心血管系統(tǒng)評估課件

心血管系統(tǒng)評估臺大醫(yī)院外科加護(hù)病房陳淑卿督導(dǎo)長心血管系統(tǒng)評估器官/系統(tǒng)在維持生命功能中的角色生命功能組成因素負(fù)責(zé)器官/系統(tǒng)OxygenationandCO2removalVentilation&diffusionCarryingPerfusionLungHgb-O

(circulation)PerfusionPumpVolumeVasculartoneHeartNutrientsintakeDigestion,absorption,regulationPerfusionRegulationG-IHeartLiverNH4removalUreaformationUreaexcretiontransportLiverKidneyHeart(pumping)VolumeH2OFluidbalanceKidney心血管系統(tǒng)評估心血管身體評估--循環(huán)功能心臟功能評估動脈功能評估—

溫度（冰冷）、顏色（發(fā)紺）、脈搏強(qiáng)度(無脈搏)靜脈功能評估--腫脹、發(fā)紺

微血管功能評估--Capillaryrefilling心血管系統(tǒng)評估

心臟功能評估----組織灌流

決定組織灌流之主要三因素Bloodvolume:intravascularfluid，脫水及出血等影響血液容量，可反應(yīng):PCWP、Basalrales---leftheartCVP(JVP)---rightatriumCardiacpumping:心肌收縮能力反應(yīng)::SBP、HR、CardiacOutput/CardiacindexVasculartone反應(yīng):DBP、SVR、PVR處理順序:Volume→pumping→vasculartone心血管系統(tǒng)評估組織灌流不足徵象Brain：changeofLevelOfConsciousnessKidney：U/O↓Heart：myocardialischemiaLung：pooroxygenation→vascularconstrictionLiver：congestion&

心源性肝小葉壞死GItract：ischemicLimbs：pale&cold、poorcapillaryrefilling心血管系統(tǒng)評估循環(huán)功能失常見的癥狀與徵候Lowcardiacoutput：heartfailure、shock、心包填塞等pale、coldlimbs、urineoutput↓、irritablepooractivitytolerance（weak）、pulmonaryedema、dyspnea、rales、limbedemaPulsuspressurenarrow（systolic－diastolic）：正常為50mmHg。congestiveliver&spleenchangeofconsciousnessPalpitation：arrhythmiaChestpain：心肌缺氧、受損心血管系統(tǒng)評估BasicCirculationCardiacoutput=strokevolumeXheartratesstrokevolumePreloadAfterloadcontractility心血管系統(tǒng)評估PreloadAfterloadPreload:TensiononthemusclebeforecontractileconsidertoLVEDP

Afterload:Loadagainstthecontractileforce

considertotheascendingaortasystolicBP

心血管系統(tǒng)評估心血管系統(tǒng)評估心血管系統(tǒng)評估測量：HR、Pulse、BP、CVP(JVP)、

CO、SVR、SVO2、SPO2

（Vitalsignalwaysfirstresponse）外觀：顏色、溫度、矢狀指、水腫、腹水癥狀：病史：檢驗(yàn)：心血管系統(tǒng)評估LowcardiacoutputDecreasedcardiacoutputcausedbycardiacfactorDecreaseincardiacoutputcausedbyperipheralfactors--decreasevenousreturnDecreasebloodvolumeDecreasevenousdilatationObstructionofthelargeveins心血管系統(tǒng)評估highcardiacoutputhighcardiacoutputisalmostalwayscausedbyreducedtotalperipheralresistanceberiberiaeteriovenousfistula(shunt)HyperthyrodismAnemia心血管系統(tǒng)評估心臟評估—HRPMI(pointmaximalimpulse，

localizedin-5intercostalspace)S3、S4:左心衰竭HeartMurmur心血管系統(tǒng)評估評估工具-聽診器、血壓計(jì)、皮尺、

聽診器適用膜面(diaphragm)高頻S1、S2、systolicclicks、腸音鐘面(bell)低頻S3、S4、diastolicmurmur長度30~46cm心血管系統(tǒng)評估

descriptionofheartmurmursIntensity—gradeTiming—early、mind、late(systolicdiastolic)Character—rumbling、blowingShape—crescendo、decrescendoLocationRadiation心血管系統(tǒng)評估心雜音分級gradevolumeThrill1/6非常輕微,僅在特殊狀況聽到無2/6可以清楚聽到無3/6比第二級大聲無4/6比第三級大聲無5/6聽診器部份抵著胸壁即可聽到有6/6聽診器不用抵住胸壁即可聽到有心血管系統(tǒng)評估

脈搏觸診測量適應(yīng)癥：動脈粥狀硬化、用主動脈弓導(dǎo)管(ECMO)、冠狀動脈移植手術(shù)脈搏強(qiáng)弱：無：-、弱：+、正常：++、強(qiáng)：+++)測量位置：anterior(脛前)Apedal(足背)Aposterior(脛後)A心血管系統(tǒng)評估PulseevaluationPulsusalternuspulsusparadoxus：

exaggeratedinspiratoryfall(＞10mmhg)insystolicPulsuspaevusPulsustardusPulsusbisferiencesBoundingPulsus心血管系統(tǒng)評估PulsusparadoxusSevereConstrictivelungdiseasepericardialtamponadeTensionpneumothorax心血管系統(tǒng)評估PulsusalternansAnalterationindiastolicvolumeleadingtobeat-to-beatvariationinpreloadAsignofdecreasedmyocardialcontractility(deletionofthenumberofmyocardialcellscontractingonalternatebeats)SevereLVdysfunction心血管系統(tǒng)評估PulsusbisferensDoublesystolicpulsation心血管系統(tǒng)評估PulsusbisferensHypertrophiccardiomyopathyAorticregurgitation心血管系統(tǒng)評估PulsusparvusWeakupstrokeduetodecreasestrokevolumeHypovolemiaLVfailureAorticormitralstenosisi心血管系統(tǒng)評估

Pulsustardus(遲緩)

DelayupstrokeAorticstenosisi心血管系統(tǒng)評估

BoundingPulsus

HyperkineticcirculationAorticregulationPatentductusarteriosusVasolilation心血管系統(tǒng)評估HyperdynamicpulseAorticregurgitationAVfistulaThyrotoxicosisAnemiaPregnancysepsis心血管系統(tǒng)評估BasicCirculationBloodpressure=cardiacoutputXsystemicresistance收縮壓：左心室射出血量施加於血管璧壓力舒張壓：血液於動脈管腔（璧）所遭受阻力心血管系統(tǒng)評估

血壓---組織灌流Perfusionpressure(灌流壓):向前引起組織系統(tǒng)灌流的趨力壓差(pressuregradient)SystemicperfusionpressureMBP-CVPCerebralperfusionpressureMBP-ICP(30mmHg,ininjuredbrain>50mmHgatleastMyocardialperfusionpressureDBP-CVP(>50mmHg)GlomerularfiltrationpressureMBP-膠質(zhì)滲透壓-鮑式囊內(nèi)壓

BP低時供應(yīng)器官血流減少之順序：肺→腎臟→肝→心臟(hypoxemia)及腦（hypoxia）心血管系統(tǒng)評估心血管系統(tǒng)評估-成人血壓分級CategorySystolicDiastolicNormal＜130＜85HighNormal130-13985-89MildHypertension140-15090-99ModerateHypertension160-179100-109SevereHypertension180-209110-119CrisisHypertension＞210＞120心血管系統(tǒng)評估AssessmentofbloodlossBP↓、CO↓、PCWP↓、CVP↓、coldskinVolumeofbloodlossChangeofvitalsignscapillaryrefillingBPHRRR<15%微降快快<2sec20~25%降>100>25>5sec40~45%量不到>110>25>5sec血量:70cc/kg身體反應(yīng):肝臟收縮→交感神經(jīng)代償→低容積休克未控制出血：MBP不需超過90mmHg大量出血：輸全血心血管系統(tǒng)評估心血管系統(tǒng)評估HypertensiveHypertensiveEncephalopathyMBP>150mmHg，超過腦部自我調(diào)節(jié)機(jī)轉(zhuǎn)→vasospasm、ischemia、edema、hemorrhage→seizureMalignanthypertensionDBP>130mmHg→endorgandamageLVhypertrophy，hematuria，proteinuria，溶血性貧血心血管系統(tǒng)評估AdvantagesanddisadvantagesonvariouscannulationsitesRadialarteryBrachialarteryFemoralarteryAxillaryarteryDorsalispedalartery心血管系統(tǒng)評估心血管系統(tǒng)評估

Six“s”(AcuteArterialOcclusion)

Pallor（loseflowingbloodinthecapillarybedthenwhitecolor）PainParesthesia(皮膚感覺異常)ParalysisPulselessnessPoikilothermia(溫度變冷)

hardness:壓力25~30mmHgSwelling(小腿周圍長)

compartmentsyndrome心血管系統(tǒng)評估C.VPheadup300Jugularveinenlargement(+)心血管系統(tǒng)評估C.VP高原因右心衰竭體液過多限制性心包炎左到右分流

三尖辦狹窄心包填塞測量時避免假性升高咳嗽、用力、呼吸器使用、藥物輸入心血管系統(tǒng)評估

周邊血管阻力(SVR)SVR↑:

血管收縮、LVH、hypovolema／cardiogenicshock、血液粘稠(B-擴(kuò)張藥物)SVR↓：血管擴(kuò)張、moderatehypolexmia、Anemia(L-收縮藥物)

心血管系統(tǒng)評估心血管系統(tǒng)評估心血管系統(tǒng)評估ArteryBloodoxygen（Hb、

PaO2）C.O

(normal4~7L)/C.I.(2.5~4L/min，C.O/體表面積)TissureO2comsumptioninfluenceSVO2之因素

SVO2↑：pathologicalshunt(L-Rshunt)

、sepsis、

cyanidetoxicity抑粒線體使用O2）、MitralregurgitationSVO2↓：Arrythmia、

shivering、

hypothermia、Anemia、

C.O↓、

Hypoxia,increasedtissueO2consumption

SVO2

心血管系統(tǒng)評估CYANOSISCENTRALCYANOSIS（hypoxia）ImpairedpulmonaryfunctionAnatomicvascularshuntingDecreasedinspiredO2AbnormalhemoglobinsperipheralcyanosisReducedcardiacoutputColdexposureRedistributionofbloodflowfromextremitiesArterialobstructionVenousobstruction心血管系統(tǒng)評估SpO2-MonitoringSpO2-4Arterialsaturation＜85﹪--CENTRALCYANOSISSpO2即是SaO2—降低抽ABG次數(shù)心血管系統(tǒng)評估脈動式血氧受下列影響

外界光線干擾周邊血流不足或脈搏太弱：如-Shock、Anemia、Hypothermia、vaso-constrictivedrugs、。有異常血紅素存在受測部位移動或人為干擾，當(dāng)PaO2小於60mmHg或大於90mmHg時，SaO2與PaO2，並無線性關(guān)係。心血管系統(tǒng)評估心血管系統(tǒng)評估皮膚溫度與顏色改變CardiacfailureAffectarterialflowfirst,thenvenousflowPink&warm→pale&cold→cyanosis&coldCompartmentsyndromeAffectvenousflowfirst,thenarterialflowPink&warm→cyanotic&warm→cyanosis&cold心血管系統(tǒng)評估

Edema

BWchangeExtremitiesabdominalgirth心血管系統(tǒng)評估水腫決定因素與原理Oncoticpressure25mmHg血管內(nèi)壓血管內(nèi)壓35~45mmHg13~15mmHgInterstitialpressureLymphaticdrainage3-5mmHg決定因素血管內(nèi)壓(出)膠質(zhì)滲透壓(回)組織間隙壓(回)微血管通透性(出)淋巴管通暢度(引流)心血管系統(tǒng)評估壓陷性水腫評估0=noedema+1=trace+2=moderate+3=deep+4=verydeep心血管系統(tǒng)評估EdemaedemaLocalizedalbumin＜2.5gdlJVDorCOAzotemiaoractiveurinesedimentDrug-induced(steroids，estrogens，vasodilaters)hypothyroidismVenousorlymphaticobstructionLocalinjury(thermal，immune，infection)Severemalnutrition，Cirrhosis，NephroticCHFRenalfailure心血管系統(tǒng)評估心血管系統(tǒng)評估-癥狀PalpitationDyspnea：

Dyspneaonexertion(DOE)、Paroxysmalnocturnaldyspnea(PND)、ShortofBreath(SOB)、Orthopnea、wheezingCough、HemoptysisNausea/vomitingfatigue/weaknessConsciousnesschange：dizziness、Confusion、orthostatichypotension、syncope詳細(xì)問七要素：QRSTAAA性質(zhì)（quality）、位置（radiationorregion）、嚴(yán)重度（severity）、時間（timing）--（何時發(fā)生,持續(xù)多久,頻率）、惡化（aggravation）或緩解（alleviating）因素、合併出現(xiàn)癥狀（associate）

心血管系統(tǒng)評估CauseofDyspneaHeartdiseaseObstructivediseaseoftheairwayDiffuseparenchymallungdiseasepulmonaryembolismDiseaseofthechestwallorrespiratorymuscles心血管系統(tǒng)評估Differentiationbetweencardiacandpulmonary

ofDyspneaCarefulhistory：肺部疾病的呼吸困難--逐漸發(fā)作examination：心肺疾病休息時無癥狀，用力時癥狀會出現(xiàn)pulmonaryfunctiontest

：肺部的疾病較少會引起呼吸困難，除了ObstructiveorrestrictivediseaseVentricularperformance：

LVejectionfractionatrest/exerciseusuallydepressedincardiacdyspnea心血管系統(tǒng)評估

檢驗(yàn)CXRLab：ABG、(K+，Na+,MG++)、BS、CBC

ECHOCardiacCathExercisetestCardiacenzyme：troponinAnticoagulant

心血管系統(tǒng)評估心血管系統(tǒng)評估-詢問病史使用藥物：強(qiáng)心、利尿、鈣離子拮抗劑、乙型阻斷劑、降壓、抗凝血過去病史：胸痛、心肌梗塞、心包膜炎、風(fēng)濕性心臟病、心雜音、開心手術(shù)、其它危險因子：年齡、性別（男＞45歲,女＞55歲或停經(jīng)）、壓力、靜態(tài)生活、抽煙(咖啡、喝酒)家族史：心臟病、高血脂、高血壓、抽菸、糖尿病Historytakingcontributes60~80﹪ofthedatafordiagnosis.心血管系統(tǒng)評估心血管系統(tǒng)立即診斷及處理情況

心因性休克嚴(yán)重胸痛急性肺水腫致死性心律不整心臟急癥：Aorticdissection、Malignanthypertension、AMI心血管系統(tǒng)評估心血管系統(tǒng)評估Shock無法維持足夠組織灌流以滿足身體所需類別特殊現(xiàn)象問題引因HypovolemicCVP低,JVD(-)VolumeBleedingdehydrationCardogenicCVP高,JVD(+)PumpingAMISepticDBP低,體溫高VasculartoneFeverInfectionNeurogenicDBP低,VasculartoneDrug,PanicRestrictivecardiactamponadeCVP高奇異脈Volume(Fillingrestriction)PulmonaryembolismSpO2低Outputrestriction心血管系統(tǒng)評估

正常心包可貯存10～15ml。

癥狀：1.CVP↑→vein回流↓→vein壓力↑2.irritable,dyspnea,cyanotic3.chesttube引流突然停止4.x-ray中膈腔變大5.吸氣時systolic下降（吸氣時Blood堆積壓迫心臟，CO↓）動脈與心室的舒張末期升高→有效的心室充填壓和血液容積降低6.脈搏壓變窄且深呼吸時脈搏變?nèi)酢婷}。

心包填塞（Pericardialtamponade）心血管系統(tǒng)評估Symptom&SignofShockConceptofvitalorgans:brain,heart,lungConceptofcompensation:sympathetictoneperfusiontovitaorgansskincool,paleGIparalysis,bleeding,“translocation”kidneyoliguria心血管系統(tǒng)評估DiagnosisofShocksymptom&signvitalsign(BP,HR,RR)ABGurineoutputcardiacoutputSvO2(mixedvenousoxygensaturation)serumlactatetonometry心血管系統(tǒng)評估UrineOutputNormalheart,kidney,endocrine,volumestatus

normalurineoutputtoomanyinterferingfactors:renaldiseases,diuretics,mannitol,glycerol,hyperglycemia,DI,ATNdiureticphases心血管系統(tǒng)評估LactateSvO2Lactate

NormalShuntorsepsisWellcompensatedlowCOVerybadAnaerobicmetabolismlacticacidHyperlactemiaVslacticacidosis

心血管系統(tǒng)評估Blooddivertedtovitalorgans

GItractisdeprivedofperfusion90%oftotalgutbloodflowmucosa&submucosaTonometry心血管系統(tǒng)評估心血管系統(tǒng)立即診斷及處理情況

心因性休克嚴(yán)重胸痛急性肺水腫致死性心律不整心臟急癥：Aorticdissection、Malignanthypertension、AMI心血管系統(tǒng)評估CauseofchestpainCardiac（CAD、AS、心包膜炎、心肌肥大）Vascular（aorticdissection、pulmonaryembolism、

pulmonaryhypertention）Pulmonary（pneumonia、pneuthorax）Gastrointestinal（esophagealspasm、billarydisease）NeuralMusculoskeleta