,dry,pinkParalysisordeficitNochestmovement

无胸部起伏,simplediaphragmatic

隔式呼吸Drugoverdose,sepsis26Shock-TachycardiaSkinpaleorflushed血色潮红Flatneckveins

颈静脉扁平MechanicalShock

机械性休克ObstructsbloodflowtoorthroughheartSlowsvenousreturn静脉回流Decreasescardiacoutput心输出ClinicalpresentationDistendedneckveinsCyanosisCatecholamineeffects肾上腺素刺激Pallor,tachycardia,diaphoresis27Shock-CurrentShockResearchPrehospitalmanagementresearchHemorrhagicshockduetotraumaand

traumaticbraininjuryinprehospitalenvironmentIntravenoussolutionsHypertonicsaline高浓度盐水maysupportvascularstatusbypullinginterstitialfluidintovascularspace.Artificialblood人造血productscarryoxygen.28Shock-PASGResearchPneumaticantishockgarment抗休克裤Uncontrollableinternalhemorrhage

duetopenetratinginjury胸部受伤Mayincreasemortality,

especiallyintrathoracicProbablyincreasesbleeding,

deathduetoexsanguination29Shock-FluidAdministrationUncontrollablehemorrhageMayincreasebleedinganddeathDilutesclottingfactors凝血因子减少Earlybloodtransfusion输血inseverecasesIVfluidscarryalmostnooxygenMoribundtraumapatientsFluidmaybeindicatedtomaintainsomecirculationLocalmedicaldirection30Shock-FluidAdministrationUncontrollablehemo