病情危重的判斷醫(yī)務科

1、1會計學病情危重的判斷醫(yī)務科病情危重的判斷醫(yī)務科病史查體輔助檢查診斷治療時間病史查體可能的診斷復蘇緊急的問題病史查體可能的診斷潛在的問題治療反應針對病因治療繼續(xù)復蘇病史查體輔助檢查修正診斷治療反應在病人穩(wěn)定之前，千萬不要離開病人平均動脈壓？血管收縮心率血管擴張心率低高Adapted from: Bone RC et al. Chest. 1992;101:1644-55.Opal SM et al. Crit Care Med. 2000;28:S81-2.非特異性損傷引起的臨床反應, 滿足 2條標準: T 38 C or 90 bpmRR 20 bpmWCC 12,000/mm3or 10%

2、桿狀核SIRS = systemic inflammatory response syndrome SIRS及及可疑或明確的感染Chest 1992;101:1644. 全身性感染伴器官衰竭頑固性低血壓SIRSSepsisSevere SepsisSeptic Shock氧氧是是生命之源生命之源一尖一尖兩底兩底兩面外側面、內側面兩面外側面、內側面三緣前緣、后緣、下緣三緣前緣、后緣、下緣細、長，較水平細、長，較水平短、粗，較垂直短、粗，較垂直上端第上端第6頸椎與頸椎與 環(huán)狀軟骨相連環(huán)狀軟骨相連下端第下端第4、5胸椎胸椎 交界處交界處自然呼吸氣道壓力氣道壓力呼氣期吸氣期0FiO2吸氧裝置低 80

3、mmHg-股動脈股動脈 SBP 70 mmHg-頸總動脈頸總動脈 SBP 60 mmHgFG：濾過梯度（跨腎小球的壓力）GFP：腎小球濾過壓PTP：近端小管壓015050100Organ blood flow(% Baseline)010020406080Organ artery pressure (mmHg)Autoregulatory thresholdSubautoregulatory slope肋骨骨折（每根）肋骨骨折（每根）150 ml骨盆骨折骨盆骨折 3000 ml股骨閉合性骨折股骨閉合性骨折15002000 ml脛骨閉合性骨折脛骨閉合性骨折 500 ml手掌大小傷口手掌大小傷口

4、500 ml胸膜腔可隱藏胸膜腔可隱藏2000 ml腹腔至少可隱藏腹腔至少可隱藏2000 ml腹膜后間隙可隱藏腹膜后間隙可隱藏 1500-3000 ml時間（小時）時間（小時） 2 4 6 8 10 20 29Hb15 g%Hb的真實水平的真實水平 失血量的估計：Hb /HCT并不能及時準確的反應失血量02040608010012014013001400150016001700180019002000血壓：紅柱；心率：虛線；CVP：藍線02040608010012014013001400150016001700180019002000輸血新鮮血漿膠體液容量缺乏更為嚴重低容量表現低容量表現心動過速

5、心動過速低血壓低血壓(嚴重者嚴重者)高乳酸高乳酸(嚴重者嚴重者)肢端溫度降低肢端溫度降低脫水表現脫水表現皮膚充盈下降皮膚充盈下降口渴口渴口干口干腋窩干燥腋窩干燥高血鈉高血鈉高蛋白血癥高蛋白血癥高血紅蛋白高血紅蛋白高血球壓積高血球壓積體位性低血壓體位性低血壓動脈血壓或每動脈血壓或每搏輸出量的呼搏輸出量的呼吸波動吸波動下肢被動抬高下肢被動抬高容量負荷試驗容量負荷試驗結果陽性結果陽性腎臟灌注減少腎臟灌注減少濃縮尿濃縮尿(低尿鈉低尿鈉,高尿滲高尿滲)BUN升高升高(與肌酐升高不與肌酐升高不成比例成比例)持續(xù)性代謝性持續(xù)性代謝性酸中毒酸中毒動態(tài)指標動態(tài)指標靜態(tài)指標靜態(tài)指標容量狀態(tài)評價容量狀態(tài)評價參數參數

6、預測正確比例預測正確比例預測正確百分比預測正確百分比PAWP31/10230CO49/9751SVR39/8844RAP54/9855Eisenberg PL, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-553心輸出量PAWPConnors(NEJM 83)ICU pts44% 42%E

7、isenberg(CCM 84)ICU pts50% 33%Bayliss(BMJ 83)CCU pts71% 62%35-30-25-20-15-10-5-0-CO (l/min)-5 0 5 10 15 20 25 30 35 40CVP (mmHg)Notarius et al Am Heart J 1998Weil MH, Henning RJ: New concepts in the diagnosis and fluid treatment of circulatory shock. Anesth Analg 1979; 58:124132Bellomo R, Chapman M,

8、 Finfer S, et al. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group. Lancet 2000 Dec 23-30; 356(9248): 2139-43多巴胺(n = 161)安慰劑(n = 163)P值Scr峰值245 144249 1470.93Scr差值62 107

9、66 1080.82Scr 300的患者數56560.92需要RRT的患者數35400.55ICU住院日13 1414 150.67總住院日29 2733 390.29死亡人數6966Bellomo R, Chapman M, Finfer S, et al. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Australian and New Zealand Intensive Care Society (ANZICS) Clinical Tr

10、ials Group. Lancet 2000 Dec 23-30; 356(9248): 2139-43Leone M, Vallet B, Teboul JL, et al. Survey of the use of catecholamines by French physicians. Intensive Care Med. 2004 Mar 3 Epub ahead of print Leone M, Vallet B, Teboul JL, et al. Survey of the use of catecholamines by French physicians. Intens

11、ive Care Med. 2004 Mar 3 Epub ahead of print Leone M, Vallet B, Teboul JL, et al. Survey of the use of catecholamines by French physicians. Intensive Care Med. 2004 Mar 3 Epub ahead of print Martin C, et al. Norepinephrine or dopamine for the treatment of hyperdynamic septic shock. Chest 1993; 103:

12、1826-31Martin C, et al. Norepinephrine or dopamine for the treatment of hyperdynamic septic shock. Chest 1993; 103: 1826-31NEDOPA劑量(g/kg/min)1.5 1.210 25有效率93% (15/16)31% (5/16)換用藥物后有效率0% (0/1)91% (10/11)存活率59%17%出院病人數96Martin C, et al. Norepinephrine or dopamine for the treatment of hyperdynamic se

13、ptic shock. Chest 1993; 103: 1826-31Martin C, et al. Norepinephrine or dopamine for the treatment of hyperdynamic septic shock. Chest 1993; 103: 1826-31ICU放射影像十問放射影像十問【1】先問病史再照片子【2】處置要針對患者而非針對片子【3】沒看過患者就不要對片子下最后結論【4】讀片要讀好片：注意明暗、解析度、大小【5】片子要全看，不要只看部份，不要跳著看【6】讀片有疑惑時，先重新評估病人【7】記得rule of 2：2角度、2關節(jié)、2側、2張

14、、2次【8】做完 procedure （中心靜脈置管、氣管插管、胸管）后再照一張【9】懷疑氣胸要在48h內評估23張【10】新入ICU患者要在72h內有CT影像（在病情允許情況下）ICU BOOK貼片與皮膚接觸處需要用水或肥皂清洗，禁用酒精，因會增加皮膚阻力；Cuff的選擇：袖帶中間有兩個白線，最邊上的有一條細白線，袖帶在綁的時候，最邊上的細白線一定要在兩條白線中間，否則就不是適當的袖帶，需要更換氧合下降胸廓運動?調FiO2=1.0氧合下降胸廓運動?調FiO2=1.0人工通氣通氣容易?呼吸機故障ETT/患者問題氣道阻力升高或順應性降低治療病因 調整呼吸機設置YesNo檢查設置與功能No氧合下降

15、胸廓運動?調FiO2=1.0體格檢查特別注意:單側插管氣胸肺不張肺水腫支氣管痙攣治療病因 調整呼吸機設置Yes氧合下降胸廓運動?調FiO2=1.0人工通氣通氣容易?呼吸機故障ETT/患者問題氣道阻力升高或順應性降低體格檢查特別注意:單側插管氣胸肺不張肺水腫支氣管痙攣治療病因 調整呼吸機設置YesNo檢查設置與功能YesNo觀察是最積極的治療！Rogers PL, Schlichtig R, Miro A, Pinsky M. Auto-PEEP during CPR: an “occult” cause of electromechanical dissociation? Chest 1991

16、; 99: 492493Rogers PL, Schlichtig R, Miro A, Pinsky M. Auto-PEEP during CPR: an “occult” cause of electromechanical dissociation? Chest 1991; 99: 492493Rogers PL, Schlichtig R, Miro A, Pinsky M. Auto-PEEP during CPR: an “occult” cause of electromechanical dissociation? Chest 1991; 99: 492493Rogers P

17、L, Schlichtig R, Miro A, Pinsky M. Auto-PEEP during CPR: an “occult” cause of electromechanical dissociation? Chest 1991; 99: 492493Rogers PL, Schlichtig R, Miro A, Pinsky M. Auto-PEEP during CPR: an “occult” cause of electromechanical dissociation? Chest 1991; 99: 492493Rogers PL, Schlichtig R, Mir

18、o A, Pinsky M. Auto-PEEP during CPR: an “occult” cause of electromechanical dissociation? Chest 1991; 99: 492493敏感性, 特異性, 陽性預期值(PPV)和陰性預期值(NPV)的四格表檢查結果患病無病總計+aba + bcdc + d合計a + cb + da + b + c + d敏感性 = a / (a + b)PPV = a / (a + c) 特異性 = d / (c + d) NPV = d / (b + d)abcdefghijklm12345678910 11 12 13nopqrstuvwxyz14 15 1