休克防治的現(xiàn)代認識課件

1、休克防治的現(xiàn)代認識休克防治的現(xiàn)代認識休克（shock） acute circulatory failure of sufficient magnitude to compromise tissue perfusion,cellular hypoxia and disturption of normal metabolic function休克（shock） acute circulatory 病理生理有效循環(huán) BP 組織灌注 缺O(jiān)2 代謝紊亂 酸中毒 微血栓DIC 各種細胞質膜破裂 細胞自溶 組織損傷 MODS MOF病理生理有效循環(huán) BP 組織灌注 代償機制：加壓反射，交感腎上腺軸興奮，選擇

2、性收縮外周及內臟血管危害因子：酸中毒 舒血管介質（組胺、緩激肽），血細胞聚集，溶酶體膜破裂，酸性水解酶溢出，氧合血紅蛋白解離曲線右移，細胞功能受損代償機制：加壓反射，交感腎上腺軸興奮，選擇性收縮外周及內臟休克的生理模型研究提示tissue hypoxia resulting frompoor tissue perfusion is the basic physiologic defect of all shock syndromes休克的生理模型研究提示tissue hypoxia res傳統(tǒng)分類 cardiogenic shock traumatic shock neurogenic sho

3、ck septic shock傳統(tǒng)分類 cardiogenic shock新分類(1975 MH, Weil)ClassificationHypovolemic 低血容量性Cardiogenic 心源性Distributive 分布性Obstructive 梗阻性新分類(1975 MH, Weil)ClassificatHypovolemicBlood lose 失血 - blood volume lose =20% Injury of solid organs & large vessels Fluid lose 失液 - extracellular fluid burn, bowel ob

4、struction, diarrheakey point - out of circulation Preload Diastolic filling CO (SVR)HypovolemicBlood lose 失血 - blCardiogenicAny type of heart failure 心功能衰竭 Myocardial infarction 心肌梗塞Cardiaomyopathy 心肌病Severe arrhythmia 心律失常CHF 心源性肺水腫 Out & In (flow) 瓣膜疾病 systolic function diastolic function CO Cardi

5、ogenicAny type of heart fDistributiveSeptic shock 感染中毒性休克anaphylactic shock 過敏性休克neurogenic shock 神經源性休克adrenal insufficiency 腎上腺功能低下Key point - redistributed within circulation Preload SVR or (CO) myocardial depression(systolic & diastolic function ) CO DistributiveSeptic shock Obstructive流出(入)道梗阻T

6、ension pneumothorax 張力性氣胸 Pericardial temponade 心包 填塞 diastolic filling diastolic function Pulmonary embolism 肺動脈栓塞 ventricular afterload systolic function 瓣膜疾病Obstructive流出(入)道梗阻Clinical features 臨床表現(xiàn)Early stage 早期 煩躁不安 緊張頭暈 口渴 呼吸淺快 面色蒼白，皮膚濕冷（肢體） 脈搏加快 尿量正?；驕p少 血壓正常 或 升高 或 脈壓差縮小Clinical features 臨床表現(xiàn)

7、EarlyClinical features 臨床表現(xiàn)Decompensation 失代償 神志淡漠 遲鈍 嗜睡 昏迷 呼吸費力 頻數(shù) 或深慢 皮膚蒼白 濕冷 花斑 脈搏細弱 血壓下降 脈壓差縮小 少尿 或 無尿血壓下降 - 休克已進展了 90%Clinical features 臨床表現(xiàn)DecomDiagnosis 診斷Shock suspected 臨床提示 Hypotension 血壓下降 Tachycardia 心動過速 Peripheral hypoperfusion 外周低灌注 Oliguria 少尿 Encephalopathy 神經系統(tǒng)癥狀 Diagnosis 診斷Shock

8、suspDiagnosis 診斷Initial Diagnostic Steps 診斷步驟Directed history & PE 病史和查體 Laboratory: Hb WBC Plt(化驗指標) PT APTT ABG Electrolytes Mg Ca PO4 BUN Cr LactateEKG Chest X-rayDiagnosis 診斷Initial Diagno休克的監(jiān)測1.一般監(jiān)測精神、皮膚 溫度 色澤 血壓脈率 脈率/收縮壓休克指數(shù)，正常0.5 1.0-1.5休克 2.0 嚴重休克尿量=30ml/h休克的監(jiān)測1.一般監(jiān)測2.特殊監(jiān)測1）CVP 5-10cmH2O , 2

9、0 心功能2）PCWP 左房、室及肺靜脈壓 615 mmHg 血容量不足 肺水腫3）CO 及CI COSV*HR=4-6L/min CI=CO/體表面積2.53.5 L/min*m2 4)外周血管阻力 SVR (MAP-CVP)/CO*80 =100-130KPa*S/L 2.特殊監(jiān)測1）CVP 5-10cmH2O , 10:1 異常9）DIC檢測 PLT3” FBG 20%10) Phi = 6.1+log (動脈 HCO3/0.33胃囊生 理鹽水PCO2) 7.357.542.特殊監(jiān)測8)動脈血乳酸 正常11.5mmol/LTherapeutic Principle 治療原則Initial

10、 Management Steps 早期處理Admit to ICU 轉入ICUVenous access and/or CVC 開放大靜脈Arterial catheter 動脈置管測壓EKG monitoring 心電監(jiān)測Pulse oximetry 脈搏血氧飽和度Hemodynamic support(MAP 65 mmHg - SvO2 70% - PAOP = 15 18 mmHg - CI 2.2 L/min/m2 (Septic or traumatic shock 4L/min/m2)Immediate Goals in Shock早期治療目Immediate Goals in

11、 Shock早期治療目標Maintain Oxygen delivery 維持氧輸送 - Hb 10g / dl 糾正貧血 - SaO2 92% 保證氧合 - Supplemental oxygen & mechanical ventilation 氧療 及 機械通氣Immediate Goals in Shock早期治療目Immediate Goals in Shock早期治療目標Reversal of organ dysfunction糾正器官功能障礙Decreasing lactate( 4.0L / min /m2 維持心輸出量Therapy 治療Distributive ShoThe

12、rapy 治療Distributive Shock 分布性休克 Septic Shock 感染中毒性休克 - Identify site of infection & drain, if possible - Antimicrobial agents - ICU monitering & support with fluids vasopressors & inotropic agentsTherapy 治療Distributive ShoTherapy 治療Obstructive Shock 梗阻性休克 Pericardial tamponade 心包填塞 - Pericardiocentesis 心包穿刺 - surgical drainage 外科引流 Tension pneumothorax 張力性氣胸 - thoracic drainage 胸腔閉式引流Therapy 治療Obstructive Shock Therapy 治療Obstructive Shock 梗阻性休克 Pulmonary embolism 肺動脈栓塞 - heparin 肝素 - ventilation/perfusion lung scan 肺核素掃描 - pulmo