兒科學(xué)交流課件：休克判斷與急診管理

1、休克判斷與急診管理 什么是休克? Shock is a critical condition that results from inadequate tissue delivery of O2 and nutrients to meet tissue metabolic demand. Tissue ischaemic sensitivity - heart, brain, lung: 4-6 min - GI tract, liver, kidney: 45-60 min - muscle, skin: 2-3 hours 休克的生理基礎(chǔ) Unit of life = cell Cells

2、 get energy (ATP) from cellular respiration: O2 + Glucose ATP + water + CO2 No O2 = no energy No energy = no life Remember: Damage to Cell Damage to Tissues Damage to Organ Damage to Body Damage to Organ System Components of tissue oxygen delivery Compensatory Compensated Shock Hypotensive Shock 休克的

3、病理生理機制 影響氧輸送的因素 Preload Contractility Afterload Stroke Volume X Heart Rate Cardiac Output X O2 Content O2 Delivery 影響血流灌注的因素 心泵功能 血容量 血管容積 正正 常常 血血 流流 灌灌 注注 休克的代償機制 Compensation Mechanism AreaSign Increased HRHeartTachycardia Increased SVR Skin Cold, pale, mottled,diaphoretic Peripheral circulation

4、Delayed capillary refill Pulses Weak peripheral pulses, narrow pluses pressure Increased renal and splanchnic vascular resistance Kidney Oliguria (decrease urine output) IntestineVomiting,ileus 休克的失代償機制 Systolic blood pressure: normal range Tissue perfusion: inadequate Maintain normal blood flow to

5、vital organs ( brain, heart) 低血壓休克的機制 Hypotension: Neonatal SBP 60mmHg; Infant SBP 70mmHg; 110 years of age SBP65mmHg 尿量 1ml/kg per hour CVP=812cmH2O ScvO2 70% Lac 70% 監(jiān)護 & 監(jiān)測 & 目標(biāo)導(dǎo)向治療 Lac 組織缺氧/ 糖產(chǎn)出/ 肝衰 目標(biāo) 增加組織灌注、糾正酸中毒 ABG PH 目標(biāo) 液體療法、通氣、糾酸 ScvO2 休克的藥物治療：血管活性藥 種類藥品效果 正性肌力藥 Inotropes Dopamine，多巴胺 Epin

6、ephrine，腎上腺素 Dobutamine，多巴酚丁胺 增加心肌收縮力 快心率 影響SVR 磷酸二酯酶抑制劑 Phosphodiesteras e Milrinone，米力農(nóng) Inamrinone，乳酸米力農(nóng) 降低SVR 增加冠狀動脈血流 增加心肌收縮力 血管擴張劑 Vasodilators Nitroglycerin，硝酸甘油 Nitroprusside，硝普鈉 降低SVR和靜脈張力 升壓藥 Vasopressors Epinephrine( 0.3mcg/kg per min) Norepinephrine，去甲腎上腺素 Dopamine( 10mcg/kg per min) Vasopressin，血管加壓素 增加SVR 增加心肌收縮力 （除外 Vasopressin） 休克管理流程 PEDIATRIC TACHYCARD IA WITH A PULSE AND POOR PERFUSION ALGORITHM PEDIATRIC BRADYCARDI A WITH A PLUS A